Critical Thinking Scenario Orthopaedics and Traumatology

Question: Discuss about theCritical Thinking Scenariofor Orthopaedics and Traumatology. Answer: Introduction In this case study different aspects of fracture surgery and related complication are going to be discussed. Assessment and intervention provided for Audrey before surgery is going to be discussed. Diagnosis of different conditions and its implication in the surgery as well different drugs and nursing intervention for each drug is going to be discussed. Pre and post operative actions for Audrey are going to be discussed. Intervention Action Rationale Safety Whole blood count Nurse should perform whole blood analysis of Audrey. It is very necessary to perform whole blood count because in patients with Neck of femur fracture, there is possibility of blood loss and it can lead to the anemia. Access to useful requirements Nurse should arrange all the requirements like wheel chair and toe guard near Audrey. As Audrey cant move, all her requirements should be near her or somebody should provide her to prevent further fall. Use of clinical pharmacist Nurse should incorporate clinical pharmacist in the care of Audrey. As Audrey is consuming multiple medicines there is the possibility of adverse reactions. To prevent these adverse reactions and to prevent allergic reaction due to the consumption of multiple drugs, clinical pharmacist should be incorporated. Obtain informed consent. Nurse should obtain informed consent from Audrey. This informed consent is important for improving the understanding of Audrey about potential risks of the procedures. Monitoring Nurse should perform neurovascular and neurological assessment, fall risk assessment. Audrey has habit of early waking up in the morning. Hence, nurse should monitor her specifically in the morning to prevent her fall (Yang et al., 2014). Hygiene and comfort Education Nurse should educate Audrey about the importance of body hygiene and oral hygiene. Nurse should also demonstrate Audrey about the procedures to maintain hygiene. Nurse should assist Audrey in toileting. Educating Audrey about the hygiene would definitely helpful in improving hygiene and prevent infection. There is high possibility of infection in patients with fractures. Bed bath/ Sponge Nurse should provide, catheter, bed bath or sponge to Audrey. As Audrey cant move from her bed, it is very important to give her bed bath or sponge. Identify needs and provide accessories Nurse should identify needs of Audrey for her comfort for sitting, sleeping, eating and other daily activities and provide her with necessary accessories. This would definitely provide more comfort to Audrey. Pain relief Nurse should provide medication for pain relief. To provide comfort. Nutrition Assess consumption of nutrients Nurse should assess consumption of nutrients in Audrey and also administer Audrey with essential nutrients. Patients with back of femur fracture are generally malnourished upon admission to the hospital. Moreover, Audrey has anorexia. Hence, nutrient consumption would be less. Assist in eating Nurse should assist Audrey for eating. Nurse should provide food to Audrey through NBM and IVT. As there is soft tissue injury in the shoulder, it would be difficult for Audrey to eat using hand. In such scenario nurse should assist her in eating. Elimination Assistance and support for elimination Nurse should provide bedpan, urinal, enemas or suppositories to Audrey. Nurse should provide privacy for elimination to Audrey to maintain her dignity. Nurse should provide positioning and hygiene to Audrey. Nurse should also monitor disposal of waste and odor control. Nurse should assist in positioning catheter. It has been observed that Audrey has constipation problem. Audrey also has urinary incontinence. Hence, nurse should provide all the necessary accessories. Activity levels Provide assistance to all the daily activities Nurse should provide assistance to Audrey for her daily activities like brushing, toileting, changing clothes, position changing during bed rest and eating. Due to her fracture she could not move from her position and moreover, she has weakness in her right side. Psychological needs Assess level of anxiety Nurse should assess level of anxiety in Audrey. For this nurse should observe verbal and nonverbal expressions of Audrey. Also, nurse should ask her few questions to assess level of anxiety. . It has also been observed that Audrey is anxious about her dog. Provide psychological calmness Nurse should ask social worker to take care of Audrey. Social worker should ask her not to think about her dog. It has been observed that Audrey is worried about her dog. (Carpenito-Moyet, 2009; Linton, 2015) Diagnosis Atrial fibrillation (AF): Atrial fibrillation is an abnormal condition of the heart in which heart rhythm is irregular and it is exhibited by the rapid and abnormal heart beat. Electrolyte imbalance and sepsis should be treated in AF patient prior to fracture surgery (Carpintero et al, 2014). Hypertension: Hypertension is the condition in which blood pressure is persistently elevated above the normal level (120/80). In studies it has been found that, women with hypertension have less bone mineral density (BMD). It increases the chances of slow healing of fracture. Also, surgery may increase blood pressure of Audrey (Carpintero et al, 2014). Left Cerebrovascular accident (L CVA): L CVA affects sensation and movement of right side of the body. Neck of femur surgery leads to physical inactivity, psychological distress, and pain. It can lead to increased risk of stroke (Jiunn-Horng et al., 2011). Type 2 diabetes: Type 2 diabetes is a long duration condition with increased level of sugar, insulin resistance and resistance to insulin. Hyperglycemia would not affect surgery unless patient is ketotic or dehydrated (Keehan, et al., 2011). Gastro-oesophageal reflux disease (GORD) : GORD is the long duration condition in which there is acidic contents of the stomach refluxed back into the esophagus. Dyspepsia, abdominal distension and constipation are the common complications occur after surgery and moreover, Audrey already has constipation problem (Carpintero et al, 2014). Osteoporosis: Osteoporosis is the condition in which there is reduced strength of the bone which increases possibility of broken bone. Due to this weakening of the bone, there may be problem in the bone surgery (Carpintero et al, 2014). Total hysterectomy: Hysterectomy is the condition in which there is the removal of uterus and cervix. Hysterectomy is the risk factor for the fracture and associated surgery (Melton, et al., 2007). Depression: Depression is the psychological feeling of sever dejection. There is the possibility of post-surgery depression in Audrey due to physical frailty (Phillips et al., 2013). Drugs Digoxin : Digoxin was used in case of Audrey for the treatment of her Atrial fibrillation. Nurse should administer digoxin for controlling heart rate. Nurse should use digoxin cautiously in Audrey because she has urinary incontinence. As digoxin is used with low dose in renal impairment, nurse should adjust dose of digoxin accordingly for Audrey. Warfarin : Warfarin is a anticoagulant which prevents formation of blood clots. As Audrey has haematoma to her left forehead, warfarin was prescribed to her. Generally warfarin should be avoided in patients with GIRD and nurse should keep in mind that Audrey has GIRD. It has been proved in studies that warfarin prolongs fracture surgery time as compared to the other anticoagulant hence it should be avoided in patients with fracture surgery (Ahmed et al., 2014). Coversyl : Coversyl is a angiotensin-converting-enzyme (ACE) inhibitor used to treat high blood pressure. Nurse should monitor Audreys blood pressure before and after administration of Nurse should place Audrey in supine position, if she develops hypotension. There is the possibility of fall in the blood pressure due to the fracture surgery, hence Coversyl should be administered with caution in Audrey (Carpintero et al., 2014). Vitamin D: Vitamin D is responsible for the absorption of calcium and it is useful for osteoporosis in case Audrey. It would also be useful in the management of fracture surgery in Audrey. Metformin: Metformin is generally used for the treatment of type 2 diabetes. In case of Audrey also it was prescribed for the management of type 2 diabetes which reduces level of increased level of blood sugar level by suppressing production of glucose by the liver. Metformin has potential to reduce the bone density in type 2 diabetic patients, hence it can affect fracture surgery in Audrey. Hence, nurse should administer metformin after checking bone density (Monami et al., 2008). Esomeprazole: Esomeprazole is a proton pump inhibitor which is used to reduce acid content in the stomach. Nurse should also monitor changes in urinary elimination in Audrey as she has urinary incontinence. Long term use of proton pump inhibitors like esomeprazole decrease bone density in Audrey (Greenstein Greenstein, 2007) Effexor: Effexor is a antidepressant drug acts as selective serotonin and norepinephrine reuptake inhibitor. Nurse should monitor Audrey for worsening of depressive condition. Nurse also should monitor cardiovascular parameters like heart rate and blood pressure. Effexor would be useful in Audrey, as there is possibility of depression post fracture surgery (Tripathi, 2013). Caltrate: Caltrate is a calcium and vitamin D3 supplement. Nurse should administer caltrate to Audrey with care, as it has potential to cause constipation and Audrey is already suffering from constipation. As calcium and vitamin D3 are helpful in strengthening bone, definitely caltrate would be helpful in the treatment of Audrey (Greenstein Greenstein, 2007) Mylanta : Mylanta is generally useful for stomach acid and it would be useful in Audrey as she has GIRD (Tripathi, 2013). Pre-Operative Intervetions Nurse should give analgesic to Audrey such as paracetamol and this analgesia should progress to opioids. Nurse should assess Audrey for anesthetic score and plan anesthesia for Audrey accordingly. Nurse should assess Audrey for possible comorbidities because it is evident from the literature that fracture surgery patients are associated with comorbidities like cardiovascular disease, respiratory disease cerebrovascular disease, diabetes, and renal disease. It is evident from the literature that patients with fracture surgery are associated with anemia. Hence, nurse should plan for approximately two units of blood transfusion. There is possibility of occurrence of leukocytosis and neutrophilia in patients fracture surgery due to trauma of fracture. Nurse should plan intervention for this condition in Audrey. Also, there is the possibility that lowering of platelet count due to anesthesia during surgery. Hence, nurse should plan for the platelet transfusion for Audrey. Nurse should perform coagulation test and Electrocardiography (ECG) in Audrey. Nurse should assess electrolyte balance in Audrey because in patients undergoing surgery it is very much required to have optimum electrolyte balance. Chest X-ray is required in patient with heart related problem undergoing fracture surgery. Audrey is associated with AF, hence nurse should plan for chest X-ray in case of Audrey. Nurse should understand exact procedure for the surgery because she should arrange all the requirement of the surgery at the time of surgery. Nurse should check with Audrey, whether she was associated with fever, cold and other common types of illness in prior week of surgery. Nurse should evaluate all the medications which were consuming by Audrey and stop medications which would affect the surgical procedure. Nurse should clean and apply disinfectant to the area, so that there would be less chances of infection due to surgery. Nurse should make sure that, Audrey should not eat and drink after midnight on the day of surgery (Boddaert, et al., 2014). Post- Operative Intervetions Intervention Action Rationale Pain Management Assessment Nurse should assess pain of Audrey using pain assessment scale. Based on the scale of pain, pain severity can be determined. Treatment Nurse should administer Audrey with analgesic medications like opioids or nerve blocking analgesic agents. Administration of pain medication to the patient undergoing fracture surgery would be helpful in reducing discomfort to Audrey. (Sieber et al., 2011). Venous thromboembolism Assessment Nurse should assess Audrey for deep vein thrombosis. Nurse can perform assessment of deep vein thrombosis using compression ultrasonography. Assessment of deep vein thrombosis is required in Audrey because from the literature it is evident that approximately 25 % patients of fracture surgery were associated with deep vein thrombosis (Kanchanabat et al., 2011). Treatment Nurse should administer Audrey, anticoagulant agents like heparins and warfarin. Administration of anticoagulant agents to Audrey would be helpful in preventing her from this life threatening condition. Anemia Assessment Nurse should perform assessment of anemia in Audrey by checking hemoglobin level. Due to the loss of blood during surgery there is the risk of developing anemia in patients undergoing fracture surgery . Management Nurse should perform transfusion of blood in Audrey after shifting to the ward. Anemia is associated with impairment in functional activities and consequently mortality in the patients developing anemia (Vochteloo et al., 2011). Infection Assessment Nurse should assess Audrey for the infection at the surgery site and for urinary tract infection. Due to loss of blood and skin incision during surgery, there is possibility of occurrence of infection in Audrey. Management Nurse should administer Audrey with appropriate antibiotic after the surgery. Occurrence of infection would be added complication for Audrey, hence it should controlled in the initial phase after the surgery. Postoperative confusion Assessment and management Nurse should assess cognitive dysfunction and confusion in Audrey by observations. Physician specialized in the psychological disorders should be called and Haloperidol or lorazepam should be administered for short duration of time. This confusion state can occur in approximately 25 % cases of post-operative fracture surgery. This confusion can lead to the difficulty in rehabilitation programme in Audrey (Roche et al., 2005). Malnutrition Assessment and management Nurse should assess nutritional status of Audrey. Nurse should incorporate dietitian in maintaining proper nutritional status of Audrey. It is evident from the literature that most of the patients admitted to hospital for fracture diet are malnourished. Intervention Action Rationale Rehabilitation Nurse should implement home physical therapy for Audrey. Nurse also should implement cognitive behavioral therapy and re-orientation therapy for Audrey. Nurse should perform rehabilitation of Audrey with the help of arthogeriatrician. From the literature it is evident rehabilitation of patients with fracture surgery have more rapid attainment functional activity and psychological well-being (Mehta Roy, 2011). Fall prevention Nurse should observe Audrey and assess for risk of fall. Nurse should assess balance, gait, vision and hearing in Audrey. Nurse should arrange care taker for Audrey for assisting her daily activities. Patients with fracture surgery are more prone to fall. Persistent occurrence of delirium, use of medications for confusion and cognition and change in the location from hospital to home also increases risk of fall in Audrey (Gillespie et al., 2003). Anabolic steroids and nutritional supplements Nurse should administer Audrey with anabolic steroids and nutritional supplement. Anabolic steroids and nutritional supplements would help in reducing the muscle and bone loss post fracture surgery (Tidermark et al., 2004). Secondary fracture prevention Nurse should also administer Audrey with Calcium and vitamin D administration. There are more chances of secondary fractures in patients with fracture surgery due to deficiency of Calcium and Vitamin D (Grant et al., 2005). Conclusion: Nurse role is very pivotal in the patients undergoing fracture surgery. Nurse should admit patient by considering all the physical, psychological and social factors of the patient. Nurse should consider safety, hygiene, nutrition, elimination, activity level and psychological needs of the patient. Nurse should take into account prior complications of the Audrey and plan surgery accordingly. 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