Need Help With My Clinical Simulation

[chall2011]

I'm a first year student and need a little assistance with this clinical simulation project that I'm supposed to do. There are 3 others in my group and I just had to post this to make sure we did it right. I'm almost positive theres stuff we left out.

Heres what we have to do. Theres 4 of us all together and we all have specific roles. One is going to be the nurse practicioner (me), another the nursing studnent, another the assigned nurse, and the other the family member of the patient.

Our simulation is fairly straight forward and easy. A 45 year old female is assisted into the ED by wheelchair. She suffered a fall while walking up an icy staircase and injured her left lower leg. She unable to bear weight. Past medical history is insignificant and she takes no medications and has no allergies. She's admitted and the nurse practcianer orders X-rays, ice to left leg, and 5 mg IM of morphine.

Were supposed to clinically simulate this simulation and what we would do. We told our teacher that we would get the xrays bakc and there was a slight tibia fracture. She said that was fine.

How would the ED handle this patient? Specifically what would the nurse and NP being doing? Were going to have the nurse delegate vitals to to the nursing studnet since her scope of practice is limited. Were also goign to have the nurse vocalize her assessment (this will be a focused assessment for example) and teach/explain why she is doing what she is doing. Another thing we had trouble with was wondering if the pt would be casted or not in the ED. Its a slight fx but does a orthopedist still need to be consulted? Please help us...we need these points :).

-Future nurse

[chall2011]

O and since the woman is in menopause age we were going to r/o osteoporosis so the np was going to have labs ordered for these during our simulation. What labs besides electrolytes and bone density would be pertinent?

[BostonFNP, APRN]

You have a great start.

Vitals first, can be delegated to student.

Nurse/NP should be gathering a symptom analysis, history (remember to ask about meds and allergies), and doing a focus assessment including respiratory, cardiac, and neuro in addition to MS. Nurse should be monitoring the patient and communicating to the NP as well as formulating nursing dx and a plan of care. NP should be working through the differentials for a fall (remember to include both the potential fracture/trauma from the fall

as well the underlying cause such as orthostatic hypotension, syncope, vertigo, etc). Hope that helps you, good start.

[nurseprnRN, BSN, RN]

what needs to happen when ortho has casted her (yep), she's had repeat films to check alignment, and her cast is good to go? does she know how to crutch walk, and if not, who teaches her?

what does she need to know about self-care at home? (check your m/s text for cast care and pt teaching)

how will she get into her home, around inside it, bathe, shower...?

[Esme12, ASN, BSN, RN]

Tibial fractures, which are infrequently life threatening but are often life changing. The focus is on the continuum of care, starting with the mechanism of injury, classification of the tibial fracture and soft tissue involvement, approaches to stabilization and treatment options, postoperative care, potential complications, and considerations to discharge preparation. The parameters of nursing care extend to pain relief and positioning, nerve and vascular assessments, safe mobility, self-care, and prevention of complications.

Tibia Fractures: An Overview of Evaluation and Treatment

Tibial Shaft Fractures Treatment & Management

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to monitor closely for compartment syndrome.

Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling. Early ambulation with weightbearing as tolerated should be encouraged. Tibial shaft fractures treated with casting must be monitored closely with frequent radiographs to ensure that the fracture has maintained adequate alignment. Adequate callus formation generally takes 6-8 weeks before cast therapy can be discontinued.

Medscape: Medscape Access requires registration but is free.

Assessment like any other patient. Vital signs.Pain assesment. Any consurrent/distracting injuries.Mechanismof injury. CSM of extremity. Is the fracture open or closed. There are 4 tibial plateu fractures......

http://www.brighamandwomens.org/Patients_Visitors/pcs/rehabilitationservices/Physical Therapy Standards of Care and Protocols/Knee - Tibia plateau fracture the care will vary according to the fracture.

Actual tibial fractures are classified as follows.......

Emergent treatment would not include checking for osteoporisis unless it showed on the x-ray of the ankle. Labs will focus around whether or not there is going to be a surgical intervention. Checking for pregancy prior to radiology is important.

Assess the patient on arrival. ABC's. Check CSM of extremity. Is the fracture open? Is there obvious deformity? What was the mechanism of injury? Are there any other injuries? What is the capillary refill of the affected exgtremily? What meds are they on? Allergies? Last time the patient ate......in case of surgicalintervention. Application of posterior mold fiberglass splint. RICE.....rest, ice, compress, elevate. Assure alignment until splint applied.

Don't forget discharge care. CSM checks @ home what to look for, Cast care, crutch walking.....followup.

I think this will help.

[psu_213, BSN, RN]

Part of it depends on what "slight" means, and, to be honest, I'm not entirely sure at what point the fracture would require admission and/or surgery versus being discharged. The only things I would add...might as well start an IV on this pt...most likely she will need more pain control that just one IM shot.

In our ER, ortho would be consulted and they would "direct" the care. More than likely, she would be "splinted"--we have fiberglass to make splints and they are made/applied by the RN or, in some cases, the MD. Whether or not she is admitted will depend on her pain control and her ability to get around with crutches. Given that the pt is 45, there is a good chance she will be discharged home with a f/u with an orthopedic surgeon in a few days....however each case is different and that was only based on here age, not on individual circumstances of the case.

[nurseprnRN, BSN, RN]

waitaminnit....didn't i just see this somewhere else? i did, i remember, i posted something on it.

[Esme12, ASN, BSN, RN]

It's in nursing student assistance.....I posted there as well.

[TheCommuter, BSN, RN]

Both of the OP's threads have been merged into one single discussion.