Video Case Study - Caring for Patients With Fractures

Nurse Kenji works on a rehabilitation unit and is caring for Sharon, a 74-year-old female with a history of osteoporosis who was admitted post-surgery for a left hip fracture requiring an open reduction and internal fixation, or ORIF.

In collaboration with the registered nurse, RN Betty, Nurse Kenji goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Sharon’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Kenji recognizes important cues, including Sharon’s vital signs, which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respirations 19 breaths per minute, and blood pressure 123/88 mmHg.

During the bedside report, Nurse Kenji learned that Sharon declined repositioning during the night shift. Upon inspection, he notes that her hip appears mildly swollen and her surgical dressing is clean and dry.

Nurse Kenji also notices that Sharon’s left foot is warm with intact sensation, 2+ palpable pulses, and she can wiggle her toes, which is consistent with RN Betty’s earlier assessment.

Nurse Kenji asks Sharon about her comfort. Nurse Kenji: I see that you stayed in the same position throughout the night.

Would you tell me your current pain level? Sharon: I don’t have pain right now, but I don’t want to move because I know it'll hurt my hip.

Nurse Kenji: I understand. Have you considered taking the prescribed medications to manage your pain?

Sharon: I really don’t like pain medicine because I’m worried about becoming addicted. Next, Nurse Kenji analyzes these cues.

He reviews the electronic health record, or EHR, and notes that Sharon is scheduled for physical therapy today. He also notes that Sharon is prescribed ice packs to reduce hip swelling, as well as oxycodone and acetaminophen every four hours as needed for pain management but hasn’t taken any medication since early yesterday evening.

Nurse Kenji understands that hip fractures are fractures that occur in the upper third of the thigh bone, called the femur.

He knows that Sharon is at risk for hip fractures due to her older age, which increases the risk for falls; being assigned female at birth, due to an increased loss of bone density as estrogen levels fall after menopause; and her history of osteoporosis, which causes bones to become brittle and fragile.

Nurse Kenji is aware that patients who’ve undergone surgery to repair hip fractures typically experience pain and tenderness around the affected area, due to tissue trauma and inflammation, which makes it difficult to bear weight on the affected leg.

He also knows that if Sharon doesn't ambulate, she can develop complications of prolonged inactivity, like skin breakdown, deep vein thrombosis, or DVT, and pneumonia, as well as experience a delayed recovery.

Nurse Kenji realizes that Sharon needs effective management to promote mobility. Now using the information he has gathered along with Sharon’s medical history, Nurse Kenji reports his findings to RN Betty, and together they choose a priority hypothesis of impaired mobility.

Then, they generate solutions to address Sharon’s pain and promote mobility that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening Sharon will successfully demonstrate at least two recommended activities by the end of her physical therapy session.

Nurse Kenji then takes action to implement these solutions. He reviews with Sharon the information RN Betty taught to her about the importance of mobility following surgery in order to prevent complications.

Then, he reinforces teaching about Sharon’s prescribed pain medications. Nurse Kenji: Sharon, I understand you're concerned about taking pain medications.

As Nurse Betty told you earlier, the risk for addiction is low if oxycodone is taken as prescribed and for a short period of time.

We recommend that you take pain medication before activity. When you’re resting, you can use other therapies like ice and acetaminophen, which can help with your pain, but isn’t habit-forming.

Sharon: Thanks for explaining again. In that case, maybe I’ll try some pain medication before my physical therapy session today.

Since Nurse Kenji knows that the physical therapist will arrive in one hour, he administers the oxycodone according to safe medication practices to allow enough time for it to take effect before her activity.

Then, he applies an ice pack to Sharon’s left hip. When the physical therapist arrives, Nurse Kenji works with them to help Sharon reposition herself in bed using the trapeze bar, to sit up at the edge of the bed, and then stand briefly at the side of the bed.

After Sharon’s physical therapy session, Nurse Kenji evaluates the outcomes of his actions. He evaluates Sharon’s pain level, which is 2 out of 10 following the activity.

He takes Sharon’s vital signs, which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respirations 19 breaths per minute, and blood pressure 108/66 mm/Hg.

Alright, as a quick recap... Nurse Kenji recognized and analyzed cues related to Sharon’s pain management and mobility needs following ORIF of her left hip, and in collaboration with RN Betty, prioritized hypotheses, and generated solutions to address this problem.

Nurse Kenji and RN Betty then took action to implement pharmacologic and nonpharmacologic measures and evaluated outcomes by comparing them to the expected outcome.

Since Sharon was able to demonstrate at least two physical therapy activities, they determined that the plan of care was