NURS: 4450 Professional Nursing Leadership and Management

H.B. is a sixty-four year old white male who was admitted to Memorial Hospital Ortho/Trauma Unit on January 31, 2015. His admitting diagnosis was left femoral acetabular fracture. Upon arrival, he complained of left hip pain after a truck that he was working on fell on him. His left lower extremity was shortened and internally rotated when compared to the contralateral side. The skin of the affected extremity was intact. A 2+ dorsalis pedis pulse was present on the left foot. In addition, the patient did not complain of pain upon palpation of the left thigh, knee, ankle, and foot. However, the patient complained of excruciating pain of the left hip upon attempted ROM. The findings of the pelvis CT scan showed a dislocation of the left femoral head superiorly and posteriorly with a comminuted fracture of the medial left femoral head and superior left acetabulum. The emergency department physician performed a reduction of the left hip with placement of skeletal traction pins before the patient arrived at the Ortho/Trauma Unit. Finally, a total hip arthroplasty (THA) was recommended and the patient is currently awaiting surgery that is scheduled on February 03, 2015. H.B.’s surgical history includes a colon resection for pre-cancerous polyp in 2013, a right wrist surgery in 2009, and a laminectomy in 1996. His medical history is composed of hypertension (HTN) and asthma. H.B. takes amlodipine and losartan for hypertension at home. He denies taking any medication for the treatment of his asthma. The patient has no known allergies.
Family and Social History H.B. is a diesel mechanic who lives in Savannah, Georgia with his wife. He has no children. The patient denies the usage of illegal drugs, but states that he chews tobacco and drinks alcohol occasionally. His support system includes his wife, in-laws, and church members. His family history includes obesity and hypertension with his father. He states that his mother has a clean bill of health. Both of his siblings have asthma. His paternal grandfather has type II diabetes and both of his maternal grandparents are obese.
Physical Assessment Findings H.B. is 5 foot and 9 inches tall, weighs 192 pounds and has a BMI of 28.4. The patient is alert and oriented to person, place, time, and situation. His judgment is appropriate. He understands English and speaks it clearly. His head is normocephalic and atraumatic. His pupils are equal, round, and reactive to light bilaterally. The sclera of his eyes is white and the conjunctiva is pink bilaterally. His ears are symmetrically aligned bilaterally with no lesions noted. His nose is midline with no lesions. His lips, gums, tongue, and throat are within normal limits. H.B.’s teeth are intact and in fair condition. The position of his trachea is midline and no bruits were noted upon auscultation of his neck. Upon auscultation of the heart, H.B. had a normal sinus rhythm (regular rate and rhythm). In addition, S1 and S2 are present with no adventitious sounds. The point of maximal impulse was palpated at the 5th intercostal space of the left midclavicular line. The patient’s lung sounds are clear bilateral and his breathing pattern is unlabored with 16 breaths per minute. His abdomen is soft, slightly distended, and non-tender. Hyperactive bowel sounds are present in all four quadrants and no masses were noted upon palpation. His upper extremities (UE) have no edema. The patient has full range of motion of UE, 2+ radial pulses, and a capillary refill within normal limits (WNL) bilateral. H.B. has a 22-gauge peripheral IV in the right forearm. The site is intact, dry, and the patient reports no pain or tenderness. Dorsalis pedis pulses are 2+ and the capillary refill is WNL bilateral. His left lower extremity (LLE) is slightly edematous, warm, dry, and pins for the skeletal traction are placed below the knee. The weight of the skeletal traction is 25 lbs. H.B.’s right lower extremity (RLE) is warm, dry, and has full range of motion. H.B.’s vital signs are stable. He has a heart rate of 83 beats per minute. His blood pressure is slightly elevated with a reading of 139/91. The patient’s respiration is 16 breaths per minute with an oxygen saturation of 98 percent and his oral temperature is 99.2 Fahrenheit. The patient stated that he has pain in his left hip that feels like somebody is stabbing him, which he rated a 6 on a scale from 0-10 at the beginning of shift. Ten milligrams of Percocet was administered upon request of the patient prior shift change.
H.B’s latest basic metabolic panel was WNL. His CBC with differential was WNL, except for his Hct, which was 40.9; this result is lower than that of the previous day Hct of 45.6. The patient’s prothrombin time and INR are WNL. The CT scan and x-ray of the pelvis that were conducted during admission showed a dislocation of the left femoral head superiorly and posteriorly with a comminuted fracture of the medial left femoral head and superior left acetabulum. In addition, a large hemorrhagic effusion of the left hip, multiple joint fragments in the joint spaces, and surrounding soft tissue edema were noted.
Nursing Care H.B.’s home medication includes his amlodipine 5 mg/daily and losartan 25 mg/daily for hypertension. Upon admission to Memorial, he received a prescription of 5-10 mg Percocet orally q4h and an order of 2-4 mg of IV Morphine q2h as needed for pain. In addition, the patient has a new prescription of oral stool softener Docusate Sodium 10 mg twice daily due to immobility and/or the prescription of narcotics, which can cause constipation. He also has an order of 1 packet Miralax orally once daily for constipation. Lovenox is to be administered SUBQ q12h to prevent blood clots. Finally, 4 mg IV Zofran q6h might be administered for nausea or vomiting. The first nursing diagnosis for H.B. is acute pain related to the fractured medial left femoral head and superior left acetabulum. According to the Agency of Healthcare Research and Quality (2011), hip fracture pain has been associated with delirium, depression, sleep disturbance, delayed ambulation, pulmonary complications, and delayed transition to lower levels of care. Due to that, it is our responsibility as healthcare providers to recognize and treat pain effectively in those patients to reduce the risk of any complications. Therefore, the nursing intervention implemented on H.B. was to evaluate the characteristic, intensity, and location of his pain by doing a pain assessment every 2 hours. During this assessment, the patient’s self-report of pain was key. H.B was asked to rate his pain on a scale of 0-10 before and after implementing measures to reduce pain. In addition, the patient was informed about prescribed medications for pain relief and they were administered per the physician order. Non-pharmacological pain relief measures such as distraction, relaxation, and deep-breathing techniques were implemented. Finally, the affected extremity was immobilized and placed in a Buck’s Traction to decrease pain and possible muscle spasm. The second nursing diagnosis for H.B. is risk for infection related to pin placement for skeletal Buck’s Traction. The nursing interventions implemented included educating H.B. about signs and symptoms of wound infections, monitoring lab values and vital signs, assessing report of pain, appropriate hand hygiene, performing aseptic pin/wound care, assessing wound appearance around the pin site and noting any character, as well as amount of any drainage if present. Davis (2003), states in his article that orthopedic pins such as the ones used in H.B., can create potential portals for infections and in most severe cases can cause osteomyelitis. This can lead to failure of orthopedic treatment, long-term pain, discomfort, and immobility. The author goes further into detail by explaining that it is vital to identify and implement effective nursing interventions such as the ones stated previously to limit the risk of those types of infections. Another example of reducing the risk of infections is by applying evidence-based measures relating to the correct use of prophylactic antibiotics after skeletal pin placement (Anderrson, A., Bergh, I., Karlsson, J., Eriksson, B., and Nilsson, K. 2012). H.B. had no order for prophylactic antibiotics and the physician was contacted. The third nursing diagnosis for H.B. is risk for deep vein thrombosis related to immobility. The nursing interventions included making sure that the anti-embolism stockings and sequential compression device were applied as prescribed. In addition, the dorsalis pedis pulse bilateral and skin temperature of both legs was assessed q2h. Also, assessment of the calf for tenderness, warmth, redness, and swelling was performed frequently. Ensuring adequate hydration and repositioning the patient to improve circulation was implemented according to the order of H.B.’s physician. Quaseem, Chou, Humphrey, Starkey, and Shekelle (2011) suggest in their article that the use of anticoagulants such as Lovenox is considered evidence-based practice in preventing the formation of blood clots in patients like H.B. So, the prescribed Lovenox was administered to H.B. according to hospital protocol. In evaluating the care of H.B., the interventions were effective and almost all of the goals were met during the shift. The expected outcome for the first nursing diagnosis of acute pain was that the patient would report a score of 5 or below on a pain scale of 0-10. This outcome was met. H.B. rated his level of pain a 4 or below throughout the shift with the aid of his prescribed pain medication and implementation of non-pharmacological interventions. The expected outcome for the second nursing diagnosis of risk for infection was that the patient would not develop any signs or symptoms of a wound infection. This goal was met. Aseptic wound care was performed, and according to his lab values, vital signs, and wound appearance, H.B. remained infection free. The only goal that was not met during the shift was to get an order for a prophylactic IV antibiotic. Finally, the goal for the third nursing diagnosis of risk for DVT due to immobility was met, which is evidenced by H.B. not developing any signs and symptoms of a blood clot throughout the shift. Overall, the care provided for the patient was very good. If changes could be made, it would be to talk to a charge nurse to address the concern of the patient not being on a prophylactic antibiotic after the surgical procedure of pin placement below the knee for H.B.’s skeletal traction.
Quality and Safety Competency Teamwork and Collaboration was a very important component in providing quality care for H.B. According to our textbook, “collaboration involves discussion of client care issues in making health decisions. The specialized knowledge and skills of each discipline are used in the development of an interprofessional plan of care that addresses multiple problems” (ATI, 2013, p. 35). When H.B arrived at the emergency department, he was seen by multiple healthcare professionals to be diagnosed with a femoral/acetabular fracture of his left lower extremity. First, a nurse probably collected all of his information and did an initial assessment. Second, the patient was seen by the admitting physician for an in depth evaluation/assessment. After that, H.B. was seen by a radiologist to get a CT scan and x-ray. In between all of that, he probably had blood drawn by a phlebotomist. These are all just a few examples that the patient might have gone through before he arrived at the Ortho/Trauma floor. However, during this shift, a nurse, a student nurse, and a patient care technician took care of H.B. In addition, the orthopedic surgeon discussed with the patient his upcoming surgery and postop expectations of physical therapy. In conclusion, without teamwork and collaboration, it would be impossible to provide excellent care with the possibility of a speedy recovery.
Discharge Planning The desired outcome for H.B. was that his hip fracture and surgical wound would heal without any complications. Recommended discharge plans included transferring the patient to the Rehab Unit at Memorial Hospital. Upon discharge, the patient needed to be educated on medication, intervention, and his treatment plan. Once the patient is able to go home, he needs a referral for home health care. Lastly, a follow up appointment with his orthopedic doctor was scheduled in 2 weeks.

Resources
Agency of Healthcare Research and Quality. (2011). Pain management interventions for hip fracture. Retrieved from http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides- reviews-and-reports/?pageaction=displayproduct&productid=676
Andersson, A. E., Bergh, I., Karlsson, J., Eriksson, B. I., & Nilsson, K. (2012). The application of evidence-based measures to reduce surgical site infections during orthopedic surgery report of a single-center experience in Sweden. Patient Safety In Surgery, 6(1), 11-18.
Assessment Technologies Institute (ATI) (2013). Nursing leadership and management: Review module (6t ed.). Content Mastery Series. Overland Park, KS: Assessment Technologies Institute (ATI).
Davis, P. (2003). Wound care. Skeletal pin traction: Guidelines on postoperative care and support. Nursing Times, 99(21), 46-48.
Qaseem, A., Chou, R., Humphrey, L. L., Starkey, M., & Shekelle, P. (2011). Venous thromboembolism prophylaxis in hospitalized patients: A clinical practice guideline from the American College of Physicians. Annals Of Internal Medicine, 155(9), 625-632.