A Fracture from a Fall: What’s Going on Here? | Case Study

Updated | Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

A new case study in which a 77 yo white female arrives to the emergency room by taxi with a suspected skull fracture. This topic was suggested by a reader – thank you so much for your ideas – keep them coming!

You are reading page 2 of A Fracture from a Fall: What’s Going on Here? | Case Study. If you want to start from the beginning Go to First Page.

Ioreth, ADN, RN

Specializes in Ortho-Neuro. Has 3 years experience. 184 Posts

Patient stated she lives with her daughter and no others, but won't provide contact information. Is there anyone else who visits frequently, or even infrequently but has seen her recently?

I would go through some safety screening, questions like: 
What is your support system?
Do you feel safe in your home?
Do you have concerns regarding personal safety, shelter, food, finances?
Have you been the victim of abuse of any kind within the last 5 years?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

Follow up information:

  • aPTT: 12 seconds (10-13)
  • INR: 0.9 (below 1)
  • RBC 4.3 million (4.2-5.4 million/mcL)

The bleeding stopped after direct pressure was applied and the wound was cleaned and sutured.

This patient is dehydrated and malnourished, so your first thought is that dementia may be involved, but her Folstein Mini-Mental score is 29/30. She says, “There’s nothing wrong with me that a little bandage won’t fix.”

While you are waiting for someone to take her to radiology for an X-ray, you ask her about her nutrition and mention that she is dehydrated. She says, “My daughter takes good care of me. I just forget to eat and drink. I’m stupid like that.” When you ask her about the bruise on her left arm she says, “I fall all the time, I’m just clumsy” You then ask her about her arthritis and mention that there are medications that can help with the pain. The patient becomes increasingly agitated. She says, “My daughter will be home from work soon and she will wonder where I am. How long is this going to take?”

You reassure the patient, but her agitation increases. Just as she says, “I’m going to have to leave.” The technicians arrive to take her for an X-ray.

X-ray: frontal bone fracture that extends to the roof of the left orbit. A nondisplaced isolated anterior table fracture is confirmed. There is no sign of subdural hematoma.

After the X-ray, the physician informs the patient that nondisplaced or minimally displaced (< 1-2 mm) isolated anterior table fractures can be managed conservatively with local wound care and analgesics. Patients should be closely observed for signs of frontal sinusitis, which may indicate fracture involvement in the nasofrontal duct.

The patient says, “Just bandage me up the best you can. I have to get home before my daughter does.”

What should you do?

 

August Saunders, ADN, CNA, LPN

Specializes in MedSURG nurse. 4 Posts

First try again to educate the patient on what’s going on and why she needs to be monitored. Offer to call her daughter for her and explain what is going on and the importance of why she needs to be monitored (to the daughter). Or if the patient is adamant on leaving, possibly her daughter should be listed as her emergency contact, so go ahead and call anyways ??? Educate her on s/s of what to look for. Offer her daughter some assistance on hooking her up with case management (if possible) so she could get some services to help with her mom while she’s at work. 

 

nursej22, MSN, RN

Specializes in Public Health, TB. Has 37 years experience. 2,749 Posts

Hmm, the patient seems to be fearful of her daughter...

Was a full body exam done to look for other injuries, besides the bruise on her arm. 

lde

lde

Specializes in Student. 5 Posts

31 minutes ago, nursej22 said:

Hmm, the patient seems to be fearful of her daughter...

 Was a full body exam done to look for other injuries, besides the bruise on her arm. 

Yeah I agree. I would definitely probe that angle more as medically she seems reasonably stable apart from the poor nutrition and dehydration which hints at not having enough to eat and drink. The agitation each time the daughter is mentioned and the hurry to get home makes this more plausible.

I'd gently ask (and I don't know the best way) if she would like to speak to someone who is skilled with domestic violence cases. But that might get her more agitated. We can say we'll call the daughter and explain she is hurt and if she still resists there's definitely something up there. How does the patient react when we say its our duty to check for domestic violence issues?

Has she ever had similar injuries in the past? Who has helped out then? Also can we check for any other signs of Alzheimer's? (not sure that MMSE already covers this?)

Edited by lde

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 41 years experience. 4,295 Posts

I would ask: "Beside your daughter, what other family do you have?  Do any of them live locally?" 

How did the patient get to the hospital?  Can Adult Protective Services be called?

I would be very loath to send the patient home on her own.  Ideally she would be admitted for rehydration and further evaluation.

heron, ASN, RN

Specializes in Hospice. Has 50 years experience. 3,420 Posts

5 hours ago, nursej22 said:

Hmm, the patient seems to be fearful of her daughter...

Was a full body exam done to look for other injuries, besides the bruise on her arm. 

Yep! 

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 41 years experience. 4,295 Posts

And we still don't know what her head connected with to cause the fracture.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

1 minute ago, TriciaJ said:

And we still don't know what her head connected with to cause the laceration.

She says she hit her head on a rock when she fell.

nursej22, MSN, RN

Specializes in Public Health, TB. Has 37 years experience. 2,749 Posts

I know when I fall, I stretch out an hand to break my fall and protect my head. 

Ioreth, ADN, RN

Specializes in Ortho-Neuro. Has 3 years experience. 184 Posts

Red flags that I'm seeing:

"I'm so clumsy." Truly clumsy people don't say this. I've only known people to say this when they are trying to hide the source of their injuries.

"I was stupid to leave my rake in the yard." "I must have hit my head on a rock." I don't believe either of these for a minute.

"I need to get back before my daughter gets home." She doesn't even want her daughter to know that she sought healthcare. A prudent and reasonable family member would want to care for her mother and would want to be involved. Something hinky here.

Lakenan

Lakenan

Specializes in ER/Trauma. Has 14 years experience. 2 Posts

Order CK levels, Troponin and Lactic acid . Order CT head and neck. Orthostatic vitals after bleed r/o. Patient can legally be kept because she is a danger to herself in this condition. 

Edited by Lakenan