You are working in the emergency department when M.C., an 82-year-old widow, arrives by ambulance. Because M.C. had not answered her phone since noon yesterday, her daughter went to her home to check on her. She found M.C. lying on the kitchen floor, incontinent of urine and stool, with complaints of pain in her right hip. Her daughter reports a past medical history of hypertension, angina, and osteoporosis. M.C. takes propranolol (Inderal), a nitroglycerin patch, indapamide (Lozol), and conjugated estrogen (Premarin) daily. M.C.'s 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, but she is able to say that her "leg hurts so bad." M.C.'s vital signs (VS) are 90/65, 120, 24, 97.5° F (36.4° C); her Spo2 is 89%. She is profoundly dehydrated. Preliminary diagnosis is a fracture of the right hip.
1. Considering her medical history and that she has been without her medications for at least 24 hours, explain her current VS.
2. Based on her history and your initial assessment, what three priority interventions would you expect to be initiated?
3. M.C.'s daughter states, "Mother is always so clear and alert. I have never seen her act so confused. What's wrong with her?" What are three possible causes for M.C.'s disorientation that should be considered and evaluated?
X-ray films confirm the diagnosis of intertrochanteric femoral fracture. Knowing that M.C. is going to be admitted, you draw admission labs and call for the orthopedic consultation.
4. What laboratory and diagnostic studies will be ordered to evaluate M.C.'s condition, and what critical information will each give you?
5. 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?
6. You carefully monitor M.C.'s right extremity for compartment syndrome. Which of these is a characteristic of compartment syndrome? Select all that apply.
a. Warmth of the extremity b. Pain distal to the injury that is not relieved by opioid analgesics c. Numbness and tingling of the extremity d. Pallor of the extremity e. Petechiae over the extremity