NU272 HESI Case Study: Compound Fracture (Preschooler)

The nurse monitors the client's lab values. Which change in serum lab values would most likely indicate the onset of osteomyelitis?

Increased erythrocyte sedimentation rate (ESR). - The ESR will increase during an inflammatory process, which would be present in acute osteomyelitis, an infection of the bone.

How is the presence of crepitus related to this femur fracture determined?

Listen for a grating sound when the affected area is moved. - Listen for a grating sound when the affected area is moved.

The child has an open fracture. What is a priority nursing intervention?

Cover the wound loosely with a sterile dressing. - The area is covered with a sterile dressing to prevent contamination of organisms from the skin.

Meet the Client

A four-year-old is brought to the emergency department (ED) by ambulance following an automobile accident that occurred while the child was headed to the park with her sister, who is also her babysitter. The child sustained a compound fracture of the femur, which requires surgical reduction, followed by skeletal traction.

The nurse assesses for pain. The child points to the FACES pain scale rating indicating a high level of pain, but she is lying still and seems vague about the location of the pain when asked by the nurse. A prescription for IV morphine every 4 hours is available. The child is due a dose of morphine, and the transport team is en route to escort her to surgery.

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Discharge Teaching: Cast Care

After 3 weeks the traction is discontinued, a long leg cast is applied, and the client is scheduled for discharge from the hospital.

The nurse identifies that a priority nursing diagnosis is injury risk for peripheral neurovascular compromise. Which lab value would be of most concern for the nurse?

Hemoglobin of 9.5 g/dl (95 g/L). - This is a low value. A low hemoglobin will not provide sufficient oxygen for tissue repair.

Another parent explains to the nurse that her 6-year-old son prefers sitting in the front seat. She feels this is the safest place because her car is equipped with front and side airbags. What advice should the nurse provide to this parent?

The child can sit in the back seat of a car while using the manufacturer's manual lap and shoulder belts. - Shoulder only automatic belts are designed to protect adults. Children should use manual shoulder belts in the rear seat. Air bags do not take the place of child safety seats or seat belts. The safest area of the car for children is the back seat. Children should use specially designed car restraints until they are 135 cm (4 ft 9 in) in height or are 8-12 years of age.

Which finding should The client's parents be instructed to report to the healthcare provider?

The client's toes are more swollen. - Swelling could be a sign of impaired circulation.

The client reports that her pain is still controlled and she is starting to get hungry. The nurse sends the UAP to provide her with a snack. Which snack selection is the best choice for the client while she is immobilized?

Yogurt. - Immobilization creates a state of decreased metabolic rate. The diet should be high in protein, with small frequent feedings.

The client's mother tells the nurse that she doesn't know how to respond to the client when the child expresses her anger. In teaching the mother, what response should the nurse suggest she use with the client?

"I am sad that you are throwing things at me." - Preschoolers need limit-setting guidelines and discipline. The parent's response should focus on the activity, rather than the child. Phrasing a response beginning with "I" rather than "you" is less judging to the child.

What is the best response by the nurse?

"It is natural to be upset when your child expresses anger toward you." - This open-ended statement offers the mother the opportunity to continue to express her feelings about the situation. The nurse can then offer reassurance that this expression of anger by the client is normal and help the mother find ways to deal with the situation. Therapeutic communication allows the person/patient to explore current personal issues and occcasionally painful feelings. Remaining professional means maintaining a calculated emotional distance, near enough to be involved but objective enough to be helpful.

The prescribed dose of morphine reads, "Administer morphine sulfate 0.2 mg/kg IV every 3 to 4 hours." The client weighs 33 pounds. The tubex of morphine contains 5 mg/mL. How many mL of medication should the nurse administer? (Enter numeric value only. If rounding is necessary, round to the nearest tenth.)

0.6 mL First, convert pounds to kilograms: 33 lbs/2.2 kg = 15 kg Next, determine the dose per kilogram: 15 kg × 0.2 mg/kg = 3 mg Last, calculate the mL needed: 3 mg/5 mg × 1 mL = 0.6 mL

After resolving the other client care needs, the nurse returns to the client's room. Which task should be delegated to the LPN at this time?

Spend time with the client to distract her from the discomfort. - This is an appropriate nursing responsibility for the LPN.

Which nursing action has the highest priority?

Assess the appearance of the client's foot. - Pain distal to the site may be the first sign of a serious complication needing immediate attention.

The nurse recognizes that the client is at risk for the onset of osteomyelitis. Which nursing intervention should be included in the plan of care to prevent this complication?

Cleanse the pin site with half-strength hydrogen peroxide. - Persons with skeletal traction are at high risk for osteomyelitis because of the potential for direct entry of microorganisms at the pin site. Cleansing the pin site with half-strength hydrogen peroxide may be initiated to reduce this risk.

The nurse talks to the client's parents about preparing her for cast removal. Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening?

Describe what the child will experience shortly before the procedure takes place. - Preparation for the procedure helps reduce anxiety.

Based on these assessment findings, the nurse recognizes that the child has developed compartment syndrome. In addition to notifying the healthcare provider of this development, what action should the nurse implement?

Obtain equipment needed for cast removal. - Compartment syndrome is the compression of structures, such as arteries and nerves, within a closed compartment in an extremity. This complication typically occurs within 24 hours of a fracture. It should be reported to the healthcare provider immediately because permanent damage can occur within 12 hours of identification of the syndrome. Cast removal is often necessary to relieve the pressure, and surgical fasciotomy is sometimes needed as well.

Given the available medical personnel, what staff assignment is best?

Ongoing monitoring of the client's foot by the LPN, while the UAP assists the postoperative client with crutches and the nurse determines if the new client has any immediate problems. - Ongoing monitoring of the client's foot can be performed by the LPN since the nurse has already made an assessment and taken action. The UAP can assist the client with crutches, which allows the nurse to assess the problems of a new client. The nurse is the only member of the team who has the expertise to perform an admission assessment and determine client needs and problems.

The UAP goes to the playroom to get the client some toys. The UAP is planning to spend some time with the client. Which activity is the best choice for the client?

Pretend beauty parlor. - Preschoolers enjoy imitative and dramatic play, and they especially enjoy adult make believe. This activity will help the client with fine motor skills, as well as communication skills, and should keep her engaged for a period of time. Preschoolers also enjoy things like village and farm sets, hand puppets, simple handicrafts, and letter flash cards.

The nurse understands that which signs and symptoms are indicative of osteomyelitis? (Select all that apply. One, some, or all options may be correct.)

Resistance to movement. - The client's pain will be constant but will increase with movement. Edema. - The client will have noticeable edema. Irritability. - The client will be uncomfortable and irritable.

What instructions should the nurse provide to the client and her parents about care related to the cast removal? (Select all that apply. One, some, or all options may be correct.)

She may feel heat or a vibration or a tickle during the removal. The machine to remove the cast is very noisy. Skin might be scaly or dry after the cast is removed.

The client insists that the play activity include Elsa, her invisible friend. While playing, the client throws some toys on the floor and scolds Elsa for dropping them. The client's mother tells her that the activity cannot continue if she is going to throw her toys. How should the nurse respond to this situation?

Support the mother's decision to hold the client accountable for her own misbehavior. - Parents can acknowledge the presence of imaginary friends/playmates, but should not allow the child the use the playmate/friend to avoid punishment or responsibility.

The client had a plaster cast applied an hour ago. The parents demonstrate lifting the cast by holding it with the palms of their hands. How should the nurse repond?

Acknowledge that the parents have correctly learned how to move the cast while it is wet. - The palms of the hands should be used to move a wet cast to avoid finger indentations that cause pressure points. Submit

Based on this assessment, what is the best nursing intervention?

Administer another dose of morphine immediately. - Lack of activity may indicate pain in the preschooler, an age at which a child is normally always on the go. Preschoolers may not be able to localize pain clearly. The child has clearly identified the degree of pain on the FACES scale and should be medicated accordingly.

Skeletal traction applies the pull directly on the skeletal structures. The nurse should immediately assess the pull of the traction on the pins. This is critical to the success of the traction and the first priority when the client arrives to the unit.

Assess toes for capillary refill and edema. - Decreased perfusion to the foot or increased edema could lead to a potentially life-threatening complication. Ensure that the amount of weight remains consistent. - The nurse should assess the amount of the weight regularly to ensure that no changes have been made to the prescribed amount of traction. Well-meaning family and friends or older children may remove weights.

If a staff member is unable to reach the child's parents, what guidelines will determine the staff's ability to provide needed care?

Emergency care may be provided after a reasonable attempt to reach the parents has been made. - Rationale: Exceptions to requiring parental consent before treating children can occur in emergency situations. Most healthcare facilities will provide emergency, life-saving medical care to a minor if unable to reach parents after a reasonable attempt has been made.

The client usually snacks on animal crackers in the morning. She has a box at her bedside. She asks the nurse if she can have some while her mother is away from the bedside. What action should the nurse take?

Give the client a few crackers and stay with her while she eats them. - It is important to maintain the client's routine. Therefore, she should be allowed to have her usual morning snack. It is also important to supervise the client because preschoolers have great imaginations and she may choose to hide some of the animal crackers in her cast if left alone while having her snack.

As the nurse assumes care for the client, which actions are most important for the nurse take? (Select all that apply. One, some, or all options may be correct.)

Immobilize the injury. Assess neurovascular status every hour. Elevate the affected extremity.

The client's parents invite the nurse to attend a parenting class at her preschool to talk about car safety. A parent in the class states that her 5-year-old son is very mature for his age and feels more grown-up using an adult seatbelt. She states that he follows the rules much better when he gets to make decisions. Therefore, he is more willing to keep the seatbelt buckled. She goes on to say that he is large for his age, weighing almost 50 pounds.

Instruct this parent that the child's age and size still require the use of a safety seat. - The American Academy of Pediatric and National Highway Traffic Safety Administration now recommend that children up to age 2 ride in a rear- facing safety seat until the child has outgrown the manufacturer's height and weight recommednations; then transition the child to a forward- facing safety seat with a harness in the back seat of the vehicle. The belt-positioning booster seats are tall and weigh 15.9 to 36.3 (35-80 lbs), and are used for children who are less than 145 cm (4 ft 9 in) depending on the type of booster seat.

Therapeutic Communication: Displaced Anger

Several days later, the client throws her toys at her mother. Her mother is in tears and asks the nurse, "Why does she only get angry with me? She never yells at the nurses or her father."

Management Considerations: Delegation

The nurse administers an additional dose of analgesic to the client after conferring with the healthcare provider and the client reports that her pain is tolerable. Other clients require assistance, so the nurse needs to utilize her team members to effectively care for all clients. A client with a pelvic fracture is being transferred from the ED and a postoperative client with crutches needs assistance ambulating to the bathroom. A licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) are available to work with the nurse.

A Complication Occurs

The child has been resting comfortably since surgery. She is receiving morphine 3 mg IV every 4 hours, and she has consistently indicated adequate pain control via the FACES pain scale and through remarks to her mother, who has been staying at her bedside. Twenty hours after surgery, the nurse administers the next scheduled dose of morphine. Two hours later, the child is crying and agitated. She points to her foot and cries, "There, there, it hurts there."

Clinical Manifestations

The child's parents are reached and they are both on their way to the hospital. They both give telephone consent for her emergency care. The nurse performs an assessment of the affected leg and notes leg deformity, swelling, and ecchymosis. EMS documentation indicates the presence of crepitus.

Ethical-Legal Issues: Consent for Care

The child's teenage sister accompanies her to the hospital. She reports that their parents are both at work.

Traction

The client goes to surgery, where reduction and fixation is performed. Following surgery, the client is transferred to the orthopedic nursing unit where she will be in skeletal traction for several weeks.

Since the child's parents are divorced, which parent should the nurse try to contact first?

The parent who has been assigned legal custody by the court. - The parent who has been assigned legal custody has the right to give consent.

Upon arrival to the unit, which nursing assessment has the greatest priority?

The pull of the traction on the pins. - Skeletal traction applies the pull directly on the skeletal structures. The nurse should immediately assess the pull of the traction on the pins. This is critical to the success of the traction and the first priority when the client arrives to the unit.

The nurse notes that in addition to the pain, the child's foot is cool and pale. What additional assessment should the nurse perform? (Select all that apply. One, some, or all options may be correct.)

Toe movement. - Neurovascular assessment includes the "5 Ps." They are pain, pallor, pulse, paresthesia, and paralysis. Changes indicate increasing pressure on the blood vessels and nerves supplying the extremity distal to the cast or injury. The integrity of the skin would not add any assessment data related to compartment syndrome. - Capillary refill should be checked when compartment sydrome is suspected.

Health Promotion: Use of Infant/Child Car Seats

When the client returns for cast removal, the nurse uses a doll that allows the client to role-play the procedure of cast removal. The nurse tells the client that the cast-cutter makes a noise, but if it touches her leg, it will probably feel like a "tickle."