Patient Outcome In Orthopedics Questions


Case consideration

  • How would you validate the outcomes of Dr. Reed’s patients? 
  • What care outcomes should be reviewed and why?
  • How should one organize the validation process?
  • Who should be involved in this research?
  • What value does this research have? Who else in the hospital would be interested in the results?
  • How would other physicians become involved?

Discussion on Leadership styles

  • What is your style after reviewing the styles
  • What are the characteristics of leaders
  • What is transformational leaders
  • What is a transactional leaders
  • What is an authentic leader
  • What is emotional intelligence
  • The five major management functions 


A.W. a 52 year old woman disabled from severe emphysema, was walking at a mall when she suddenly grabbed her right side and gasped. Oh something just popped. A.W. whispered to her walking companion,” I can’t get any air.” Her companion yelled for someone to call 911 and helped her to the nearest bench. By the time the rescue unit arrived, A.W. was stuporous and in severe respiratory distress. She was intubated, an IV of Lactated ringers at KVO was started and she was transported to the nearest emergency department.

On arrival at the ED the physician auscultates muffled heart tones, no breath sounds on the right and faint sounds on the left. A.V. is stuporous, tachycardiac, and cyanotic. The paramedics told the physician that it was difficult to ventilate A.W. A portable chest x ray shows an 80% pneumothorax on the right

Chart review

  • ARterial blood gasses
  • PH 7.25
  • Pco2 92 mmhg
  • Pao2 32mmhg
  • Hco3 27 mmol?l
  • Sao3 53%


  1. Given he dx of pneumothorax explain why he paramedics had difficulty ventilating her?
  2. Interpret A.W arterial blood gasses
  3. What is the reason for A.w. Abg results?
  4. The physician needs to insert a chest tube. What are your responsibilities As A.W. nurse


Hx information

Mr. Kiley a male age 33 ,

Black American Lives with sister employed as a auto mechanic

No cultural considerations Pre Existing conditions type 1 diabetes Diabetes Mellitus

Bipolar 2 disorder


Regular insulin (Humulin R, Novolin R}

Lithium, 50% dextrose (D50),glucagon( GlucaGen)

Mr. Kiley is a 33 yr old technician who presents to the emergency department after losing consciousness at work. The emergency medical technicians EMT reports that Mr. Kiley was unconscious when they arrived at the auto shop, and finger-stick blood glucose could not be measured on the glucometer because it was so slow. A fellow employee recounted the event for the EMT’S stating ,”He was told that he was fine all day.

In fact, he was in a great mood, talking and telling me how he stayed up all night surfing the Internet and buying hundreds of dollars of Elvis memorabilia for his collection. Then for a time he was quiet. He was working under a car. When I was asking him a question and he didn’t answer. I pulled him out from under the car and he was sweating buckets.

He would not talk to me. We know he is a diabetic, so we tried to give him juice. But he would not swallow. ” The client’s vital signs when the EMT’s arrived were blood pressure 140/70,pulse 122, respiratory rate of 38 and temperature 89 F (31.7C). Enroute to the hospital, the client was covered with blankets , an Intravenous(IV) access was established and the client was given an ampule of 50% dextrose IV Bolus


Upon arrival in the emergency department, the client’s skin is cold and he is diaphoretic. He is having seizure activity. The client ‘s vital signs are blood pressure

146/74, pulse 118, respiratory rate 34, and temperature 90 F.(32.2C) , blood pressure( 32.2%) glucose is 24 mg/dl. A second IV access is established to allow for the simultaneous administration of medication and 5%dextrose in water (D5W) as prescribed by the HCP.

Warm blankets and warming lights are used to help raise the client’s body temperature. The client is given a second ampule of D50. Oxygen is administered via nasal cannula, and the client is monitored for potential cardiac dysrhythmias. The client begins to regain consciousness. His seizure activity has subsided. His serum glucose is 84 mg/dl, and his temperature has risen to 93F(33.9 C).

Mr. Kiley’s sister has arrived in the emergency department. She tells the nurse that her brother is bipolar. She states,” He is usually very good about taking his medication and keeps his sugar in good control. This happened to him once before, He stopped taking his lithium and lost track of when he had taken his insulin. Last time this happened, he took way too much insulin and I found him unconscious in our apartment.

I was away on a business trip this past week. It is my fault. If I had called more often while I was away and checked on him I could have noticed in his voice that he was off his meds. When asked, Mr. Kiley reveals that he has not been taking his lithium and did not eat today. When asked he client denies ingesting alcohol, engaging in vigorous exercise, smoking marijuana, or taking other recreational drugs, or prescription medications.

Mr Kiley is admitted to the intensive care unit ICU, and his treating psychiatrist is notified of the admission so that the admitting HCP can collaborate with the psychiatrist to plan the client’s medical care.


  • Define hypoglycemia. What are hypoglycemia blood glucose values in an adult?
  • Describe the clinical manifestations of hypoglycemia. How low does a client’s blood glucose need to fall before the client exhibits clinical manifestations?
  • Provide a rationale for why the HCP asked the client about alcohol intake, vigorous exercise, marijuana, the use of recreational drugs and prescription medications.
  • Briefly define hypothermia, and explain why the client with hypoglycemia is often hypothermic.
  • If an IV access site could not be established, could the 50% dextrose (D50) be administered intramuscularly? What is another medication that the HCP might prescribe to treat the client’s hypoglycemia, and what is that Medication’s most common adverse effect?
  • Briefly discuss bipolar disorder and the distinguishing feature of bipolar II disorder.
  • What are the characteristic manifestations of the manic and depressive episodes?
  • experienced by a client with bipolar disorder? Briefly discuss the clinical manifestations of bipolar disorder that the client exhibited in the past 24 hours.
  • Discuss how Mr. Kiley’s bipolar disorder contributed to his hypoglycemia.
  • Mr. Kiley’s sister told the nurse that the client usually maintains good control of his blood glucose. The client’s hemoglobin AIC (Hba1c) is 5%. What does an HBa1c value represent, and does the client’s value indicate good control?
  • Help the nurse identify three priority nursing diagnoses to include in Mr. Kiley’s plan of care.
  • The ICU nurse noticed that the skin around the IV site on Mr. Kiley’s left hand was inflamed and warm. What is the most appropriate nursing intervention?
  • Although his fellow employees were trying to help Mr. Kiley, why was their attempt to give him juice an inappropriate intervention?
  • Briefly discuss how Mr. Kiley’s why was their attempt to give him juice an inappropriate intervention?

Define hypoglycemia, What are hypoglycemic blood glucose value in an adult Hypoglycemia (also called an insulin reaction in a known diabetic_is abnormally low glucose level. In an older adult under 60 years of age, the normal range of blood glucose is between 80 and 105 mg/gl. In an older adult (over 60), the normal blood range of blood glucose is between 80 and 115 mg/dl. Hypoglycemia is defined as blood glucose.


Mrs. Harriet is a female 68 yrs old who is alert and oriented. She presents to the emergency department with complaints of chest tightness, shortness of breath , cough, and congestion. She states, “I have been having these symptoms for three days now. I have been taking Maximum Strength Robitussin for my cough but it has not helped very much.

When I woke up this morning, I felt very weak so I came in to be checked out. Her vital signs are blood pressure 110/70, pulse 94, respiratory rate of 28, and a temperature of 102.7F. Her oxygen by nasal cannula . The HCP prescribed a 12-lead ecg, and chest x-ray, Laboratory test prescribed 12 lead ECG, ECG, and chest x-ray, Laboratory test was admitted to the hospital ethnicity is Black American. Allergies to erythromycin and aspirin coexisting is obesity

She is retired; lives at home with her husband;

Volunteers as a receptionist at a local adult community center.

Smokes a half of a pack of cigarettes per day.

Positive tobacco use for 54 yrs.


Dextromethorphan hydrobromide, (Robitussin Maximum Strength} Isoniazid (INH Nydrazid); ceftriaxone sodium (Rocephin } erythromycin; azithromycin (zithromax); albuterol (proventil, Ventolin) acetaminophen (tylenol)

Prioritization Respiratory isolation until dx of TB is ruled out.

Delegation: Smoking cessation and weight loss program


Mrs. Harriet is a 68 year old woman who is alert and oriented. She presents to the emergency department with complaints of chest tightness, shortness of breath, cough and congestion. She states, “I have been having these symptoms for three days now. I have been taking maximum Strength Robitussin for my cough and congestion and it has not helped very much. When I woke up this morning, I felt very weak so I went in to be checked out” Her vital signs are : blood pressure 110/70, pulse 94, respiratory rate of 28, and temperature of 102.7F (39.3C).

Her oxygen saturation on room air is 92%. She is placed on 2 liters (L) of oxygen by nasal cannula. The HCP prescribes a 12 lead electrocardiogram (ECG, EKG) and a chest x ray , Laboratory tests prescribed include complete blood count, basic metabolic panel, brain natriuretic peptide (B-type natriuretic peptide assay or BNP}, total creatine kinase {CK,CPK}, creatine kinaseMB (CPK-MB), and troponin. The HCP will also assess blood cultures x 2, ABGs on room air,sputum culture and sensitivity (C&S) and ask that the client have a Mantoux(tuberculin purified protein derivative or PPD test.


Mrs. Harriet’s ECG shows normal sinus rhythm (NSR) with a heart rate of 98 beats per minute. The CXR reveals a right lower lobe (RLL)infiltrate, Laboratory tests include the following results:

White blood cell count (WBC) 12,200cells/mm3, 72% seg neutrophils with a left shift of 11 % bands and a BNP of 50.9pg/ml. ABG on room air PH 7.44 partial pressure of carbon dioxide PAC0 239mmHg, bicarbonate (HCO3_)26.9mEq/L,partial pressure of oxygen (PaO2 58 mmhg and oxygen saturation of 92%, Results of the sputum culture showed Streptococcus pneumoniae. The CPK,CPK-MB and troponin are all within normal limits.

Mrs. Harriet is five feet three inches tall and weighs 224 pounds (101.8kg). On assessment , the nurse hears expiratory wheezes and rhonchi bilaterally with diminished lung sounds in the right base. Her thoracic(chest) expansion is equal but slightly decreased on inspiration. Accessory muscle retraction is not noted and she does not exhibit central cyanosis. Capillary refill of the client’s nail beds is four seconds Mrs. Harriet is admitted with acute bronchitis and pneumonia. The HCP prescribes oxygen via nasal cannula to keep the client’s oxygen saturation>or equal to 95%, ceftriaxone sodium, erythromycin, albuterol, acetaminophen every four to six hours as needed , bed rest, an 1800-calorie diet, increased oral (PO) fluid intake to 2 to 4 liters per day, Coughing and deep breathing exercises and use of an incentive spirometry (IS).


  • Discuss additional assessment data that would be helpful in gaining a more thorough understanding of Mrs. Harriet’s symptoms.
  • Discuss the causes of pathophysiology, and symptoms of acute bronchitis. 
  • Discuss the pathophysiology and causes of pneumonia in general
  • Compare the defining characteristics of community-acquired (HAP) and viral pneumonia.
  • Discuss the factors that place Mr. Harriet at greater risk for the development of pneumonia.
  • Mrs. Harriet asks the nurse to explain what her HCP saw on her chest X Ray. She asked,”The doctor said something about a trate he saw on my lung. What did he mean by that? How would the nurse explain what an infiltrate is?
  • Briefly explain the pathophysiology, and identify at least five clinical manifestations of the respiratory diagnosis that is being ruled out for Mrs. Harriet by administering the Mantoux test.
  • While awaiting test results to confirm if Mrs. Harriet has TB what precautions should be taken when assigning her to a room and providing nursing care?
  • Discuss the measurement of induration that would indicate a positive Mantoux test for Mrs. Harriet. If she tested positive for exposure to TB but did not have assessment findings consistent with active disease, what medication could be prescribed and what is the benefit of this treatment?
  • The nurse asked Mrs. Harriet if she had been using her incentive spirometer. Mrs. Harriet states,”I tried to use it a couple of times but I think it is broken. When I blow into it the ball does not go up and like I was told it should” How should the nurse intervene?

11.   Briefly discuss the significance of each of the following laboratory results:

  • WBC 12, 200 cells/mm3
  • 72 % seg neutrophils,
  • left shift of 11% bands d BNP 50.9pg/ml
  • results of the sputum culture shows s. pneumoniae
  • CPKwithin normal limits
  • CK MB within normal limits
  • Troponin within normal limits

12. Analyze Mrs. Harriet’s ABG Determine whether each value is high or low or within normal limits; interpret the acid-base balance; determine if there is compensation; and indicate whether the client has hypoxemia.

13.The nurse calls the HCP to request a change in the medications that have been prescribed for Mrs. Harriet. Discuss which medication the nurse is concerned is unsafe

for this client;

14.   Provide a rationale for each of the following prescribed components of Mrs.

Harriet’s treatment plan: oxygen to keep the client’s oxygen saturation greater than or equal to 95%, ceftriaxone sodium, albuterol, acetaminophen, bed rest, 1800 calorie diet, increase oral {P0} fluid intake to 2 to 4 liters per day , coughing and deep breathing, exercises and use of an incentive spirometer.

15.   Mrs. Harriet was taking dextromethorphan at home to help manage her cough. The HCP did not prescribe continued use of the dextromethorphan during hospitalization. Explain this omission.

16.   If it was learned that Mrs. Harriet has a past medical history of chronic obstructive lung disease (COPD),how would the HCP’s prescription that oxygen be delivered to keep the client’s oxygen saturation greater or equal to 95% be changed?