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Fractured Femur and Humerus

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Kylie McCormick

on 25 November 2014

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Transcript of Fractured Femur and Humerus

Fractured Femur and Humerus
Bone Fracture
Occur when the resistance of bone against the stress being exerted yields to the stress force.
In children fractures heal much faster!
Thickened periosteum and generous blood flow supply
Osteoblasts are stimulated to maximal activity
New bone cells are formed in immense numbers almost immediately after the injury and a bulging growth of new bone tissue between the fractured bone fragments
Deposition of calcium salts to form a callus
Remodeling
: process that occurs in the healing of long bone fractures in growing children (like adolescents!)
The irregularities from the fracture become indistinct as the angles and bone overgrowth are smoothed out, giving the bone a straighter appearance
Rule of thumb
: an angulated fracture will remodel by 1 degree/month in growing children

Initial Assessment as K.B. is admitted to the floor
Information from the PACU nurse
SBAR report
Pain/sedation medication used in surgery, how the surgery went, any complications and the length of sedation
VS trends - emphasis on anything that is unexpected or abnormal
Information about the dressing & cast
I&Os - IV fluids, urination since surgery, and last BM
When the next antibiotic is due
Most recent assessment - neuro, neurovascular, pain, etc
Case Study Progression
K.B. has been settled into her room and begins to complain of pain (7/10) in her leg and arm. She weighs 65 kg. You note the morphine order in her chart, and your drug reference states that the appropriate does is 0.05-0.1 mg/kg every 4-6 hours
Prioritized Orders
1. VS per routine
2. Neurovascular checks Q1H
3. Neurologic checks Q2H
4. Ice pack & elevate RLE and RUE
5. Morphine sulfate 5 mg IV Q4-6H PRN
6. IV fluids D5 1/2 NS @ 100 ml/hr
7. Cefazolin (Ancef) 880 mg IV Q6H
8. NPO
9. Turn, cough & deep breathe and incentive spirometer (IS) every 2 hours while awake
BY: Jennifer Bustamante, Evelyn Jaramillo, & Kylie McCormick
Case Study
K.B. is a 16-year-old who fell while skiing. She was transported down the hill by the ski patrol after being stabilized and then was flown to the hospital. She has a fractured right femur and humerus. She is admitted to your unit after an open reduction and internal fixation (ORIF) of the femur fracture and casting of her leg and arm.
Immediate Assessment
Assess level of consciousness and pain
Look at dressing for any redness, swelling, discharge
Vital signs, neurological, neurovascular
Administer antibiotics and pain meds at the appropriate time
Safe Dose
0.05 mg/kg x 65 kg = 3.25 mg/dose
0.1 mg/kg x 65 kg = 6.5 mg/dose

3.25 - 6.5 mg/dose
5 mg dose is
SAFE!

2 mg/ml concentration
(5mg/2mg) x 1 ml =
2.5 ml
Open Reduction & Internal Fixation
First the bone is reduced, or put back into place. Next an internal device is placed on the bone. This can be done with screws, plates, rods, or pins that are used to hold the broken bone together.
Done if the fracture would not heal properly with casting or splinting
Prior to the procedure:
Physical exam: blood circulation and nerves around fracture
X-ray, CT scan, or MRI
Blood tests
Post operation:
NPO status with IV fluids until about to eat
Ambulation, PT, possible assistive devices
Cough and deep breathe
Elevate the affected limb above the heart to decrease swelling
K.B. has been on the unit for approximately 6 hours. You identify the following changes in your assessment data:
K.B. is difficult to arouse, but when awake she is able to identify who and where she is
PERRLA is 1+ with slower reaction time than earlier
Color is pale, pink
Skin is cool and clammy
HR is 126 beats/min, RR is 28 breaths/min, temperature (oral) is 102 F (39 C); SaO2 is 90%.
You find that neurovascular checks of the affected extremities are unchanged.
What will your immediate nursing interventions include?
Raise the HOB (if possible)
Reassess VS & pain
Assess surgical sites for redness, swelling and distal perfusion
Cough and deep breathe
Cool towels on head and neck, and remove thick blankets
Call for help - nurse/MD
Check for standing oxygen orders and Narcan orders
Keep her awake
K.B. is transferred to a PICU and treated for changes in her neurologic status. The following day, her primary care provider (PCP) determines she is stable and has her transferred back to the peds unit.
It is now 36 hours post-op. K.B. suddenly begins to complain of extreme pain in her lower right leg. She rates her pain as a 10/10!
Early Signs of Compartment Syndrome?
a. Diminished pedal pulse
SBAR for the Ortho surgeon
K.B.'s cast is split and her foot pulses are restored. K.B. and her parents are extremely anxious.
Provide the parents and patients with information as to why the cast has been removed and what is achieved by removal
Explain that removal of the cast does not inhibit bone growth but actually helps to facilitate healing by allowing proper circulation to the lower portion of the leg.
Then explain that once proper circulation is restored, another cast will be applied to help stabilize the left prior to discharge
K.B.'s status continues to improve Physical and occupational therapists work with her on transfers and performing activities of daily living (ADLs). She has many questions about how she will be able to go to school and resume her normal routine.
K.B. is discharged to home on post-op day 5 with home bound schooling ordered and follow-up with orthopedics in 2 weeks
Recognizing her developmental and cognitive stage, which of these statements are appropriate as you explain her care on discharge?
a. Adolescents are capable of thinking in concrete terms only.
Discharge planning:
Insurance coverage
Equipment at home
Follow up appointments
Education:
Medication
Signs and symptoms of compartment syndrome
Encourage use of muscles
Keep a clear path for ambulation
Elevate lower limb when sitting & avoid standing for too long
Cast and stabilization care
Wound care and aseptic technique
Psychosocial - ways to avoid social isolation
Discharge with the multidisciplinary team
Situation:

K.B. was just transferred from the PICU and she is experiencing extreme pain in her right leg.
b. Adolescents are preoccupied with the immediate situation rather than future events.
c. Adolescents can anticipate future implications of current decisions.
d. Family acceptance is more important than peer acceptance.
b. Macular rash
c. Edema
d. Paresthesia
e. Cap refill < 2 seconds
f. Increased pain
Background:

K.B. is a 16 year old female who is 36 hours post-op from a right femur and right humerus fracture due to a ski accident. She had an ORIF on both extremities. She was in the PICU for changes in her neurological status.
Assessment:
Perfusion to her lower extremities is diminished, the capillary refill is > 2 seconds, there is swelling to her lower extremity and she has an inability to move her toes. She reports her pain as a 10/10 in her right lower extremity.
Recommendation:

We would like for her cast to be split to release the pressure and allow for circulation to return to her leg.
Is the dose safe for your patient?

Ordered dose: 5 mg IV Q4-6H PRN

The morphine for injection comes in a concentration of 2 mg/mL. How much will you draw up and double check with an RN?
K.B.'s Glosgow Coma Scale begins to delcine. What are possible reasons for changes in her neurological status?
Due to a prolonged state of pain
Respiratory distress
Sepsis
Compartment syndrome
Education & Support for K.B. & her parents
Physical/Occupational Therapy
Able to use equipment properly
Home exercises
Nutrition
Need for a specific diet
Bone healthy
High in calcium
Protein and vitamin intake
Watch for inadequate nutrition
References:
Hockenberry, M. J., & Wilson, D. (2014). Wong's essentials of pediatric nursing. St. Louis, MO: Mosby/Elsevier.

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