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

Initially, inspect the wound area and note the size, depth, amount of bleeding, presence or absence of any foreign body. Inspect the immediate area for any other lesions. After which, proceed with a focused physical examination and assess the neuromuscular function of the affected hand. Ask the patient to move each finger and note if there is any difficulty with the flexion or extension of the joints. Check also for the sensory. Assess if the patient is able to feel light and deep touch, blunt and sharp objects, as well as difference in temperature.

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

The presence of a wedding band in a wounded area would risk the possibility of a ring avulsion injury. To reduce this risk, ask the patient to remove the wedding band.

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?

The doctor has to completely assess the patient and make sure that there is no tendon or nerve damage which may cause more problems in the long run.n

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

An Xray of the hand would identify the presence of fractures as well as the location of any metal fragments, if present. The Xray should show in detail the proximal, middle, and distal phalanx, as well as the interphalangeal, metacarpophalangeal, and carpometacarpal joints.

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?

To prepare J.T. for the surgery, a pretest evaluation should be done. A complete and thorough medical history should be done. After which, explain to J.T. about the surgical procedure, how long it will last, any anesthesia to be given, what does he need to do in order to prepare for surgery, as well as what can he expect after the surgery.

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

To verify that the patient understands any pre surgery evaluation, ask him to sign an informed consent form before the planned surgery.

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?

No problem is anticipated. Patients undergoing surgery that has to be put under anesthesia are advised to have no solid food at least 8 hours prior to surgery and no clear liquids until 2 hours prior to surgery.

8. Does J.T. need a tetanus booster? If so, will he receive a Td or Tdap?

J.T. has had his last tetanus shot 12 years ago. Based on the CDC guidelines, an adult should receive a booster every 10 years, so J.T. needs a tetanus booster. Either Td or Tdap may be given.

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 nurse may tell J.T. that a surgical wound may have skin discoloration for around 2-3 days after the surgery and it is normal.

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." - Naproxen is generally taken after ingesting a meal to help prevent common side-effects such as indigestion.

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?

The nurse may further educate J.T. that if the surgical wound site has persistent redness then this might be a sign of infection and he should come back to see the doctor immediately.