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Critical Thinking Case Study | Nursing Management

The following case study discusses about the Nursing care and management of a patient, namely Mrs. Audrey Smith. She is a widower, 75 years in age, and lives in 440 Collins St. Melbourne Victoria 3000. She was brought to the hospital and admitted in the Emergency department at 10:45 am after having been found on her Kitchen floor at 9:45 am by her neighbor.  Audrey has been diagnosed with a fractured left neck of femur (NOF) in an event that she has reported as an accidental tripping.  Her medical assessment suggests her to undergo Left hip anthroplasty which has been scheduled at 5:00 pm. The aim of this paper is identification and implications of nursing management in the discussed medical case for taking proper care of the patient before, during and after the procedure by necessary immediate pre-operative preparations to the post-operative management including the requirements before she gets transferred to a Fast track rehabilitation facility.

Nursing care Interventions

  1. Safety

Severe surgeries as in case of Audrey, especially when understanding the other associated medical complications with her, make her more prone to variety of risk factors including peripheral neurovascular dysfunction (Davey, Bracha and Svendsen, 2005). To avoid such conditions, nurses must maintain the function of limbs as evidenced by sensation and movements within normal limits. Alongside, nursing case must evaluate the capillary refill, skin color and temperature time to time and compare with non-operated right limb. Audrey has to undergo unremitting pain, joint instability and selected fracture. The nursing care should prioritize the needs of Audrey by preventing any more complications, alleviating pain, promoting optimal mobility and providing information about diagnosis, prognosis and other needs. Monitoring of heart-rate, restlessness, confusion, chest-pain, should always be assessed consider ........

er neighbor.  Audrey has been diagnosed with a fractured left neck of femur (NOF) in an event that she has reported as an accidental tripping.  Her medical assessment suggests her to undergo Left hip anthroplasty which has been scheduled at 5:00 pm. The aim of this paper is identification and implications of nursing management in the discussed medical case for taking proper care of the patient before, during and after the procedure by necessary immediate pre-operative preparations to the post-operative management including the requirements before she gets transferred to a Fast track rehabilitation facility.

Nursing care Interventions

  1. Safety

Severe surgeries as in case of Audrey, especially when understanding the other associated medical complications with her, make her more prone to variety of risk factors including peripheral neurovascular dysfunction (Davey, Bracha and Svendsen, 2005). To avoid such conditions, nurses must maintain the function of limbs as evidenced by sensation and movements within normal limits. Alongside, nursing case must evaluate the capillary refill, skin color and temperature time to time and compare with non-operated right limb. Audrey has to undergo unremitting pain, joint instability and selected fracture. The nursing care should prioritize the needs of Audrey by preventing any more complications, alleviating pain, promoting optimal mobility and providing information about diagnosis, prognosis and other needs. Monitoring of heart-rate, restlessness, confusion, chest-pain, should always be assessed considering Audrey’s condition.

  1. Hygiene and comfort

Due to decreased mobility prior to surgery and inadequate secondary defenses as an attribute of Audrey’s old age, she can face the risk of infection that may delay the wound healing process or can lead to erythema ( Cury, Cinagawa, Camargo, et al, 2015). Nursing care must make proper interventions to promote good health and hygiene for Audrey. This should include strict aseptic and clean techniques, maintaining patency of drainage devices, assessing skin/incision, color or temperature. . If required, antibiotic must be administered to prevent infection under physician’s prescription. Nursing care must make sure that Audrey feel relaxed and take proper sleep. This can be achieved by demonstration of relaxation skills like deep breathing, guided imagery, visualization or meditation. Audrey’s blood management becomes a critical factor as replacement surgery often causes significant blood loss and lead to adverse outcomes.

  1. Nutrition

Audrey must be encouraged to increase fluid intake and high-protein diet with roughage by nurses. Audrey needs closer observations and continuous electronic monitoring. Nurses must take and report vital signs, ADLs, elimination, ambulation, drain output and feeding information for interpretation of complication as to provide rapid response to developing adverse changes

  1. Elimination

Anthroplasty has been linked with increased risk of renal injury (Kimmel, Wilson, Janardan, et al, 2014; Voss,  Skopec, Saleh,  et al. 2015). The condition become more complicated in High-risk patients (advanced age, hypertensive disease, and high ASA scores), therefore nurses should identify these risks early for further optimization pre- and intra-operatively (Hassan, Sahlström & Dessau, 2015). Audrey will suffer a transient renal impairment post the surgical procedure. The renal function will return essentially to the preoperative level within few days if no complications are arised (Nergelius, Vinge, Grubb & Lidgren, 1997).

  1. Activity Levels

Owing to Audrey’s painful conditions and discomfort in purposeful movements, nurses should assist her to perform continuous passive motions (Vogel,  CarotenutoBasti, and Levine,  2011). Nurses must be engaged in investigation of sudden increase in pain and restrict her from any physical stress. Demonstration and assistance in performing range of motion exercises and providing support positions with pillows and wedges will prevent dislocation of hip prosthesis and prolonged tissue pressure thereby reducing risk to ischemia. Nurses should motivate to participate in ADLs and rehabilitation programs to enhance her self-esteem and promoting independence (Singh and Lewallen 2014).

  1. Psychosocial Needs

Considering the vulnerability to depression in Audrey’s previous medical history, nurses are required to meet her psychosocial needs which are expected to be altered as per her conditions (Pinto, Faiz , Davis et al 1963). It has been observed that patients with anxiety and depression n prior to surgery procedure show poor pain relief and thus slower recovery from the surgery. Nurses thus should keep her motivated and by encouraging her to boost her self-esteem. If required Audrey can be provided with additional support systems to address her anxieties and expected outcomes.

 

Past Medical History

  1. Atrial Fibrillation

Atrial fibrillation is referred to as cardiac arrhythmia characterized by complete absence of coordinated contractions in the atria (Bajpai & Rowland, 2006). The dis-coordinated contractions are thus result of initiation of heart impulses from AV node instead of SV node. Audrey’s heart-rate of 100-175 beats per minute is result of this phenomenon. Audrey is thus required to be undergone cardioversion. However, this can increase her risk to thromoembolism which is often a very common manifestation following anthroplasty. Ventricular rate should be controlled in such cases of AF.

  1. LCVA (Left Cerebro-vascular Accident)

Cerebro-vascular accidents are referred to as sudden neurological deficit due to vascular cause, mainly occurring because of insufficient oxygenation to the brain areas. It can be both ischemic and hemorrhagic in nature (Mckenzie & Porter 2015).  The slight weakness in the right side of Audrey’s body is compliant with this condition. Nurses are thus required t o continuously monitor her blood glucose levels and cardiac movements. Audrey was diagnosed with GCS of about 14/15, nurses must therefore prevent any fall in GCS, observing which should be consistent with further diagnosis to avoid any major complication (Mena SanchezRubiano,  et al.  2011).

  1. T2DM (Type 2 Diabetes Mellitus)

Type 2 Diabetes Mellitus can be defined as a heterogeneous metabolic disorder characterized by insulin resistance, resulting in frequent and persistent hyperglycemia (Olokoba & Obateru, 2012). Therefore, there is need for proper monitoring of Audrey’s blood sugar levels by nurses in order for subsidence of the abnormal values for medical management.

  1. GORD ( Gastro Oesophageal Reflux Disease)

Gastro-oesophageal reflux disease refers to a heterogeneous entity causing reflux of gastric juices, due to low sphincter pressure or transient lower oesophageal sphincter relaxation (Diamant, 2006).  It may account for explaining the severe heart burns and chest pain frequently observed in Audrey (Kahsilas & Hughes). This suggests that the patient should be using the proton pump inhibitors for the management of her clinical condition which should be reported by the nurses (Dekel, Morse and Fass 2004).

  1. Osteoporosis

Osteoporosis is defined as low bone mass, structural deterioration and porous bone that leads to increased fracture risk (Johnell O & Kanis J 2005). The clinical implications of the condition are thus supplementation with calcium and vitamin tablets and other osteoporosis medication.  Chronic pain and a decrease in ability to carry out normal activities can occur following a broken bone as in case on Audrey’s hip anthroplasty (Handout on Health: Osteoporosis, 2014). Therefore, nurses must be taking care of management of the pain and supplemented nutrient-rich diet. Nurses should check the t-score of Audrey for further assessments. Evidences show that Osteoporosis treatment reduces the risk of fracture in the patients with hip fracture with a T-score of -2.5 or more negative at neck of femur without secondary causes (Kling Juliana M., Clarke Bart L., & Sandhu Nicole, 2014).

  1. Total Hysterectomy

Total Hysterectomy is defined as the complete removal of uterus and cervix in females (Mckenzie & Porter, 2015). Studies have shown that there are chances that indicate statistically significant increases in overall fracture risk with total hysterectomy. The most common complications of hysterectomy that predisposed Audrey post the hysterectomy include infections, venous thromboembolic, genitourinary (GU) and gastrointestinal (GI) tract injury, bleeding, nerve injury (Clarke-Pearson DLGeller EJ, 2013). It may explain the inconsistency and back pain in the Audrey’s assessment.

  1. Depression

Depression is a debilitating psychiatric disorder.  Antidepressant medications are used for subsidence the symptoms but they do not reduce the recurrence once their use is terminated (Ghoneim and O’Hara 2016). Audrey’s complications and anxiety suggests that the nurses must provide her emotional support and encourage her to relaxation exercises. This can also be supplemented with psychotherapies for effectively dealing with the post-surgery depression.

 

Medical History

  1. Digoxin 62.5 mcg OD

Digoxin is an antiarrhythmics drug and works by blocking sodium pumps in the body. This medication seems consistent with the Audrey’s  Atrial Fibrillation (Isabelle  and Gheorghiade 2013; Scalese and  Salvatore, 2016).  Digoxin dose however should be referred considering the fluctuating blood pressure in Audrey. Continuous blood pressure and heart rate monitoring is thus an important nursing intervention to avoid any complication.

  1. Warfarin 2mg OD {INR result 2.0 in ED}

Warfarin is an oral anticoagulant that is referred in stroke and abnormal heart conditions. The INR, International Normalized Ratio, that measure how long it takes the blood to coagulate was found to be 2.0. The 2.0 score indicates that the coagulation time was within accepted range. However, INR can be fluctuated and lead to serious complications, therefore nurses should perform proper monitoring and report it to the medical practioners prior to the procedure to prevent Audrey from associated risks that including hemorrhage (Molteni & Cimminiello, 2014).

  1. Coversyl 5mg OD

Coversyl, with generic name of Perindopril, is used to treat high blood pressure. Audrey has been diagnosed with hypertension by inhibiting Angiotensin Converting Enzyme (ACE). Considering Audrey’s susceptibility to cardiac events, Coversyl along with Digoxin may also prevent such risks.

  1. Vitamin D 1,000 units OD

Vitamin D supplements are prescriptions that Audrey must have been taking after been diagnosed with Osteoporosis ( Sunyecz, 2008). Vitamin D is required for regulation of both calcium and Phosphorus in the bones.

  1. Metformin 500mg BD

Metformin is an anti-hyperglycemic drug that helps in management of type 2 Diabetes Mellitus by improving the glucose tolerance and lowering both basal and postprandial plasma glucose (Knowler, Barrett-Connor, and Fowler, 2002; Bailey and Turner, 1996). Nurses should report the physician about the usage of this drug by Audrey, as Metformin is suggested to be temporarily suspended prior to any surgical procedure. Additionally, nurses should assess Audrey’s renal function to counterbalance the potential of Metformin for decrease in renal function in elders.

  1. Esomeprazole 40mg OD

Esomeprazole are gastro-resistant tablets that reduce gastric acid secretion by inhibiting H+K+-ATPase pump in parietal cells. The use of this drug by Audrey corresponds to her treatment of erosive reflux oesophagitis (GORD). Nurses must take proper care of Audrey by giving enough vitamin D and Calcium supplementation as Esomeprazole tend to increase risk of fracture in conditions like osteoporosis. The Esomeprazole has been found to be interacting with warfarin, therefore reporting the simultaneous uses of both drugs should be done.

  1. Effexor 150 mg OD

Effexor is the generic name for Venlafaxine that is antidepressant drug in nature. This complies with the medical history of depression in Audrey. Venflaxine inhibit uptake of both serotonin and non-epinephrine. Effexor often leads to headache, nausea and fatigue as side effects which should be managed by nurses by giving appropriate medications to relieve her.

  1. Caltrate 600mg OD

Caltrate is given as calcium supplement in the form of calcium carbonate in the cases of osteoporosis. Audrey must have been given caltrate along with Vitamin D to treat osteoporosis.

  1.  Mylanta 15-30 mls PRN

Ranitidine, with generic name of Mylanta, is given in conditions of acid indigestion, sour stomach, heartburn, and upset stomach. One of the side effects of Mylanta is constipation that was observed in Audrey’s condition. Mylanta is known to interact with Digoxin, so further assessment of the medications should be reported by nurses.

Pre-operative Nursing Management

Nursing management should take full responsibility to deliver complete information about the procedures in simple and friendly manner to avoid any misinterpretation and development of preventable complication. Nurses should develop a healthy relationship with Audrey to promote a positive surgical experience.  They must also discuss the need of safe and caring environment to witness faster recovery.

Pre-operative Nursing assessment include gathering medical history and physical examination of the Audrey. Audrey’s significant cardiac, hematology, renal and neurological condition needs further consultation for proper care and management of her condition. Nurses must assess the Audrey’s conditions by evaluation of the diagnostic studies including x-rays, bone scan, CT/MRI that may reveal soft-tissue swellings, fractures, deformity, extent of degeneration and help in ruling out malignancy.

Pre-operative nursing assessment must include a chart review of all previous medical condition, history and prescribed medication along with the recent physical examination laboratory reports and ECG results etc. Pre-operative education helps to alleviate patient fears and anxiety. Nurses must make proper arrangements for surgical procedure as per the indications.

Post-operative Nursing Management

Post-operative care is a multi-disciplinary responsibility in case of Audrey. . Her previous medical history accounts for further post-surgery complications and more risk factor that should be taken care of to prevent any co-morbidities. Immediate post-operative management includes medical stability, NVS assessment and pain alleviation. Complications like, bleeding, nausea, venous thromboembolic events, hemodynamic instability and other adverse reaction must be assessed post the surgery procedure. Audrey should be checked for any infection. Pain management in Audrey’s case can help to alleviate the adverse experience. Anticoagulants, such as warfarin, can be used to reduce the risk of thromophlebitis.

Discharge

Audrey does not have live in caregivers; she must be discharged to a short-term care facility providing physical therapy and heath care.

The discharge goal of Audrey should be compliant with the post-operative assessment that should indicate minimized complications, increase in mobility, and relieved pain. Audrey must be made completely aware of diagnosis, prognosis and therapeutic regimen before actually getting discharged.

The Discharge planner must provide emotional support and guidance to Audrey to comply with her health. Discharge planner nurse should coordinate with rehabilitation facility before the actual discharge. They must be knowledgeable about patient-benefits and hospital’s strategies to interact with Audrey to facilitate discharge process. A multi disciplinary approach must be adapted by medical and nursing to maximize the rehabilitation potential.

Conclusion

Nursing care should manage critical pathway for Audrey’s care. It must include designing and implementing a structured approach for Audrey’s routine assessment, medications, pain management, psychosocial issue and discharge planning. Nursing care should be committed to educate Audrey throughout the peri-operative experience. Recommending life-style changes is also the parts of patient education to optimize the implant longetivity and care of the patient. Thus, Nursing management provides a critical link to give necessary care to the patient throughout the peri-operative phase.

 

 

 

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