Assessment of the Musculoskeletal System and Pain
Assessment of the Musculoskeletal System and Pain
Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a slight rotation of his right leg.
Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.
Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.
After reviewing the above scenario please answer the following questions.
Based on the information provided, how will you prioritize your care, what assessments will you include and in what order? Please provide rationale for your response.
Considering this patient’s age, injury, past medical history, and list of current medications, what, if any, concerns do you have related to his potential need for surgery?
Should surgery to repair his right femur be required; what type of clearance and pre-op orders would you anticipate receiving related to his diet, meds, lab work, and so on?
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Upon meeting and introducing myself to Fred I would obtain a set of vital signs and do a complete head to toe assessment on him focusing a little more on his right side due to the injury report and paying attention to what his blood pressure reading is due to the fact he is on Lopressor for hypertension. I would ask him since he is alert and oriented if anything precipitated his fall such as did he become dizzy, lightheaded, or just lose his balance seeing that he is a diabetic and on two blood pressure medications (Lopressor & Lisinopril) that he could have become hypoglycemic or hypotensive. The report states he is very bruised from his fall most likely related to the ASA and Plavix he takes, both which interfere with the clotting process, so I would assess him for any hematoma formations that might not have been apparent when in the ER or cuts or scrapes that may need to be treated. I would also ask if he hit his head during the fall because I would be concerned about a possibility of a subdural hematoma formation and would want to obtain a CT of the head to rule that out. I would make sure that his right leg is immobilized in the position of the injury as not to move it causing increased damage or pain. I would then check his femoral, popliteal and pedal pulses and compare making sure his rotation of the right leg is not affecting blood flow to the extremity also checking for coolness or mottling/cyanosis of the extremity. He already has A PMH of PVD and bilateral iliac stents which is indicative of poor circulation previously and I would ask him if he is having any numbness, tingling or loss of sensation to his RLE. Swelling of the affected extremity may be due to internal bleeding and would need to be monitored again with his increased risk due to blood thinners. Also noting if the injured extremity is visually shorter than the uninjured one which occurs in fractures (www.medtrng.net). He is rating his pain scale as a 6 on a scale of 1-10 so I would check the standing orders from the ER to see if I could give him something else IV for pain. I would not want to give him any oral pain medication to maintain his NPO status for impending surgery on his right hip. After making him as comfortable as possible I would ask him the last time he ate or drank so I know moving forward if that would possibly delay surgery and remind him that he cannot eat or drink anything by mouth even if brought in by his wife. I would check a current blood sugar reading to see if he is within parameters seeing that he may be NPO for some time and if low consult the physician. If surgery may not be scheduled for some time we may be able to at least provide him with clear liquids or potentially switch his IVF over to D5 ½ NSS to assist with elevating his blood glucose level until able to eat post-surgery.
I would then go and review the chart to see what tests had been ordered in the ER, review the radiology report on his right leg/hip and check his lab values that were drawn in the ER. Seeing that he will most likely be a surgical candidate I would make sure that a baseline CBC, Chem 7 panel, and PT/PTT/INR was ordered, this would be needed prior to surgery and to check his bleeding time. Seeing that Plavix is usually recommended to be held 7-10 days prior to surgery which is unrealistic in this case we may need to administer Vitamin K IV or fresh frozen plasma to assist with returning his levels to an acceptable number which is usually < 2.0 for surgery (labtestsonline.org). With Fred’s age and cardiac history, I would be concerned about his ability to handle this type of surgery, which places added stress on the heart. He may also have difficulty due to poor circulation, liver & kidney function metabolizing anesthesia medications out of his system related to his age and decreased lung function lending itself to increase difficulty extubating him post-surgery. Fred also suffers from sleep apnea this “condition makes anesthesia riskier because it slows down breathing and can make you more sensitive to its effects. Sleep apnea also can make it more difficult to regain consciousness and take a breath after surgery” (www.asahq.org (Links to an external site.)Links to an external site.). An anesthesia consult would be beneficial to possibly see if he is a candidate for the administration of a spinal block instead due to all his predisposing factors. Fred may also be at risk for formation of an embolism due to his immobility and fracture. “A femur fracture may cause blood clots to form within the large veins of the thigh. If these clots break free and travel through the bloodstream, they may eventually lodge in the lungs, creating a life-threatening condition called a pulmonary embolism” (www.health.harvard.edu).
Prior to surgery, I would expect him to be NPO for a minimum of 8-hours pre-surgery, his medications will be held except for his blood pressure medications which can be given with small sips of water as indicated by anesthesia. Most prefer the patient to receive their blood pressure medications to help with better control intra-operatively. A cardiac consult would need to be obtained along with an EKG for comparison related to his cardiac history of two previous MI’s. If indicated a medication-induced cardiac stress test may be required as well for further evaluation prior to surgery. A CXR is a normal protocol for a patient over the age of 50 and typically medical clearance from his attending PCP is required as well. A repeat FBS and PT/PTT/INR should be ordered for the morning of surgery as well as any other lab values that were out of normal parameters on admission.
References
https://labtestsonline.org/tests/prothrombin-time-…
https://www.asahq.org/whensecondscount/preparing-f…
https://www.health.harvard.edu/a_to_z/leg-fracture-
https://www.medtrng.net/efmb/tasks/081-833-0064.ht…
Kim
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