Scenario

M.C., an 82-year-old widow, arrived by ambulance to the emergency department. Because the
weather had turned icy and snowy, M.C.’s daughter had not been able to check on her in the last
24 hours, and M.C. was not answering her phone. M.C.’s daughter found her lying on the patio,
incontinent of urine and stool, with complaints of (C/O) pain in her right hip.
Her daughter reports a past medical history (PMH) of hypertension (HTN), angina, and
osteoporosis. M.C. takes propranolol (Inderal), nitroglycerin patch, indapamide (Lozol), and Evista
(raloxifene). The daughter reports that her mother is normally very alert and lives independently.
On examination you see an elderly woman, approximately, 100 pounds, holding her right thigh.
You note shortening of the right leg with external rotation and a large amount of swelling at the
proximal thigh and right hip. M.C. is oriented to person only and is confused about place and time.
M.C.’s vital signs (VS) are 96.0° F, 120, 24, 90/65, with pain 8 out of 10, her Sp O2 is 89%. She has
tenting skin turgor, and dry mucous membranes. Her skin is cool to touch. She has a 10 cm x 3 cm
lesion on the prone aspect of her right forearm. The wound has jagged edges, with dried
sanguineous drainage covering the majority of the lesion. Preliminary diagnosis is fracture of the
right hip. The doctor’s orders include continuing M.C.’s home medications. In addition, the doctor
has ordered prn medications for pain including hydrocodone-acetaminophen (Lortab) for severe
pain, tramadol for moderate pain, and acetaminophen for mild pain.

1. In view of the fact that MC has been exposed to frigid elements and has been without her
medications for at least 24 hours, explain her current vital signs.
a. Temperature
b. Pulse
c. Respirations
d. Blood Pressure
e. Pain

2. Based on her history and your initial assessment, identify and prioritize three (3) nursing
diagnoses.
RT AEB
(patient problem) (medical diagnosis or condition) (patient. signs/symptoms)

(patient. signs/symptoms)

(patient. signs/symptoms)

RT AEB
(patient problem) (medical diagnosis or condition) (patient. signs/symptoms)

(patient. signs/symptoms)

(patient. signs/symptoms)
 RT AEB
(patient problem) (medical diagnosis or condition) (patient. signs/symptoms)

(patient. signs/symptoms)

(patient. signs/symptoms)

3. Using the medication administration form on eCollege, complete this form for M.C.’s
scheduled and prn medications.

4. To evaluate M.C.’s condition, a laboratory study that will be drawn is a complete blood count
(CBC). Give rationale why this lab was ordered.

5. Using one of the nursing diagnoses listed in #2, complete a written nursing process using
the written nursing process form found on eCollege.

6. Bonus question: In evaluating M.C.’s pulses, you find her posterior tibial pulse and dorsalis
pedis pulse to be weaker on her right foot than on her left. What could be a possible cause
of this finding?

Case Study Progresses

X-ray films confirm the diagnosis of intertrochanteric femoral fracture. The Open Reduction and
Internal Fixation (ORIF) was performed, and M.C. is now 2 days post surgery. She usually rates
her pain as 5 out of 10, and receives pain medication every 4 hours. This morning M.C. was placed
on prophylactic warfarin In addition to the use of foot pumps and a hip abductor pillow, M.C. has
incision and wound dressing changes ordered every 24 hours and prn.

Your morning assessment of M.C. includes the following:

 Skin turgor is elastic

 Skin is warm, dry and intact except for the wound on her right forearm, and the right hip
incision.
 The right hip incision has approximated edges that are slightly red and edematous, with
surgical staples intact, and no drainage, warmth or pain.
 The right forearm dressing was changed 24 hours ago. During your assessment, you note
there is a 5cm area with drainage that has seeped through the entire thickness of the
dressing. Upon removing the dressing, you note a moderate amount of white, malodorous,
purulent drainage on the internal aspect of the dressing. The wound has swelling and
edema extending 3 cm around the perimeter of the wound, and. M.C. complains of
throbbing pain, 6 out of 10 at the site. The wound area is very warm to touch.
 Decreased bowel sounds, and reports no BM since her injury

7. Given the findings of your morning assessment of M.C., what are your nursing priorities?
8. Why are SCDs contraindicated for M.C.?

9. What medications may be contributing to the decreased bowel sounds and lack of bowel
movement? What nursing interventions will address this problem?

10. Bonus question: Because M.C. has been started on warfarin, what side effects should be
monitored? (including physical assessment and lab findings)