Open Reduction Internal Fixation Worksheet

You are working evenings on an orthopedic floor. One of your patients, J.O., is a 25-year-old man who was a new admission on day shift. He was involved in a motor vehicle accident (MVA) during a highspeed police chase on the previous night. His admitting diagnosis is status post (S/P) open reduction internal fixation (ORIF) of the right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He speaks some English but is more comfortable with his native language. He is under arrest for narcotics trafficking, so one wrist is shackled to the bed and a guard is stationed outside his room continuously. Another drug dealer told him he is “coming to get him.” Hospital security is aware of the situation. Your initial assessment reveals stable vital signs (VS) of 116/78, 84, 16, 98.6 ° F. His only complaint is pain, for which he has a patient-controlled analgesia (PCA) pump. Lungs are clear to auscultation. His abdomen is soft and non-tender. He has a nasogastric tube connected to intermittent low wall suction. His IV of D5LR is infusing in the proximal port of a left subclavian triplelumen catheter at 75 mL/hr; the remaining two ports are heparin-locked. His right femur is connected to skeletal traction. The dressing is dry and intact over the incision site. J.O.’s right leg is connected to 10 pounds of skeletal traction. 1. J.O. has not had a cigarette since the accident. He is irate because the day nurse would not let him smoke. What is your major concern about J.O.’s smoking? 2. Do you think J.O. would be a good candidate for a nicotine patch? Why or why not? State your rationale. 3. J.O. has an antiembolism stocking ordered for his left leg. What is the rationale for putting stockings on this leg only? 4. J.O. has a Foley catheter inserted to drain his urine. What would you assess for in relation to the Foley catheter? 5. In view of the threat made on J.O.’s life and his vulnerable situation, what precautions should the nursing unit take to protect him? CASE STUDY PROGRESS The nurse in the emergency department phones to tell you that J.O.’s immunization status could not be determined when he arrived, so no tetanus immunization was given. When you ask J.O. the date of his last tetanus shot, you find out that he was born and raised in Colombia and immigrated to the United States 5 years ago. He does not know whether he has ever had a tetanus shot. You inform the physician, and he orders diphtheria/tetanus toxoid 0.5 mL IM and tetanus immune globulin (HyperTET) 250 units deep IM. 6. Why is J.O. getting two injections? 7. When you give J.O. the tetanus injections, you find J.O. in the position illustrated below. Are any of these findings of concern to you? If so, how would you fix it? 8. While assessing distal to the fractured femur, you note that his toes are slightly cool to the touch. What other assessment findings should be gathered? CASE STUDY PROGRESS At 2100, J.O.’s guard summons you to his room. J.O. is pale, slightly confused, and complaining of chest pain and dyspnea. VS are 90/60, 120, 28, 100.0 ° F (37.8 ° C), and Sa O 2 of 84%. His pulse is weak and thready, and there are petechiae on his chest. You immediately suspect a fat embolism. 9. Explain the pathophysiology of a fat embolism. 10. List the priority actions you should take next and the rationale for each. Arterial Blood Gases on 2 L Nasal Cannula pH 7.32 Pa CO 2 53 mm Hg HCO 3 22 mmol/L Pa O 2 84 mm Hg 11. Interpret J.O.’s ABG results. The physician comes and examines J.O. He writes the following orders, then leaves, stating he will be back in 1 hour to check on J.O. 12. Describe a plan for implementing these orders in order of priority. 13. What is the expected outcome associated with each of the medications ordered for J.O.? Physician’s Orders Bed rest Oxygen (O 2 ) to maintain Sa O 2 of 90% Change D5LR IV rate to 125 mL/hr ECG monitoring Repeat arterial blood gases (ABGs) in 1 hour CBC with differential and serum lipase now STAT CXR Methylprednisolone (Solu-Medrol) 12 mg IVP now Furosemide (Lasix) 60 mg IV push now Digoxin 0.25 mg IV push now ■ Chart View Arterial Blood Gases on 10 L Face Mask pH 7.29 Pa CO 2 56 mm Hg HCO 3 22 mmol/L Pa O 2 74 mm Hg 14. J.O. is placed on oxygen at 10 L via face mask. ABGS are redrawn after 1 hour. Interpret the results. 15. What intervention do you anticipate, based on your interpretation of these values? CASE STUDY PROGRESS The physician returns to reexamine J.O. Because J.O.’s status is deteriorating, despite the application of oxygen and the administration of the IV medications, the physician writes to transfer J.O. to the ICU for ventilator support. 16. You accompany J.O. on the transfer to the ICU. Why would you do this, and what information would you provide to the ICU nurse? CASE STUDY OUTCOME J.O. recovered for several weeks in the hospital before being sent to jail to await trial. Shortly before his trial date, he was found stabbed to death in his cell. …