Musculoskeletal Case Study

J.T. has injured his hand at work and is accompanied to the emergency department (ED) by a co-worker. You examine his left hand and find a piece of a drill bit sticking out of the skin between the third and fourth knuckles. There is another puncture site about an inch below and toward the center of the hand. Bleeding is minimal. J.T. is 41 years old, has no significant medical history, and has no known drug allergies. He states the accident occurred when a mill at work malfunctioned and knocked his hand onto a rack of drill bits. His last tetanus booster was 12 years ago. It is your job to provide the initial care for J.T.'s injury.

 1. You examine J.T.'s hand. What is the priority action? What should you include in your initial assessment, and why?

 

You record that J.T.'s fingers are warm with capillary refill in less than 2 seconds. Sensory perception is intact. He is able to flex and extend the distal joints but not the proximal joints of the third and fourth fingers.

2. You notice J.T.'s wedding band and promptly ask him to remove it. Why is this important?

3. J.T. asks you why the doctor can't just pull the bit out and then he can go home. How should you respond to his question?

4. What common diagnostic test will identify fractures and the location of metal fragments in J.T.'s hand?

 

The drill bit is impaled ½ inch below the surface of the skin, and there are no fractures. Because the hand contains so many blood vessels, nerves, ligaments, and tendons, the ED physician decides to consult a surgical hand specialist. A neurologic consult says there is no nerve damage. The surgeon suspects tendon damage and decides to operate immediately.

 5. You accompany the surgeon to J.T.'s bedside and listen to the explanation of the surgery, and then you witness J.T. signing the surgical consent form. What do you need to do to prepare J.T. for immediate surgery?

 

6. How will you verify that he understands about the surgical procedure?

7. You record that J.T. has had no food "since 8:00 pm yesterday" and drank "some water" this morning. Based on this information, do you anticipate problems during surgery, and why?

 8. Does J.T. need a tetanus booster? If so, will he receive a Td or Tdap? Explain your answer, based on the latest Centers for Disease Control and Prevention (CDC) guidelines.

 

The surgeon repairs two partially severed tendons and wraps the hand in a large, padded dressing. The distal ½ inch of each digit protrudes from the bulky dressing.

 9. While in the short-stay recovery area, J.T. asks the nurse why his fingers look yellowish brown. How should she respond to his question?

 

The surgeon tells J.T. that he had to repair tendons in his third and fourth fingers and instructs J.T. that he is not to work until approval is given after being reevaluated. He gives J.T. prescriptions for ceftazidime (Ceptaz) and naproxen (Naprosyn). He instructs J.T. to make an appointment to see him in the surgery clinic in 2 days. The nurse provides patient teaching about the purpose of these medications, as well as how to take them, and possible side effects.

10. Which statement by J.T. indicates that further teaching about the medications is needed?

 a. "I need to take these pills on an empty stomach."

b. "I won't stop taking these until the prescription is finished."

c. "I will not drink alcohol or take over-the-counter medicines while on these drugs."

d. "I will call my doctor if I notice a rash, diarrhea, or increased bruising."

 

11. What additional instructions should the nurse in the short-stay area discuss with J.T. and his wife before releasing him?

 

(1) Based on the above scenario, the priority of action would be to determine the extent of the injury, the level of pain and to provide pain relief.

In the initial assessment, it is important to check the sensory perception of the hand. The patient can be asked to move his fingers to determine the extent of the injury and if any nerve has been damaged. It is also important to assess the color of the skin as well as capillary refill. Delayed capillary refill may indicate compromised circulation.

(2) The wedding band needs to be removed immediately because swelling of the fingers are expected and the ring can compromise circulation to an edematous digit.

(3) Inform the patient that you can't just pull an impaled object from his skin as this may cause further damage to the nerves and blood vessel precipitating extensive bleeding. In addition, a puncture wound can easily become infected because objects harbor germs, viruses and bacteria.

(4) Doctors can diagnose bone fractures with x-rays. It is the most common diagnostic test to identify fracture. An x-ray of the hand can show presence of fractures, the number and location of metal fragments in the hand.

(5) The things that you need to do to prepare the patient for immediate surgery:

• Make sure the patient has social support (contact wife or any family member) An unexpected need for emergency surgery is stressful and can cause anxiety to the patient.
• Ensure that the patient's questions and concerns regarding the surgery are addressed. 
•  Ensure that all patient's pertinent information are listed on the chart such as allergies. Attach the signed surgical consent form on the patient's chart.
• Ensure labs works are done prior to the surgery and all results are posted on the chart.
• Prepare the bowel for surgery. Have the patient empty his bladder prior to surgery.
•  Assist and dress patient in a hospital gown.
•  If family members are not present, patient's personal items should be secured in a valuable's envelope labeled with patient's name and locked in a safe.
• Start IV as ordered.
• Administer preanesthetic medication as ordered, and keep the patient in bed with the side rails raised to ensure patient safety.

(6) In order to verify that the patient understands the surgical procedure is to let the patient state his understanding on what is to be done and what to expect including the risks involved in the surgery. This method ensures informed consent.

(7) No problems are anticipated. Usually, before having a surgery, the patient will not be allowed anything to eat or drink. No drinking or eating before surgery is a common instruction.

(8) After the initial tetanus shot, booster shots are recommended every 10 years. Since the patient experience a puncture wound, it's best to get the booster shot regardless of when he had his last tetanus shot. On this case, the patient has not had a tetanus vaccine in 12 years, so he definitely needs a booster. Typically, a Td (tetanus and diphtheria) vaccine is used but based on the latest CDC guidelines, Tdap is a vaccine recommended for all adults. The guidelines state that if a patient is due for a tetanus booster, a Tdap vaccine should be given.

(9) The yellowish brown color of his fingers are due to the iodine cleanser that was used to scrub his hand before the surgery. The patient should be reassured that it can be rinsed off.

(10) Answer: (A) "I need to take these pills on an empty stomach."

• Medicines such as NSAIDs should be taken with food to reduce untoward gastrointestinal symptoms/stomach upset and to prevent ulcerations.

(11) Additional instructions the nurse should discuss with J.T. and his wife before releasing him are:

• Stress the importance of compliance with the follow up appointment.
• Take home medicines as ordered.
• Take pain medicines as prescribed.
• Elevate hand and apply ice pack on the affected area to reduce swelling.
• In order to prevent infection, the surgical site must be kept clean and dry. 
• He is to call his health care provider or go to an urgent care clinic if he experience increased bleeding, drainage, swelling or redness at the surgical site, a fever over 38 degrees Celsius, severe pain or pain not relieved by medicine.