Musculoskeletal Case Study J

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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?