Miss Rosemary Wood id a 92-year-old women who lives in her own home. She has assistance from her local church members who provides her with a cleaner once a week for 2 hours, and a gardener once a week for one hour. She still cooks her own meals but does not eat very much, (she tells her PCP that her terrier dog eats more than she does). She walks with a walking stick and still manages to walk around the block with the dog once a day, with some degree of pain in the calf. The pain ceases when she rests. She does not drive and prefers to take a taxi to do her shopping or to go to the doctor. She talks weekly with her only relative- a niece, who lives one hour away.
Miss Wood has a history of atrial fibrillation, rheumatoid arthritis, type II diabetic, osteoporosis and chronic venous insufficiency. She currently has a 2cm ulcer on the top of her left foot, and one on her left big toe which a nurse has taught her to dress. Miss Wood’s medications are digoxin, warfarin, ibuprofen, and cilostazol (Pletal). She has a regular bi-weekly appointment with her PCP, at which he checks her INR and monitors her falls risk.
1. What would be the wound management of choice for Miss Wood’s leg ulcer?
A. Dry dressing
B. Betadine and leave open to air
C. Barrier cream and transparent film
D. Hydrocolloid dressing
2. Poor circulation can result in tissue damage for patients with peripheral arterial disease. Identify three important teaching tips and the rationales that will help prevent complications for Miss Wood.
Teaching Tip
Rationale
3. International Normalized Ratio (INR) is a test that measures blood coagulation and used to monitor warfarin therapeutic levels. What is the expected therapeutic range for Miss Wood?
A. 0.2-0.5
B. 2.0-3.0
C. 20-30
D. 14-20
4. What is the antidote for warfarin (Coumadin)? _______________________________
Miss Wood has begun to lose weight recently. She now weighs 102 pounds and is 4’9” in height. The PCP refers Miss Wood to a dietitian. The dietician fully assesses Miss Wood and finds that she eats a plain piece of toast with for breakfast, drinks a cup of soup made with a stock cube for lunch, and generally makes a cheese and tomato sandwich for her evening meal. She examines Miss Wood’s mouth and finds she has multiple ulcers on her gums and upper palate. Also, her dentures are ill-fitting. A dental appointment is made for Miss Wood and she is encouraged to purchase and drink nutritional supplements.
5. Based on this information, what dietary guidelines are appropriate for Miss Wood and why?
6. What other measures would the nurse have recommended to manage Miss Wood’s leg ulcers?
A. Adopt a program to increase distance walked, take 2 aspirin daily and decrease salt intake.
B. Rest in bed for two weeks, apply lanoline to flaky skin and discontinue warfarin.
C. Dangle both feet over the bed while sitting, wear warm socks, and keep room as warm as possible.
D. Take dressings off before applying heating pad at night for warmth.
Miss Wood enjoys the community nurse visits and she has been feeling better, having been drinking the supplements for one month. She has continued to walk around the block each afternoon. One day, as she was walking, she tripped on a loose piece of concreate in the footpath. She fell to the ground and immediately felt intense pain in her right hip area. The pain was so great that she could not move.
A man riding his bicycle stopped to assist. Miss Wood told him how much pain she was in and he could see that the left leg was longer than the right. He immediately called 911 and requested an ambulance. The call center asked if she was conscious and urged the man not to move Miss Wood and to wait with her until the ambulance arrived.
7. Why did the man state Miss Wood’s left leg was longer than the right? What anatomical findings are consistent with hip fractures?
Miss Wood was taken to the nearest emergency department, where she underwent primary and secondary assessments, insertion of an intravenous catheter, pain relief, blood tests, and radiological exams. The nursing staff contacted Miss Wood’s closet relative, her niece, and informed her that Miss Wood has suffered a fractured right hip of the head and neck of the right trochanter and would require surgery.
8. Why did the call center urge the bystander not to move Miss Wood?
A. Given the location of the fall, it was best to keep her there so that the ambulance team can see where she fell and document a more thorough history.
B. She may have hit her head. If she tries to get up she may feel dizzy and fall again.
C. Given the location and the symptoms, they would suspect a fractured hip. This is prone to vascular disruption and so moving Miss Wood incorrectly might cause permanent damage.
D. This would be the best location for the ambulance to load the patient.
9. After taking over care from the paramedics you perform a neurovascular assessment including the 6 P’s. Identify and explain the rationale for each ‘P’.
1.
2.
3.
4.
5.
6.
Miss Wood had been maintaining better nutrition, thanks to the supplements and new dentures. Her chemistries (BMP) and her complete blood count (CBC) were within normal limits and so it was decided that she would be fit to undergo surgery in the next 12 hours. Early surgery is preferable to treat hip fractures. She had been taking warfarin, so the anesthesiologist administered the antagonist to reverse the anticoagulation effects of warfarin. Miss Wood underwent an open reduction and internal fixation of the right hip.
Postoperatively, the nurse monitored Miss Wood’s vital signs, including pain score, IV fluids, urine output through an indwelling urinary catheter, deep breathing and coughing, and observation of surgical dressing for signs of bleeding and infection. The nurse also monitors the neurovascular status of Miss Wood’s leg through observation and documentation of the leg. Attention was paid to proper alignment of the leg, including the use of an abductor pillow between the legs.
10. Identify three complications could occur post-operatively for Mrs. Wood and what findings would you be on alert for if these complications were to occur?
Complication that could occur……
Three findings (each) to be on alert for….
Two nights after the operation, Miss Wood becomes agitated, pulling at her IV, trying to roll over and screaming, “I need to get out of bed now!” The nurse checks the urine catheter to ensure it was not blocked and the catheter was patent. The provider was called and concerned about postoperative delirium. Postoperative delirium is a reversible mental health condition that is common in the elderly population, anesthesia, and narcotics.
11. Other things could also cause Miss Wood’s delirium. Which of the following could cause Miss Wood to become confused? (Select all that apply)
A. infected leg ulcer
B. urinary tract infection
C. anesthesia drugs
D. pain medications
E. low blood sugar
F. history of alcohol abuse
She was given IV antibiotics. The delirium got better after a few days. Fall precautions were placed on Miss Wood and the multidisciplinary team decided she will be sent to a rehabilitation center for physical therapy. Miss Wood is not able to care for herself in her current postoperative state and she is not happy about this decision. Miss Wood is concerned about her dog and she wants to go home.
12. Identify the members of the multidisciplinary team who will facilitate this transition.