About the case
The case is related to Mrs. Audrey Smith, a 75 year old female admitted to the emergency ward for an injury due to slip-and-fall accident. The diagnosis of Mrs. Smith’s condition revealed that she has a fracture on the left neck of femur, injury to the soft tissue, bruise on her left shoulder, and a small haemotomia to her forehead. The patient has active orientation and anxious about the care of her dog. She has been sent for the pre-operative care as she needs surgery for Arthroplasty. The present study assesses the past medical history, medication history, social history, nursing assessment and allergies of the patient and utilizes the critical thinking skills for the nursing interventions that are required for the pre operative and post operative care of the patient. A discharge plan with a speedy rehabilitation is also prepared for the case.
The nurse has an important role in the preparation, care, and providing support all through the surgical journey of the patient. The nurse should assess the patient in a holistic way and an effective planning for the pre-operative and post-operative care enables the efficient care and optimal recovery of the patient.
Safety of the patient is an essential and vital component of the nursing care. it is essential to determine the patient factors that are significant in enhancing the risk. Nurse should assess the vulnerabilities of the patient in such a way that they can be identified that the complexities could be efficiently managed in the pre-operative environment. (Malley, 2015). As Mrs. Audrey smith is an aged patient proper care should be provided by the nurse for her mobilization.
Nursing care related to hygiene are the fundamental activities performed by a nursing professional and the patients of intensive care highly value these activities. These are indicators for the perceptions of their families on the quality of attention.(Curtis,2008). Nursing interventions some cases is to respond to the needs and services of patients with no appreciation from patient. In a situation where the task is to promote the well-being of the patient it is important to go beyond procedures and the benefits associated with it. (Larson et.al, 2004). As Mrs. Smith is an aged patient the nurse should focus on the interest of the patient in providing hygiene and comfort.
Malnutrition is considered as a significant factor for the impairment of intestinal immune function, a decrease in the digestive or absorptive capacity occurs due to the altered gut architecture. Nurse interventions in addressing malnutrition for preoperative patients include oral supplementation and artificial feeding. The pre-operative nutritional intervention creates a greater interest and value to the patient that enhances post-operative outcomes. While designing a nutritional plan it is important for the nurse to advice dietician on health, medical history and age should be considered. The patient in the present case is aged and injured, so nurse should intervene in her diet schedule by considering these additional points.
Most of the pre-operative tests are guided by the needs of patients, this enables to assess the preexisting health problems of the patient.(Garcia et.al,2003). In the present study, the patient has constipation that should be taken care of by the nurse. In addition to this, the patient has urinary incontinence. Nursing intervention should effectively eliminate the constipation and urinary incontinence before surgery.
Nurse should focus on avoiding delirium by orienting the patient in a frequent manner, fractures associated with neck can disrupt vascular supply and that should be taken care of. Even though the patient is at bed, it is important to reposition the patient in a regular manner in such a way it is least painful to the patient. (Ucas,2004). As the patient is aged, nurses and physiotherapists should plan for improving the activity levels.
Severe pain is associated with poor quality of life, and it is important to focus on controlling the pain is important for a nurse.(2012). Delirium is one important risk factor that is associated with these type of pre operative condtiions, and it is important to consider this risk factor for the nurse. It is observed that the patient is in anxiety about the fate of her dog and the anxiety should be attended upon with counselling.
Patients with pre operative Atrial fibrillation (AF) and undergoing surgery for arthroplasty require additional care as this condition is associated with increased post operative anemia, increased transfusions and increased risk of complications and readmissions. (Agarwal et.al,2013). The pre operative care should include prevention of cardiac dysfunction, in addition to arterial thromboembolism. Mrs Smith is an aged patient and utmost care should be taken to prevent further complications.
Prolonged wound discharge in arthroplasty is associated with risk of infection, hypertension has a potential role in prolonging the healing of wound. It is important to consider these complications for the clinical management of arthroplasty. In addition to this there is a high risk of developing thromboembolic disease in arthroplastic surgery. (Ahmed et.al,2011).
The patient has a history of left CVA with a weakness on right side, an ischemic stroke occurred due to a lack of blood supply to the part of brain. This is a predictor of perioperative stroke, and an optimal interval is necessary for surgery. However, from the available information the risk of stroke is very low or nil. Nonetheless, the patient needs special care in this aspect.(Sanders et.al,2015).
In surgeries, the uncontrolled diabetes increases complications associated with respiratory, cardiac and genito urinary systems. Diabetes increases the risk of respiratory embolism and infections after surgery. It is important control diabetes before surgery to avoid associated complications. (Guzman et.al,2014). As the patient is a chronic diabetic patient, it is necessary to check blood sugar levels on a regular basis.
The patient has the disorder where there is a backflow of gastro duodenal contents and nurse should take care of patient to avoid this complication by giving advice to sleep on elevated bed. The patient should lay on bed to the left to decrease the reflux, and she should take counselling on changes in timings of diet consumption with low intake at smaller intervals. (Dempsey,2011).
Osteoporosis is one of most common disorder associated with bones, the complications of this condition associated with arthroplasty include, increased risk of perioperative prosthetic fracture, and a late aseptic loosening. The patient needs suitable therapy for the recovery of bone mass before surgery. Quality of the bone has crucial role in minimizing complications after surgery. (Bottai et.al,2015).
The patient has undergone total hysterectomy for uterine abnormalities, pre malignant and malignant diseases. There is a possibility of infections after surgery and care is necessary to avoid the infections. (Broder ,2000).
Depression is a common disorder that is prevalent in most of the patients with arthroplasty. A chronic pain is the clinical symptom that can lead to depression in these patients. It is necessary to understand the patient at a greater level as the patients will be sad and loss of interest on life. An effective pain management and counselling by health care professionals can improve the situation. (Sharma.,2003).
Digoxin of 62.5mg Once a day is prescribed for the patient for AF. This medicine makes ventricular beat to slower down. Patient consumes this medicine daily, due to this it is essential to monitor the patient with ECG and pulse at regular intervals. It is also essential to monitor the effectiveness of this medication.. (Lehne, Moore, Crosby & Hamilton, 2013).
The medicine is an anticoagulant is used. This drug was prescribed to the patient for venous thrombosis, PE, and thromboembolic complications associated with AF and CVA. The Warfarin however is adjusted according to INR blood test results. The patient is AF and CVA, to avoid complications, it is important to regularly monitor the. coagulation process (McKenna & Lim2012).
In the treatment of hypertension, Coversyl inhibits ACE. Hypertension of the patient needs a regular monitoring to avoid risk. Electrolyte levels and renal function needs monitoring.
To prevent deficiency of calcium, and osteoporosis, Vitamin D is administered. Monitoring of the patient should be done for renal impairment and the drug should be consumed on a daily basis to avoid complications.
glycemic levels are controlled by Metformin and it treats adult type 2 diabetes. There is a need to monitor the blood sugar levels at regular intervals before and after surgery to avoid infections and other complications. (McKenna & Lim, 2012).
Esomeprazole provides a symptomatic relief to gastroesophageal reflux disease (GORD).. It is important to regularly monitor the pathology of kidney and liver while using this drug. The drug is administered before a meal and checked for side effects such as gastrointestinal irritation.
This drug treats major level of depression, and social anxiety disorder. After the patient consumes this drug along with food, she should be monitored for fatigue, tachycardia, hypertension, hypotension weight loss.
To prevent and treat osteoporosis, Caltrate, a calcium supplement is used. The drug needs to be consumed with food.
esophageal reflux can be treated with Mylanta, an antacid, it also reduces heartburn and indigestion. phosphorus deficiency.caused by this drug requires needs to be maintained. Patient needs to take this medication after two hours of her schedule cardiac medications to avoid interaction of these medications.
The social history of the patient indicates that she is alone at home.and a home care counsellor visits her fortnightly. She has a daughter who visits often and she meets senior citizens once in a week with her neighbor. She is
Unidentified problems can be eliminated by physical examination patient. Evaluation of comorbidities such as cardiovascular disease, cerebrovascular disease, stroke and endocrine disorders and diabetes needs attention as the patient is at the increased risk of myocardial infarction, angina, claudication, transient ischemic attack, stroke..Laboratory tests such as complete blood count, prothrombin (PT), INR, activated partial thromboplastin time (aPTT), and basic tests such a analysis of urine and blood sugar should be performed at regular intervals. A cross matching of the blood needs to be done, as the surgery may be associated with intraoperative and perioperative blood loss. Obtaining a complete and accurate list of current medications is mandatory and it is important to discontinue Warfarin for a minimum of three to five days prior to surgery. It is necessary to normalize time (PT) and corresponding INR before surgery. A Oral hypoglycemic should be held at the day of surgery (Stoner SC, 2003). Patient should be empty mouthed before to surgery to avoid aspiration during the surgery. Accurate identification of the patient with good marking at the surgical site is necessary for safety considerations. (Timmel J &., 2010). For a proper anesthetic dose. It is important to record height and weight and it is also necessary to explain the procedure to the patient and obtain consent.to get the consent from her.
Post-operative management of patient who has gone through hip surgery should focus on pain management, prevention of secondary complications and early mobilizations. The vital signs and consciousness levels of patient needs to be checked and recorded more frequently. A variation in pulse, respiration and temperature are early warning signs of infection and bleeding. Provision for adequate ventilatory support by providing oxygen based on necessity is important. Spo2 levels needs to be frequently checked along with the change of the color of skin. Observation is necessary for hypovolemic shock, and the IV fluids for the patient should be continued to maintain hydration. An intake and output chart is mandatory to understand the fluid balance. Drain is checked constantly for any possible bleeding. Assessing the Pain levels reduces the stress and discomfort experienced by patient. In addition to that, she can be informed about the available analgesics like PCA. An effective pain management helps in early mobility and recovery. An early prophylactic antibiotic treatment has to be started, as they are commonly administered to prevent wound infection (surgical site infection, SSI) following orthopedic procedures. Neurovascular complications may occur due to direct injury to the nerve and blood vessels or from increased tissue pressure. Neurovascular assessment of the affected leg every 10 minute will help to identify these complications. Venous thromboembolism is one of the leading causes of postoperative morbidity and mortality in patients with hip fracture. The patient is made to maintain increased fluid intake and ankle and foot exercise. She has to be assessed every 2- 4 hour for DVT and presence of anti-embolic stockings, use of compression devices and administration prescribed anticoagulant are important in prevention of post-operative DVT. Patient needs encouragement for deep breathing and coughing for every 2 hours to prevent pulmonary complications. Skin breakdown is of common occurrence in people with hip fracture, so patient should be assisted to change positions frequently to prevent pressure sore. Repositioning should include using 1-2 pillows in-between the legs to keep the affected leg in an abducted position to prevent the chance of dislocation of the prosthesis. BSL needs to be checked on hourly basis to prevent hypoglycemia and beginning a post-operative light diet after 4 hours if it is recommended ( Dempsey,2011).
The patient needs to teach about the delayed complications of surgery, such as infection, nonunion and prosthesis and report them to doctor immediately if that occurs. She needs to adhere to the weight wearing regime and able to perform physical activities. In addition to that, she should be taught practice specific exercises before discharge. She must be able perform wound care, transfers and use mobility aids independently.
The patient is living alone and needs some psychological support after she is discharged from the hospital. A referral to social workers has to be arranged and also arrangements should be done for her to meet her dog. A community transport has to be arranged for her to attend the social club once in a week as she cannot drive.
Constipation is one of overlooked complication which can occur even after the discharge. It occurs due to the decreased mobility and hydration together with certain medications. Constipation can be prevented with regular monitoring of bowel functions, early mobilization and adequate hydration. The patient should return home with some laxatives.
Home modifications for the use of special equipment and aids have to be done for the patient before she is discharged. A referral has to be send to occupational therapist and physiotherapist. These referrals provide patient with resources to cope with the problems as well as demands post discharge. A follow up has to be booked for her with GP before being discharged.
The admission of the patient to the ward with fractured left NOF necessitated arthroplasty and she is ready to get discharged to a fast track rehabilitation facility 10 days after surgery.. The case discussed the admission process of Mrs. Audrey using critical thinking skills by prioritizing nursing interventions related to her safety, hygiene and comfort, nutrition, elimination, activity levels and psychological needs. The past medical history and their relation to current diagnosis and management were discussed. Mrs. Audrey’s current medication and their indication for use is explained in the case study. Specific nursing interventions for her pre-and post-operative care were discussed. Finally, a detailed discharge was planned to enable Mrs. Audrey for a fast track rehabilitation facility.
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