Introduction
The patient is a 91-year-old female and was admitted to the Emergency Department after being the unrestrained passenger in a motor vehicle crash. She sustained many serious injuries, mostly on the right side. The patient presented with fractures of the right tibial plateau and right supracondylar humerus, a nondisplaced comminuted fracture of the right patella and a laceration of the right knee. Additionally, she has been given diagnoses of atrial fibrillation, diastolic congestive heart failure, anemia, pulmonary hypertension, kidney cysts, and constipation. The patient has a medical history of only atrial fibrillation prior to admission. The patient had x-rays taken of the chest, right elbow, right knee, right humerus, right forearm, and an operating room fluoroscopy. Additionally, the patient had CT scans of the cervical spine without contrast, Chest/Abdomen/Pelvis with contrast, Extremity lower, and head post fossa without contrast. Based on diagnostic findings, the patient required various surgical procedures. On October 2nd, the patient had irrigation and debridement of the right tibia, arthrotomy of the right knee for debridement of open tibia fracture, and attempted casting and eventual splinting of the right distal humerus fracture. On October 5th, closed treatments of the right tibial plateau fracture and right patellar fracture were performed as well as an open reduction internal fixation of the distal humerus.
Current and Complete Picture of Patient
A full assessment of the patient allowed for better insight into her current condition. The patient is alert and oriented to person, place and situation but not to time and is extremely depressed, anxious, and tearful. She had no difficulty focusing and follows directions well. Her face is symmetrical, tongue is midline, and she has no difficulty swallowing. Speech is normal with no receptive or expressive aphasia Upon inspection of the eyes, pupils are each 3mm, round, reactive to light and accommodation. There are no visual deficits and the patient is able to parallel track object with eyes per the six cardinal positions of gaze. She has decreased range of motion in the right upper and lower extremities. The patient is able to perform a weak hand grasp on the left hand but not on the right. Likewise, the patient is able to perform finger to nose with the left hand but not the right. She is able to dorsi-flex and plantar flex on the right and left feet. She has complained of numbness and pain in right arm which is edematous.
Upon auscultation, the apical pulse is irregular. The patient denies any chest pain. There is edema, erythema, and warmth in the right arm and edema in both feet. Radial pulses and dorsalis pedis pulses are present and equal bilaterally. Extremities are warm and capillary refill occurs in less than three seconds. The lungs are clear bilaterally on auscultation. The patient has been titrated down to room after from 3 L nasal cannula the night before. Respirations are 20 with no shortness of breath. The patient denies having a cough.
Bowel sounds are present in all four quadrants and the abdomen in soft, non-distended and non-tender on palpation. The patient complains about aching abdominal pain but no nausea or vomiting. Bowel movements are infrequent but the patient is continent of stool. She is voiding a sufficient quantity of clear, yellow urine without any pain or burning.
The patient is not able to ambulate, can not bear any weight, and has her right leg immobilized. The patient has difficulty moving the right arm and leg against gravity. She has much better musculoskeletal strength on the left side. Her skin is clean, dry, warm and intact with moist mucous membranes. A stapled surgical incision on the right arm in open to air and has some edema and erythema. Skin is taut and there is some ecchymosis on both arms. The patient also has a small tear in the left knee as well as a coccyx fissure. She has rated her pain at a 6 all over and made specific complaints about her right arm and abdomen. Refer to ‘Relevant Lab Values’ for laboratory assessments and ‘Current Medications’ for all prescribed medications with rationales.
RELEVANT LAB VALUES
LAB
LAB VALUE
WHY IS THIS RELEVANT TO THE PATIENT?
HgB
8.7
The hemoglobin is low which is consistent with diagnosis of anemia and is likely due to trauma and blood loss. We need to know this value if we are giving Lovenox.
Hct
28.4
The hematocrit is low which is consistent with diagnosis of anemia and is likely due to trauma and blood loss.
Plts
231
We need to know this value if we are giving Lovenox.
Cr
.97
We need to know this value if we are giving Lovenox.
MCHC
30.6
The value is low which is a sign of iron deficiency anemia.
RDW
14.7
The value is high which means there may be a Vitamin B12 deficiency.
(Laboratory Values: NCLEX-RN, n.d.)
CURRENT MEDICATIONS
MEDICATION
DOSAGE
PURPOSE FOR PATIENT
Bisacodyl (Dulcolax)
10 mg
Constipation
Acetiminophen (Tylenol)
650 mg Q6H
Mild pain
Gabapentin (Gralise)
200 mg TID
Neuropathic Pain
Docusate Sodium (Colace)
100 mg BID
Constipation
Enoxaparin (Lovenox)
30 mg SubQ q 12 hr
Prevention of DVT and PE after surgery
Metoprolol (Lopressor)
12.5 mg BID
Stable symptomatic heart failure, A Fib, Pulmonary hypertension
Senna (Ex Lax)
17.2 mg QHS
Constipation
Cyano-cobalamin (Vitamin B12)
1000 mcg daily
Low blood levels of Vitamin B12
Polyethylene Glycol (MiraLax)
I PKT daily
Constipation
Vitamin D
1 cap q 7 days
Low blood levels of vitamin D
Nalaxone (Narcan)
.4 mg IV push q 2 min PRN
Respiratory depression
Odansentron (Zofran)
4 mg IV push q 8 hr PRN
Prevention of nausea and vomiting
Oxycodone (Oxycontin)
2.5-5 mg PRN
Moderate to severe pain
(Lippincott Drug Advisor, n.d.)
Cultural Assessment
The patient is Italian, a culture that is described by Lippincott Advisor’s document ‘Italians,’ (n.d.) as generally seeing family closeness as being extremely important. Italian patients often wish to not be left alone, but to rather be surrounded by family and other loved ones who are expected to participate in care. Despite her Italian culture, the patient did not have a single visitor. When questioned about her family she expressed that they “don’t bother with her” and appeared to be distressed. The patient doesn’t live with anyone in her family, but instead with a roommate who she has admitted she does not like. It is likely that the lack of support from loved ones is contributing to the anxiety and depression that the patient is experiencing, especially given her culture’s beliefs and values pertaining to family.
It is crucial to consider the patient’s age of 91 when providing care and determining the best plan of care. Had someone younger withstood the same or similar injuries, it is likely the illness would be less severe with a much shorter course. At this age, given the diagnoses, pain management is the most crucial aspect of care. It is likely that the patient will not return to optimal health regardless of medical intervention.
The patient has a DNR order, meaning that if her heart stops or she stops breathing she does not wish for the high intensity interventions that would be required to save her. In cases where patients have a DNR order, it is important to consider what may have led them to this decision. The measures taken to keep a patient alive can result in multiple serious injuries. Especially at the age of 91, it is important to question what the quality of life would be after withstanding such injuries and whether or not the patient has much time left anyway. The patient expressed that her reasoning behind choosing to be DNR was because she ‘lived a long good life.’ A sad reality, however, is that the patient’s sadness, anxiety, and lack of a support system could be playing a part in her wishes to not be resuscitated.
Pathophysiology Discussion
As previously mentioned, the patient presented with multiple fractures including a fracture of the right tibial plateau, fracture of the right supracondylar humerus, and a nondisplaced comminuted fracture of the right patella. The patient presented with physical evidence of a fracture including abnormal movement or impaired function, tenderness and bruising at the fracture site, and pain. The body responds to injury with inflammation and this leads to tenderness at the fracture site. The bruising is due to the bursting of capillaries that occurs with injury. Furthermore, as explained by Whiteing in her article ‘Fractures: Pathophysiology, Treatment and Nursing Care,’ (2008) when bones break, movement looks and feels different due to pain and the new arrangement of bones. After there is an injury that causes a loss in bone continuity, the fracture site fills with blood and the broken part becomes necrotic. Bone building and resorption cells invade the blood clot. Ossification begins after 2 weeks, helping bone to regain mechanical strength. Remodeling takes place for a full year and sometimes lasts longer in the lower extremities. Depending on the severity of the trauma that caused the bone to break, there may be crushed muscles, ruptured blood vessels, torn ligaments or a contaminated wound as well.
According to Segers and Guiles in their article ‘Pathophysiology of Diastolic Dysfunction in Chronic Heart Failure,’ (2013) when a patient is experiencing heart failure, there is an inadequate amount of blood leaving the heart to the rest of the body. Since the patient has been diagnosed with diastolic heart failure, as opposed to systolic heart failure, there is an issue with the filling of the heart rather than the the pumping of blood out of the heart. Diastolic dysfunction is defined as ‘decreased left ventricular compliance or increased left ventricular end diastolic pressure resulting in impaired left ventricular filling (Segers and Guiles, 2013).’ There are several factors that can contribute to diastolic dysfunction. Arterial hypertension can lead to left ventricular hypertrophy, meaning there is less space in the left ventricle for blood to fill, hence less blood is leaving the heart as well. Constricted blood flow in the pulmonary vessels means that the heart is forced to work harder in order to circulate blood throughout the body. The increased work eventually leads to hypertrophy of the cardiac tissue because it is a muscle which grows with work. Valvular diseases also play a part in diastolic dysfunction as they can induce myocardial hypertrophy, left atrial dilation, or ventricular stiffness. A diagnosis of atrial fibrillation means that the heart is beating quickly, is quivering, and is not sending out all of the blood that it should be.
Atrial fibrillation can lead to heart failure which can lead to worsening atrial fibrillation. As explained by Cottrell in her article ‘Atrial Fibrillation Part 1: Pathophysiology,’ (2012) when tissue becomes thickened and scarred due to heart failure, there can be dysfunction of the electrical signals that help to control the heart’s rhythm. The atria contract (ejecting blood to the ventricles) when there is an impulse initiated on the heart’s natural pacemaker, the SA node. When atria are not triggered by the SA node but rather by signals from all over the atria the atria become uncoordinated and quiver. Atrial fibrillation may present itself as palpitations, shortness of breath, tiredness, irregular pulse, chest pain, or decompensated heart failure. On auscultation of the patient’s apical pulse, the beat was irregular. The patient complained of a racing heart and slept for most of the day.
The article ‘Pulmonary Hypertension’ (n.d) from the American Journal of Respiratory and Critical Care Medicine elaborates on how pulmonary hypertension has many mechanisms of disease. In this patient’s case, according to the article, it is likely that it is related to increased pressure in pulmonary vessels due to left sided heart failure. Failure of the left ventricular pump, left ventricular stiffness, and valve disease can all lead to pulmonary hypertension. When the heart is not pumping adequately, the blood is not moving in or out of the heart as quickly as it should be. While this causes circulation problems due to lack of blood flow, it also means that there is a back up of the blood that the body is attempting to move into the heart. This back up is what causes the increased pressure in the pulmonary vessels.
Having suffered blood loss as a result of trauma and surgery, the patient is suffering from acute blood loss anemia. In their article ‘Pathophysiology of Anemia and Nursing Care Implications,'(2008) Coyer and Lash discuss how a decrease in blood volume and red blood cells leads to hypovolemia of the cardiovascular system. The body compensates with hemodilution and moves fluid into the intravascular space, leading to a higher plasma volume and decreased concentration of cells and solids in the blood. With less red blood cells and increased intravascular fluid, the blood flow becomes quicker, placing pressure on the ventricles. This pressure can lead to heart valve dysfunction. Upon assessment, the patient had multiple symptoms consistent with a diagnosis of anemia; these included: petechiae, ecchymosis, anorexia, tachypnea, tachycardia, and ankle edema.
Nursing Diagnoses
The first and most important nursing diagnosis for this patient is acute pain related to movements of bone fragments, edema and injury to the soft tissue secondary to fractures as evidenced by reports of pain, facial mask of pain, and crying. This is the most pertinent nursing diagnosis because given the patient’s age and diagnoses, it is not likely that she will fully recover. With that being said, it is most important that the patient is comfortable and that her pain is managed. The goal is to get the patient to a place where she is able to manage the symptoms of her illnesses, and this can not happen if pain is not managed.
The next most important nursing diagnosis for this patient is hopelessness related to impaired functional abilities, prolonged discomfort, and abandonment as evidenced by social repression and decreased affect. The patient was visibly distraught and anxious throughout the day. Her health is deteriorating, she is in an abundance of pain, and she does not seem to have any sort of support system. As a result, she avoided social interaction as best she could and barely touched her breakfast and lunch. It is important to address the psychosocial effects of the illness because without doing so, adequate healing will not occur.
The last nursing diagnosis for this patient is impaired physical mobility secondary to injuries to right upper and lower extremities. The patient has grossly impaired mobility to the right side of her body. The right leg is immobilized and the right arm can be moved against gravity with pain, but not against resistance. With that being said, the patient is not able to bear any weight. She was only able to participate in physical therapy for a very short period of time due to inability to perform the exercises. Impaired mobility has a negative effect almost every body system. With that being said, improving the patient’s mobility could help to improve her overall health.
References
- Cottrell, C. (2012). Atrial fibrillation part 1: pathophysiology. Practice Nursing, 23(1), 16-21. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=104523760&site=ehost-live
- Coyer SM, & Lash AA. (2008). Pathophysiology of anemia and nursing care implications. MEDSURG Nursing, 17(2), 77-“91. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105746281&site=ehost-live
- Italians. (2016, November 4). Retrieved October 14, 2018, from https://advisor-lww- com.udel.idm.oclc.org/lna/document.do?bid=26&did=504241
- Laboratory Values: NCLEX-RN. (n.d.). Retrieved from https://www.registerednursing.org/nclex/laboratory-values/
- Lippincott Drug Advisor, from https://advisor-lww-com.udel.idm.oclc.org/lna/home.do?m=selection&selectedBookId=6
- Pulmonary Hypertension. (n.d.). American Journal of Respiratory and Critical Care Medicine.,175-184. Retrieved October 14, 2018, from https://www.thoracic.org/patients/patient-resources/breathing-in-america/resources/chapter-17-pulmonary-hypertension.pdf.
- Segers, V. F. (09/01/2013). Pathophysiology of diastolic dysfunction in chronic heart failure. Future Medicine
- Whiteing NL. (2008). Fractures: pathophysiology, treatment and nursing care. Nursing Standard, 23(2), 49-“58. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105676490&site=ehost-live