NR 305 Week 7 Discussion Topic, Assessment of the
Musculoskeletal System and Pain
Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and
oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over
a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to
your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a
slight rotation of his right leg.
Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral
iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.
Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.
After reviewing the above scenario please answer the following questions.
1. Based on the information provided, how will you prioritize your care, what assessments will you
include and in what order? Please provide rationale for your response.
2. Considering this patient's age, injury, past medical history, and list of current medications, what, if
any, concerns do you have related to his potential need for surgery?
3. Should surgery to repair his right femur be required; what type of clearance and pre-op orders
would you anticipate receiving related to his diet, meds, lab work, and so on?
Fred, an 83-year-old male is being admitted to med/surgical unit, status post fall after
tripping on a curb. He is alert and oriented. He landed on right side and is bruised from jaw to
knee and has a slight rotation of the right leg.
Immediately he is moved to from the stretcher to the bed, using a slide board to minimize
painful movement. The initial assessment includes watching for grimacing or clenching with the
movement and doing a pain assessment. The pain assessment is crucial to assess first so that he
may better function and tolerate the rest of the assessments. He had recently had Morphine in the
ED. I will ask him to rate his pain using the numerical pain scale. And have him describe where
it hurts, what the pain feels like. Deep somatic pain comes from blood vessels, joints, tendons,
muscles, and bone. Bone pain is usually described as aching or throbbing and sharp pain with
movement (Jarvis,2016). With the rotation of his leg, I’m assuming he has either a femur or hip
fracture that will be determined by x-ray.
My next step is to provide him pain medication that is ordered for him. The route for
administration is preferably IV as he may need to be NPO for possible surgery. If morphine is
due and worked to relieve some of his pain in the ED, that will be my first choice. Toradol, is
another option depending on lab results and kidney function.
When the pain is tolerable and managed, I will do a physical assessment. Checking the
five Ps. Pain, pulse, pallor, paresthesia, and paralysis. Checking the pulses above and below the
injury will verify adequate circulation. Lack of pulse or cold to touch alerts to a compromise in
circulation. Can he wiggle his toes or flex and extend his ankles? Check and compare his joints
and assess edema and bruising. Does he have impaired skin integrity? How was his balance and
gait prior to the fall? I will ask about assistive devices such as cane or walker use. He will be
placed on fall precautions because of age, recent fall, pain medications, possible surgery, and
pain with movement. The rationale will be explained to him.
, NR 305 Week 7 Discussion Topic, Assessment of the
Musculoskeletal System and Pain
The purpose of a preoperative evaluation is to determine and optimize conditions that
increase perioperative morbidity and mortality (Feely, Collins, Daniels, Kebede, Jatoi, & Mauck,
2013). Prior to a possible surgery and because of Fred’s heart history, he will need a consult and
clearance from a cardiologist. EKG and cardiac enzymes should be addressed. Glucose level,
A1C, and CBC should be obtained. He will need PT/INR drawn as he has been on Plavix and
aspirin. He is at a higher risk of bleeding because of being on blood thinners. Knowing the
coagulation counts can help to manage hemostasis (Feely, et al, 2013). Respiratory therapy will
be notified for his sleep apnea to form a baseline. If he is on a CPAP at home, his family will be
asked to bring that in. I will explain that he may be on oxygen after surgery because the
medication may shallow or slow his breathing, and pain may cause him not to take full deep
breathes. I will teach him of incentive spirometry and encourage its use before and after surgery.
Fred seems active as he was out at the casino with his wife. If medically cleared for
surgery, it is a good idea, to pursue it, as it will benefit his activity and quality of life. Orders to
look for pending surgery would be an NPO status (prevent aspiration when sedated), hold ASA
and Plavix (risk for increased bleeding), CBC (baseline Hct & hgb), PT/INR (clotting factors to
see if he is in a safe range for surgery), BMP (assess kidney function and determine if he is safe
to take Toradol).
References
Feely, M. A. MD, Collins, S. MD, Daniels, P. R. MD., Kebede, E. B. MD., Jatoi, A. MD., &
Mauck, K. F. (2013). Preoperative Testing Before Noncardiac Surgery: Guidelines and
Recommendations. American family physician, 15(87), 6th ser., p. 414-418. Retrieved
June 11, 2017, from http://ago.org/2013/0315/p414.html.
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA.
Saunders.
Shelley, you have some great ideas here! A couple of questions: would this patient benefit from any thing
physical that can be done if h has a fractured hip? Would it help with pain control as well? Also, is the fact he is
on metformin be a red flag for any thing? Professor Cox
ReplyShow Less
Shelley Derrreply to Instructor COX
Email has been sent.
6/14/2017 6:51:43 PM
Musculoskeletal System and Pain
Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and
oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over
a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to
your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a
slight rotation of his right leg.
Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral
iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.
Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.
After reviewing the above scenario please answer the following questions.
1. Based on the information provided, how will you prioritize your care, what assessments will you
include and in what order? Please provide rationale for your response.
2. Considering this patient's age, injury, past medical history, and list of current medications, what, if
any, concerns do you have related to his potential need for surgery?
3. Should surgery to repair his right femur be required; what type of clearance and pre-op orders
would you anticipate receiving related to his diet, meds, lab work, and so on?
Fred, an 83-year-old male is being admitted to med/surgical unit, status post fall after
tripping on a curb. He is alert and oriented. He landed on right side and is bruised from jaw to
knee and has a slight rotation of the right leg.
Immediately he is moved to from the stretcher to the bed, using a slide board to minimize
painful movement. The initial assessment includes watching for grimacing or clenching with the
movement and doing a pain assessment. The pain assessment is crucial to assess first so that he
may better function and tolerate the rest of the assessments. He had recently had Morphine in the
ED. I will ask him to rate his pain using the numerical pain scale. And have him describe where
it hurts, what the pain feels like. Deep somatic pain comes from blood vessels, joints, tendons,
muscles, and bone. Bone pain is usually described as aching or throbbing and sharp pain with
movement (Jarvis,2016). With the rotation of his leg, I’m assuming he has either a femur or hip
fracture that will be determined by x-ray.
My next step is to provide him pain medication that is ordered for him. The route for
administration is preferably IV as he may need to be NPO for possible surgery. If morphine is
due and worked to relieve some of his pain in the ED, that will be my first choice. Toradol, is
another option depending on lab results and kidney function.
When the pain is tolerable and managed, I will do a physical assessment. Checking the
five Ps. Pain, pulse, pallor, paresthesia, and paralysis. Checking the pulses above and below the
injury will verify adequate circulation. Lack of pulse or cold to touch alerts to a compromise in
circulation. Can he wiggle his toes or flex and extend his ankles? Check and compare his joints
and assess edema and bruising. Does he have impaired skin integrity? How was his balance and
gait prior to the fall? I will ask about assistive devices such as cane or walker use. He will be
placed on fall precautions because of age, recent fall, pain medications, possible surgery, and
pain with movement. The rationale will be explained to him.
, NR 305 Week 7 Discussion Topic, Assessment of the
Musculoskeletal System and Pain
The purpose of a preoperative evaluation is to determine and optimize conditions that
increase perioperative morbidity and mortality (Feely, Collins, Daniels, Kebede, Jatoi, & Mauck,
2013). Prior to a possible surgery and because of Fred’s heart history, he will need a consult and
clearance from a cardiologist. EKG and cardiac enzymes should be addressed. Glucose level,
A1C, and CBC should be obtained. He will need PT/INR drawn as he has been on Plavix and
aspirin. He is at a higher risk of bleeding because of being on blood thinners. Knowing the
coagulation counts can help to manage hemostasis (Feely, et al, 2013). Respiratory therapy will
be notified for his sleep apnea to form a baseline. If he is on a CPAP at home, his family will be
asked to bring that in. I will explain that he may be on oxygen after surgery because the
medication may shallow or slow his breathing, and pain may cause him not to take full deep
breathes. I will teach him of incentive spirometry and encourage its use before and after surgery.
Fred seems active as he was out at the casino with his wife. If medically cleared for
surgery, it is a good idea, to pursue it, as it will benefit his activity and quality of life. Orders to
look for pending surgery would be an NPO status (prevent aspiration when sedated), hold ASA
and Plavix (risk for increased bleeding), CBC (baseline Hct & hgb), PT/INR (clotting factors to
see if he is in a safe range for surgery), BMP (assess kidney function and determine if he is safe
to take Toradol).
References
Feely, M. A. MD, Collins, S. MD, Daniels, P. R. MD., Kebede, E. B. MD., Jatoi, A. MD., &
Mauck, K. F. (2013). Preoperative Testing Before Noncardiac Surgery: Guidelines and
Recommendations. American family physician, 15(87), 6th ser., p. 414-418. Retrieved
June 11, 2017, from http://ago.org/2013/0315/p414.html.
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA.
Saunders.
Shelley, you have some great ideas here! A couple of questions: would this patient benefit from any thing
physical that can be done if h has a fractured hip? Would it help with pain control as well? Also, is the fact he is
on metformin be a red flag for any thing? Professor Cox
ReplyShow Less
Shelley Derrreply to Instructor COX
Email has been sent.
6/14/2017 6:51:43 PM
