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H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control of his truck. The truck flipped and landed on the passenger side. H.K. was transported to the emergency department with a deformed, edematous right lower leg and a deep laceration wound approximately 2 inches (5 cm) long over the deformity. Blood continues to ooze from the wound. 1. What further assessment will you make of the leg injury and what precautions will you take in making this assessment? 2. What is the most appropriate method for controlling bleeding at this wound site? 3. What is the best way to immobilize the leg injury before surgery? 4. From the information given, it is clear that H.K. is a smoker. List at least three issues related to his smoking that can complicate his care and recovery. What interventions could be instituted to counter these complications? CASE STUDY PROGRESS H.K. is taken to surgery for open reduction and internal fixation (ORIF) of the tibia and fibula fractures. He returns with a full-leg fiberglass cast with windows over the areas of surgery. 5. Describe the assessment of a patient with a long leg cast involving trauma and surgery. 6. In assessing H.K.’s cast on the third day postoperatively, you notice a strong foul odor. Drainage on the cast is extending, and H.K. is complaining of pain more often and seems considerably more uncomfortable. Vital signs are 123/78, 102, 18, 102.2° F (39° C). What is your analysis of these findings, and what action is needed? CASE STUDY PROGRESS H.K. returns to surgery. The wound over H.K.’s fracture site has become necrotic with purulent drainage. The wound is debrided and cultured and a posterior splint is applied. H.K. returns to his room with orders for wet-to-moist dressing changes. The physician suspects osteomyelitis and orders nafcillin (Unipen) and ciprofloxacin (Cipro). Contact precautions are implemented. 7. Why are two antibiotics ordered? 8. H.K. asks you about the isolation precautions. “Does this mean I have something bad?” What is your best answer? a. “These are precautions that we use for every patient who has surgery.” b. “These are precautions we are taking to help your infection get better.” c. “This is an extremely serious infection; these precautions will keep the infection from getting worse.” d. “These precautions prevent the spread of the infection to other patients and to health care personnel.” 9. As you continue to assess H.K. over the following days, what evidence will you look for that antibiotics are effectively treating the infection? 10. Develop a teaching plan concerning the care of his cast. 11. After the teaching session, you use the Teach-Back method to assess H.K.’s learning. You ask H.K.: “We have reviewed a lot of information on how to care for your cast. To make sure that I explained it well to you, please tell me three things you will do.” Which statements by H.K. indicates a good understanding of cast care? Select all that apply. a. “I will not get the cast wet.” b. “I will keep plastic over the cast to protect it.” c. “I will call my doctor if I notice a bad odor or see drainage.” d. “I will keep my leg elevated above the level of my heart for the first 2 days.” e. “I will use a long file if it gets itchy inside my cast to scratch my skin gently. 12. What nutritional needs does H.K. have and why? CASE STUDY PROGRESS To ensure pain management, H.K. is given hydromorphone (Dilaudid) 2 mg IV push every 4 hours prn pain. You prepare to give him the first dose. 13. Name this drug’s therapeutic category. 14. What signs and symptoms would you see if he were to have a toxic or overdose reaction to the Dilaudid? Select all that apply. a. Nausea b. Pruritus c. Dilated pupils d. Respiratory depression e. Central nervous system (CNS) depression 15. What is the first thing you will need to do if you note a toxic or overdose reaction to the Dilaudid? 16. What is the antidote for toxic opioid reactions? How is it administered? CASE STUDY PROGRESS H.K. has no further complications with his leg wound and responds well to physical therapy. The discharge planner meets with him to discuss his post-hospital care. 17. What issues would the discharge planner need to address with H.K.?
SCIENCE
HEALTH SCIENCE
NURSING
NURSING 210

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