Mrs. Olsen is a 72-year-old white woman

Mrs. Olsen is a 72-year-old white woman who resides at Shady Oaks Care Center. She fell today and could not get up again because of the pain. An x-ray examination obtained at the nursing home showed a proximal femoral fracture near the right hip joint. She has been transferred to your hospital for a preoperative medical evaluation in preparation for possible surgical repair of her right hip fracture later today. Mrs. Olsen has a history of a meningioma, which has been resected three times. Two days ago, she had an episode of apparent dysfunction of the left upper and lower extremities associated with a period of hypertension and agitation, all of which resolved within 24 hours. Mrs. Olsen also has a history of deep vein thromosis (DVT) following one of her surgical procedures, but she is not receiving ong-term anticoagulation therapy. Selected Admission Laboratory Values RBC: 3.76 million/mm3 Hb: 11.7 g/dl Hct: 34% WBC: 10,200/mm3 Sodium: 141 mEq/L Potassium: 4.3 mEq/L Chloride: 101 mEq/L CO2: 22 mEq/L Glucose: 157 mg/dl ABO/Rh type: O Phenytoin level: 7.6 g/m Nursing Physical Examination Height: 5 feet, 6 inches Weight: 135 lb (61.4 kg) Vital signs: BP 170/90; TPR 99.6, 102, 22 LOC: Awake, alert, slightly confused; daughter states that her mother is asking in Danish where she is and what happened EENT: PERRLA; evidence of cranial surgical scars on right frontal region; slight left facial droop; hand grasps equal Cardiac: Regular rate and rhythm without gallop or murmur Pulmonary: Clear bilaterally Abdominal: Soft, nontender, active bowel sounds Genitourinary: Foley catheter inserted in ED draining clear yellow urine Peripheral pulses: 3/4 without edema, some shortening of right lower extremity Initial Treatment Plan Medications Phenytoin (Dilantin) 200 mg PO or IV bid IV: D 5LR TKO Diet: NPO Activity: Bed rest with mattress overlay and trapeze Additional assessments: Vital signs, neurologic checks, and neurovascular assessment checks q 4 hr Treatment: Ice to right hip continuously Diagnostic tests: CT scan of head Mrs. Olsen’s CT scan revealed no further progression of her meningioma. She successfully underwent surgery for endoprosthetic replacement of the right proximal femur. Postoperatively, the surgeon orders the following: Advance diet as tolerated Soft wrist and Posey restraints as needed to protect self Physical therapy to initiate progressive ambulation with weight bearing as tolerated Incentive spirometer while awake Medical therapy: cefazolin (Ancef) 1 g IV q 8 hr 4, enoxaparin (Lovenox) 30 mg SC q 12 hr, docusate sodium (Colace) 100 mg PO daily, meperidine (Demerol) 75 mg with hydroxyzine (Vistaril) 25 mg IM q 3 hr prn, and Vicodin 500 mg q 4 hr prn. Mrs. Olsen pulls out her Foley catheter 36 hours postoperatively. The urine had become cloudy and odorous. Recordings of the time and amount of voiding and trimethoprim-sulfamethox- azole (Bactrim) 1 tablet PO bid are ordered. Consider the factors that precipitated the need for this drug. Mrs. Olsen continues to speak primarily in Danish. Because she is incontinent, she requires disposable undergarments. She also refuses to eat, and the nurse is unable to determine why. The IV infusion was discontinued after Mrs. Olsen pulled it out during her bath. Attempts at ambulation have been unsuccessful because of communication difficulties. A Danish interpreter is not available, and although Mrs. Olsen’s daughter speaks Danish, she has had to return to her job and family responsibilities. The physician is planning to release Mrs. Olsen to Shady Oaks tomorrow. Discharge Criteria and Post-Treatment Considerations • Average length of stay (insurance certification): 8.5 days with transfer to skilled care on day 5 • Complete transfer form • Initiate social services referral to coordinate transfer Questions to Be Considered 1. Mrs. Olsen becomes increasingly agitated while in restraints. What alternative measures might the nurse consider to protect Mrs. Olsen? Discuss the ethical implications surrounding physical and chemical restraints. 2. Consider the implications that Mrs. Olsen’s neurologic problems (meningioma, seizures, and a possible stroke) may have had in relationship to her fall. What other factors may have contributed to the fall? What actions should the nurse take to protect her from future injury? 3. Based on her admission assessment data, calculate Mrs. Olsen’s score on the Glasgow Coma Scale. What influence does Mrs. Olsen’s use of the Danish language have on your calculation? How is her situation different from someone who is not bilingual? 4. How has Mrs. Olsen’s recovery been compromised because of her lack of mobilization? Identify the potential complications that may occur as a result of immobility. How may they be prevented? Discuss methods of communication you might use to facilitate Mrs. Olsen’s recovery and rehabilitation. 5. Discuss the effects that Mrs. Olsen’s refusal to eat will have on the processes of wound healing and immunity. 6. Review the nursing implications and related client education for the administration of phenytoin and trimethoprim-sulfamethoxazole. 7. Compare and contrast brain tumors in terms of treatment and prognosis. SCIENCE HEALTH SCIENCE NURSING NURSING NUR2221

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