Surgical Nursing Student Question

Published

I am doing a case study on a hypertensive 82 year old patient who is disoriented, confused and short of breath and who had fallen on her hip the day previous. Her BP is currently 90/65, resps 24 and saO2 89%. She had an xray which showed a intertrochanteric femoral fracture. Her temp is 38.6 and her pulse is 140 and is complaining of SOB and is anxious. She is usually clear and alert.

Part of my study is to determine the possible causes for the high temp/high pulse, SOB and confusion. I suspect that she may have an infection and her confusion could be caused by that or the pain in her hip. Any more suggestions?

I also need to research what lab and diagnostic studies would be ordered prior to surgery. I have not yet worked with pre-op patients so I am not sure. I am thinking a urine analysis to determine a possible UTI, blood work to determine base sign values... any other tests?

Thanks again for any help or direction

Up Vote Up Vote ×

Here comes a bunch of us playing doctor!

My first thought wouldn't be UTI, but infection is more than likely the issue. Actually those symptoms all fall in line with sepsis ( ER has a sepsis flowchart/algorythm).

They'd still do a UA. Blood cultures x2. Lactic Acid for sure! ABG's.BMP, H&H. (Basically a full sepsis workup). The patient would probably end up in ICU. They'd figure that out based on labs/what not.

Up Vote Up Vote ×
Specializes in Adult Internal Medicine.

If maybe some fat broke off that fractured bone...

Up Vote Up Vote ×

All posters are incorrect thus far [EDIT: just looked at BostonFNP's post, can't assume everyone is incorrect anymore, my bad]...but not for a lack of trying...

Hypoxia and increased work of breathing can cause an elevation in body temperature, as can an active inflammation process, markedly so in the very old (your patient) and the very young...but that's not the most concerning about this scenario, so ignore this for now, lets dive in...

While I don't think this case study is actually trying to just give away an "infection" answer, I do believe that the correct process of elimination approach would mean you'd have to rule that out first. So don't be so quick to assume infection, but don't rule it out until you've got the labs/cultures to prove it, but keep in mind you can't conclusively dx an infection until the culture has been sent for at least 48-72hrs...

Your assignment is to, with the quick pt status information, 1. list off the possible causes of temperature elevation and heart rate increases, 2. Research and list diagnostic studies and lab you should expect pre-op...so let's do this.

1a. A few causes of temperature elevation/fever/pyrexia: immune response, failed thermoregulation, infectious process, inflammation process, thrombo-embolic process.

1b A few causes of increased heart rate: sympathetic response, anxiety, hypoxia, blood loss, fluid imbalance, electrolyte imbalance, increased metabolic demands, inflammatory response

1A&B as it r/t pt: Pt is 89 yo female disoriented, confused, short of breath, confirmed femoral (hint: long bone) fx from fall likely related to disorientation/confusion. Our pt is currently unstable r/t latest VS: BP 90/65 (concerning, but not my priority), Resp 24, sat 89% (emergency) temp 38.6 (still not my priority, but concerning), pulse of 140, definitely concerning, especially after combining that result with the others...pt is ACTIVELY COMPLAINING OF SHORTNESS OF BREATH AND ANXIETY.

What's my priority? Before even going ON to list the pre-op check list basics...

My patient is hyperventilating, and extremely hypoxic. Something is going terribly wrong....(posting this, continuing on another post)...

Up Vote Up Vote ×

The priority, before ANYTHING ELSE for this patient is to correct the oxygenation issue she is ailing from...but to do this, we have to figure out the CAUSE of her respiratory issue...

The pt scenario tells me that my pt is communicating her complaints, which means that her airway isn't probably compromised. She's telling me that she's short of breath and that she's anxious...these two symptoms are commonly paired, because when I can't breath, I'm anxious about suffocating, but actually, in THIS scenario, that anxiety clue is more significant....

What do we know about our pt's trauma? She broke what? She broke her femur. Only the sturdiest of human long bones. Oh no.

What risks are associated with long bone fracture? Oh Boston! I see your post...you were leading, great, sorry, you're on the right track...Boston wrote a really good hint....a long bone fracture is prone to throwing fat into the blood stream.

So without actually writing out the answer to where I'm leading you, let's just get you really close...

If pt's long bone fracture has been possibly throwing fat into the blood stream since the night before, when she broke it, and is now coming into the hospital confused, disoriented, and having trouble breathing, terrible oxygenation sats, and a panicked circulatory system, and is anxious...how could those problems/symptoms be related? What could be going on that would trump surgical prep 100% of the time?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I am doing a case study on a hypertensive 82 year old patient who is disoriented, confused and short of breath and who had fallen on her hip the day previous. Her BP is currently 90/65, resps 24 and saO2 89%. She had an xray which showed a intertrochanteric femoral fracture. Her temp is 38.6 and her pulse is 140 and is complaining of SOB and is anxious. She is usually clear and alert.

Part of my study is to determine the possible causes for the high temp/high pulse, SOB and confusion. I suspect that she may have an infection and her confusion could be caused by that or the pain in her hip. Any more suggestions?

I also need to research what lab and diagnostic studies would be ordered prior to surgery. I have not yet worked with pre-op patients so I am not sure. I am thinking a urine analysis to determine a possible UTI, blood work to determine base sign values... any other tests?

Thanks again for any help or direction

You have gotten good advice. Use your critical thinking skills

First what is a intertrochanteric femoral fracture? What complications can arise from this kind of LONG BONE FRACTURE? What is a common complication that presents after TRAUMA and long bone fracture that causes tachypnea, hypoxia, hypotension, tachycardia? Can hypoxia cause confusion?

Fat Embolism Syndrome | Doctor | Patient.co.uk

Hip Fractures-OrthoInfo - AAOS

What are typical tests ordered per-operatively on elderly patients..... Hip Fractures-OrthoInfo - AAOS What would be important to know? Your patient is HYPOXIC!!! What lab do you want to do to check the arterial blood for oxygenation? What would you want to see to check the heart rhythm/tachycardia?

Now tell us what you think and we will help you further.

Up Vote Up Vote ×
Specializes in Hospital Education Coordinator.

so many possibles. Fat embolism, dehydration (might also explain BP & fever). Looks like you have some research to do. Good luck!

Up Vote Up Vote ×

I just want to say thank you! I did a lot of research and finally came across the complications associated with long bone fractures...fat embolism. She was presenting with all the S&S. However, the most helpful posts here for me were the ones that broke down the issues and made me critically think about which symptoms I needed to address first and work backwards. You cant always assume fever = infection and I am starting to see that now. Thank you so much again and I really appreciate you guys taking the time to help me problem solve this.

Up Vote Up Vote ×
Specializes in Family Nurse Practitioner.

Embolus was first thought...especially with the fracture. She is SOB, Spo2 is dropping, confused, pulse is up, temp is up...it fits. http://emedicine.medscape.com/article/300901-overview

Oh...now I see that you found your answer...

Up Vote Up Vote ×
+ Join the Discussion