ED Case Study

You are the day nurse getting report on a 12 year old female patient who originally came in through the ED as a trauma case.

This patient who received surgery for a fracture of the tibia & fibula.  She weighs 105lbs and has an allergy to dogs.  She is the oldest of 6 children and her parents own a store. When you receive her she has an external fixator in place on her L leg.   You hear from the night RN that she was leaning on an outside wall when the wall fell on her crushing her L leg; an ambulance was called, and an IV was placed in the truck en route to the ED. 

In the ED, another IV was placed and she received a fluid bolus of 20 ml/kg.  She also received fentanyl and ketamine in order to set her leg, but the reporting RN was unsure of the doses.  The orthopedic surgeon was called, but couldn’t do the surgery until the morning, despite the pain and the fact that pulses were lost x 2.

After the pedi hospitalist was consulted for pain management and discussion with the ED doc as well as ED nursing staff, the ortho surgeon came in to complete the surgery around 0200.  The patient was admitted on nights from the PACU.  She has been on the floor since 0530, very sleepy with good pain control.  She currently has LR running at 60mL/hr.  She is not going to be discharged until the following day, because she needs 24hr of antibiotics.  You are coming in as the day nurse, your current pain options are Morphine 1mg q4h.

  1. What is the weight of this patient in kilograms?

2)   How much total fluid did she receive in the ED?

3)   What type of fluid do we expect she received?

4)   Where can we look for this if the ED RN forgot?

5)   What do you expect the room to look like when you walk in?

              *Hint think about safety checks, diagnosis, age

6) What class of drugs is Morphine?

What would be the correct weight based dose for an opioid naive patient (someone who does not take narcotics regularly)?

Side effects?

7)  What class of drugs is Zosyn?                                                       

What would we expect the correct dose to be?

Any side effects?

8)  What class of drugs is fentanyl?

Correct Dose?

Side effects?

9) What class of drugs is ketamine?

Correct doses?

Side effects?

10) Based on her weight, is the fluid running at the correct rate?

(Hint use the 4-2-1 formula)

11) Ok, think as an RN.  What if this were your patient and you were the ED nurse what would you do regarding the surgeon situation?

12) Do you think the parents and/or patient might be upset? 

What are some ways you can prepare yourself to start the day with this family in a positive light?

13) What are some goals for your day?

14) What are 3 nursing diagnosis’ you would be thinking about for this patient?

(Hint: think beyond her diagnosis, think age, development….)

You enter the room at 0730, and she is weepy, but awake…

15) What do you do with the second IV line?     


16) How should her leg be positioned?

17) Given that she is “very sleepy” what might you want to see at her bedside, if she is not already on one?

18) She’s starting to become more alert and wake up with the start of the day. Her diet is advance as tolerated, she has not had anything to eat since yesterday, what would you do next with this?

*Think about pain control, why might this be especially concerning?

19) What do you think you should do about pain control?

20) You were told the pedi hospitalist was consulted for pain control..what would you do to follow up with this?

You now have Toradol 15mg IV q6h

                             Tylenol 650mg PO q6h

                             Oxycodone 2.5mg PO q4h PRN

                             d/c morphine-why?

21) You gave morphine earlier, but now your patient is still in pain, what are you going to give next?

22) What is your biggest concern when considering diet and pain control?

23) Your patient has been weepy and crying on/off all day, is this expected?  Why do you think?

24) PT is consulted to work with this patient, what do you want to do prior to them coming in?

What might your first choice for medication be?

25) do you think she needs a psych consult?

26) what are some ways we can use to address her fear and worry? 

27)  what type of equipment will she need when she goes home?

28)  what do we need to be thinking about in terms of her home environment?

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