Case study

Herzing University

NU 302: Adult Health II

Professor Barb Katchmar

July 13, 2021

Introduction Comment by Katchmar, Barb: This should be the same as the title of your paper and should start with number 1. No numbers on page one, Great opening!

Mrs. Damarae is a 77-year-old widowed black American female. Patient reports no known allergies. Patient states she lives alone and has one daughter. She presents to the emergency department after slipping on ice and falling onto her right hip. Patient has been admitted onto the floor status post fall. Physical exam shows bruising to right hip, right leg is shorter than the left leg and right leg is externally rotated. An X- ray was ordered and results show extracapsular fracture of the trochanter region of the right hip.

Patient History Comment by Katchmar, Barb: Great section!

Mrs. Damarae has a medical history of osteoporosis and type 2 diabetes mellitus. She has a 30 pack-year smoking history. Patient is a current smoker and reports no desire to stop smoking. Patient reports a family history of breast cancer and type 2 diabetes. She states both parents had type two diabetes and reports her mother passed of metastatic breast cancer in 1995. Patient reports surgical history of a cesarean section. She states her current medications are metformin and alendronate sodium (Fosamax).

Pathophysiology

Osteoporosis is a disease described by low bone mass and weakening of the bones. Comment by Katchmar, Barb: Great information but you needed to tie in the hip fracture to the osteoporosis. I can tell you did great research on this section

Osteoporosis occurs when the bone formation, resorption and remodeling is interrupted (Huether et al., 2016). Osteoclasts are a type of bone cells that work on reabsorbing bone. Ibrahim et al. (2020), explains that insufficient bone development is caused by large activation of osteoclasts in response to the hematopoietic precursor cells. This produces excessive bone reabsorption that results in loss of new bone formation and trabecular structure of the bone (IbrIahim et al., 2020). Osteoblastic replacement takes longer in the resorption phase causing an increase in bone remodeling which leads to damage in bone building and affects loss of bone mass (IbrIahim et al., 2020). The osteoclast variation pathway fluctuates depending on proliferation, maturation, fusion, and activation (Huether et al., 2016). Also, the pathway is reliant on hormones, cytokines, and paracrine stromal cell processes (Huether et al., 2016).

Type 2 diabetes mellitus is characterized as insulin resistance in response to the deviation of the insulin molecule, down regulation of insulin receptor, high amounts of insulin antagonists, and variation of glucose transporter (GLUT) proteins (Huether et al., 2016). In response to genetic predisposition, obesity or lifestyle factors, hyperinsulinemia develops which leads to beta-cell dysfunction and as a result creates deficiency in insulin dysfunction. Blood sugar is increased due to a rise in glucagon because of pancreatic alpha cells being less responsive to glucose inhibition (Huether et al., 2016). Amylin and ghrelin are decreased, thus resulting in insulin resistance and an increase in fasting insulin levels. Heuther et al. (2016), explains that the kidneys also influence type 2 diabetes as they play an important role in renal reabsorption of glucose through the sodium-glucose cotransporter 2 (SGLT2) as they control serum glucose levels and new medications aimed at blocking it. As a result, this causes a decrease in blood glucose levels, weight, and blood pressure (Huether et al., 2016).

Nursing Assessment Comment by Katchmar, Barb: Fantastic assessment

Allergies: No known drug allergy. No known environmental allergy. No known food allergy.

HEENT: Head symmetrical, head full of hair, hearing intact, PERRLA: pupils are equal, round, reactive to light bilaterally, nose symmetrical, teeth present, tooth decay noted, oral mucosa pink and moist.

Nuero : Alert and oriented to person, time, place and situation, Glasgow coma score (GCS)= 15, patient cooperative with care but noted restless. Comment by Katchmar, Barb: typo

Integumentary: Skin is intact, skin tone appropriate to ethnicity, dark discoloration noted on right hip due to fall, skin is warm to touch and dry, mucus membranes are moist and intact, skin turgor normal, no tenting of the skin noted.

Vital Signs: Blood pressure 155/76, pulse 103, respirations 22, temperature 98.9 F, SP02 94% (room air), Pain assessment: 6 out of 10 on numeric pain scale, pain reported to right hip.

Respiratory: Lung sounds clear bilaterally, respirations normal, non-labored breathing.

Cardiovascular: S1, S2 heart tones, no murmur auscultated.

Musculoskeletal: +2 pulses to left upper extremity (LUE), right upper extremity (RUE) and left lower extremity (LLE), +1 pulse right lower extremity (RLE). +1 pitting edema noted to RLE. Capillary refill <3 seconds (LUE, RUE, LLE RLE).

GI: Bowel sounds present and active x 4 quadrants, no abdominal distention, last bowel movement 7/10/21.

GU: Foley catheter 16 Fr, catheter patent and draining clear, yellow urine, urine output 500 mL.

Vascular Access: 18G PIV to left forearm, IV patent, no redness, warmth, or drainage noted to IV site, IV dressing is intact and dry, IV fluids 0.9 NS at 100 mL/hr, morphine 1 mg IV push every 4 hours as needed for pain.

Diagnostics

The diagnostic testing used to visualize Mrs. Damarae’s hip fracture include anterior/posterior lateral hip and femur X-rays. Additionally, a chest X-ray was ordered to help rule out underlying disease and it is necessary in pre-operative clearance. EKG was ordered to evaluate the electrical signals in the heart and to assess the heart prior to surgery. Gil et al. (2020), explains that computed tomography (CT) scan can be used to assess osseous anatomy but not preferred due to further radiation exposure and has the potential to miss hip fractures, particularly in the geriatric population. Magnetic resonance imaging (MRI) is preferred in diagnosing hip fractures because it reveals bone marrow edema without exposing the patient to radiation (Gil et al., 2020).

Labs Comment by Katchmar, Barb: great thinking ahead. If the patient is going to need surgery they are definitely going to need a type and cross

A complete blood count (CBC) with differential was ordered and is important as it allows the health care provider to assess white blood cells (WBC), hemoglobin and platelet count. A comprehensive metabolic panel (CMP) was ordered to assess the patient’s chemical balance, electrolytes, and metabolism. Prothrombin time (PT) and partial thromboplastin time (PTT) was also ordered to assess blood coagulation and bleeding disorders if any. A type and screen was ordered to determine Mrs. Damerae’s blood type in the event she would require a blood transfusion. All the laboratory studies mentioned are used to help determine Mrs. Damerae’s current medical condition and to prepare her for pre-operative evaluation for open reduction of the fracture and internal fixation (ORIF) surgery.

Related treatments Comment by Katchmar, Barb: great info

Upon Mrs. Damerae’s arrival to the emergency department (ED), her right hip was placed in an immobilizer, she was started on IV fluids 0.9 NS at 100 mL/hr and given morphine 1 mg IV push every 4 hours as needed for pain. Labs were drawn, diagnostic testing completed per MD orders. Orthopedic surgeon was consulted after confirmation of right hip fracture. History, physical and surgical risk assessment done by MD. Patient cleared for ORIF surgery the next morning. Nursing is to check vital signs as ordered. Foley catheter inserted per MD orders in preparation for surgery, intake and output every 4 hours. Circulation, motion, and sensation (CMS) checks every 4 hours to bilateral lower extremities (BLE). Nursing to hold all drugs as ordered by MD in anticipation of planned surgery. Nursing is to notify operating room (OR) of upcoming surgery when appropriate.

Conclusion

The case study reviewed analyzed a right hip fracture to patient known as Mrs. Damarae. She is a 77-year-old widowed black American female who presented to the ED after slipping on ice and falling onto her right hip. Ramponi et al. (2018), states 80% of hip fractures occur in women with an average age of 80 years old, due to a fall-related injury. Hip fractures are linked with increased mortality, 12%17% of patients with hip fractures die within the first year (Ramponi et al., 2018). Hip fractures are common injuries in the elderly population, notably in women who have a history of osteoporosis and multiple comorbidities. Comment by Katchmar, Barb: Loved the paper! The flow was fantastic and I can see you researched this well. The only thing I would have added would be risk factors

References

Gil, H., Tuttle, A. A., Dean, L. A., Johnson, D. A., Portelli, D., Baird, J., & Raukar, N. P. (2020). Dedicated

MRI in the emergency department to expedite diagnostic management of hip fracture.

Emergency Radiology, 27(1), 41-44. doi: 10.1007/s10140-019-01729-5

Huether, S. E., & McCance, K. L. (2016). Understanding Pathophysiology (6th Edition). Elsevier Health

Sciences (US). https://ambassadored.vitalsource.com/books/9780323354097

Ibrahim, N., Nabil, N., & Ghaleb, S. (2019). Pathophysiology of the risk factors associated with

osteoporosis and their correlation to the T-score value in patients with osteopenia and osteoporosis in the united arab emirates. Journal of Pharmacy and Bioallied Sciences, 11(4), 364-

372. doi: 10.4103/jpbs.JPBS_4_19

Ramponi, D., & Kaufmann, J. (2018). Hip Fractures. Advanced Emergency Nursing Journal, 40, 8-15. doi:

10.1097/TME.0000000000000180