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Introduction

Intentional thinking of the nurses enables them to develop relationship among their skills, attitudes and knowledge, which are attributed to clinical reasoning, critical thinking, problem-solving and nursing process (Swinny, 2010). Execution of nursing process provides the nurses with creative approach to do and think in order to obtain, analyse and categorise patients’ information and plan actions accordingly to meet the needs of the clients. This write-up strives to analyse a critical thinking scenario in order to develop a detailed pre-, post-operative and discharge plan of a 75 years old female, named Audrey.

Interpretation, Analysis, Explanation and Relevance of Relevant Nursing Problems

Audrey’s nursing intervention should include her comfort and safety, hygiene, nutrition, elimination, activity levels and psychosocial needs. From the case study, it could be mentioned that Audrey’s fracture occurred as she had tripped over her pet dog. Fracture gives rise to tremendous pain that should be taken into consideration with high priority. Pain management would promote patient comfort and safety. Limb rest should be maintained. Joint support should be provided below the fractured area, especially during turning and moving. It ensures patient stability diminish muscle spasms, eliminate possibility of uncomfortable alignment that enhances healing. Initial comfort and patient stability ease the process of further nursing assessment by promoting interaction between the patients and the care providers (LaBranche, 2011). Evaluation and observation of splinted extremity is necessary for resolution of oedema. Thomas splint could be used in order to provide immobilisation of fracture in case of excessive swelling of tissue. After reduction of oedema, splint readjustment could be made for stable alignment of the fractured site. Besides leg fracture, bruising to left shoulder and small haematoma to her left forehead have also been reported. Hence, skin examination should be performed. It provides information on problems, skin circulation and oedema formation which require medical intervention.

It is impossible for Audrey to move from her bed, hence, nursing intervention should include maintenance of her personal hygiene and toileting. Therefore, she is assisted with an indwelling catheter (IDC). The catheter size should be small that diminishes urethral trauma and ensures sufficient drainage of peri-urethral glands. The frequency of change in catheter need to be based on clinical indications, such as, catheter-associated urinary tract infections, bleeding, and leakage. The drainage bag should be well supported in order to ensure that the balloon is not twitched into the bladder neck due to the drainage bag’s weight while it gets filled (Lee, 2011). Catheter sleeves and straps could be used in order to secure bag’s position and diminish taction-associated complications like soreness and discomfort surrounding the catheter and bypassing urine.

During nursing intervention, taking care of Audrey’s nutritional factors are highly significant. This is because due to fracture, her regular smooth movement gets diminished, which might also affect her adequate diet intake. As she is unable to sit, she should be recommended with liquid diet. From the case study it is known that Audrey is under intravenous therapy. Nurses should check the flow every 15-20minutes in order to ensure proper administration of IV fluid volume as recommended. It helps to maintain electrolyte and fluid balance, restore circulatory volume along with patient’s nutritional status. Adequate amount of fluid administration would ensure proper elimination of waste materials. Inadequate elimination of urine and bowel could worsen Audrey’s present situation.

Nurse should monitor urinary elimination considering volume, colour, and consistency. These parameters enable the care providers to determine adequate functioning of urinary tract. As a short-term management, the patients should be provided with urinary incontinence garment, which can reduce embarrassing moments of urinary incontinence. Limiting fluids 2 hours prior bedtime could be helpful in decreasing urinary retention and overflow, thereby, promoting rest. Urinary output should be recorded, which serves as an indicator of renal and urinary tract function and fluid balance. Catheterisation helps in maintaining tonicity of bladder muscle, prevent overdistention and complete emptying. Listening to the bowel sounds, noting the characteristics and location is important as bowel sounds could be absent due to the shock after femoral fracture. Abdominal distention should be observed. Nurses should also note any complaints of vomiting and nausea as gastric bleeding may occur during fall. Stool consistency need to be checked. Intestines should be stimulated with laxatives in constipation.

Nurses should evaluate extent of immobility produced by Audrey’s fall and should also note her perception about immobility. Audrey may feel restricted by self-perception due to physical limitations. Hence, intervention of activity levels is important that promote progression of patient wellness. Footboard should be provided to maintain functional position of limbs and prevent further complications. Periodic placement of patient in supine position stabilise lower limb fracture. This lessens the possibility of flexion contracture of hip. Periodic repositioning support deep-breathing exercises and coughing that prevent respiratory and skin complications, such as pneumonia, atelectasis and decubitus (Bozic & Kurtz, 2012). Later, Audrey should be assisted with range of motion exercises of the unaffected limbs. This increases flow of blood towards the bone and muscle to improve muscular tone, joint mobility, prevent atrophy with calcium resorption.

It is known that Audrey stays alone in her house, which necessitates providing her with support workers at her home after the discharge from the hospital. She should be encouraged in participating recreational activities and maintain stimulating environment such as TV, radio, short walking or roaming during early morning and evening. It provides chance of releasing energy, refocus attention and increase self-worth and self-control and helps in diminishing the feeling of social isolation. Consulting with physical and rehabilitation specialists is also recommendable (Aprile, 2014). It helps in forming individualised exercise program and activities. Audrey may need long-term assistance with movement and use clutch, walker or cane. She may require elevating toilet seat and reachers.

Explanation of 8diagnoses Referred to in Mrs. Smith’s Past Medical History

Mrs. Smith’s past medical history demonstrates that she is hypertensive, diabetic and had undergone atrial fibrillation, left cardiovascular accident, acid reflux, osteoporosis and total hysterectomy.

Atrial fibrillation or AF is an irregular heart rate that often beats at a faster rate and causes poor flow of blood. AF gives rise to fatigue, breathing shortness and palpitation of heart. This indicates a need of treating AF as it may cause a severe stroke (Gillinov, 2008). CVA or stroke is referred to the condition when blood flow towards a part of human brain get obstructed and stopped by blockage or rupture of blood vessel. In hypertensive condition, the force of blood flow against the artery walls increases, improper management of which could give rise to cardiovascular accident. T2DM or type II diabetes mellitus is referred to as a metabolic disorder, which is characterised by insulin resistance, lack of insulin and high blood sugar (Yarek-Martynova & Shamkhalova, 2010). Common related symptoms include frequent urination, weight loss and increased thirst. Gastro-oesophageal reflux disease (GORD) refers to the situation where acid leaks out from the stomach and irritates the lining of the food pipe. Heartburn and acid reflux more than twice in a week indicates GORD (Fox, 2006). Osteoporosis is said to be a condition where bones become brittle and weak. With an increasing age, the mass of osteocytes reduces that further weakens the bones and causes tremendous pain. Mrs. Smith’s osteoporotic condition might have exacerbated the risk of fracture following a fall. Removal of cervix and uterus is known as total hysterectomy. Mrs. Smith’s urinary incontinence could be an adverse effect of her total hysterectomy. Persistent sadness and loss of interest are the major characteristics of depression. Mrs. Smith has developed depression after the death of her husband, which could be a major reason to support her depressive condition.

Drug Therapy Appropriate to the Patient Care

Warfarin: it is a blood thinner that does not affect the blood viscosity. It inhibits clotting factor syntheses that are depended on vitamin K. It reduces blood clot movements towards important organs, for example brain and lungs. For emergency administration purpose fast acting anticoagulant should be administered like: heparin. Audrey’s medical history demonstrates AF and CVA, hence, recommending her with Warfarin is effective. Nurses should evaluate PT/INP prior initiating warfarin therapy. Dose should be adjusted to maintain PT at 15-35% normal prothrombin activity and INR 2-4 based on diagnosis (Waldo, 2008).

Digoxin: it is cardiac glycosides that treats congestive heart failure. It controls ventricular rate in arterial fibrillation. Digoxin is excreted by the kidneys, hence, risk of toxic reaction to digoxin may be greater in patients with impaired renal function. But, Audrey’s medical history demonstrates no renal complications hence it is beneficial for Audrey. Prior administration, nurses should measure apical pulse for a minute considering rhythm and heart rate. It should not be administered if pulse is greater than 50-60/minute (Wang et al., 2010).

Coversyl: it is an antihypertensive drug. It controls elevated level of blood pressure by relaxing the blood vessels. It is also prescribed to treat congestive heart failure and reduces risk of cardiac events after a recent stroke or individuals with coronary artery disease. Audrey is hypertensive and experienced left CVA, which indicates that prescribing Coversyl to Audrey is highly beneficial.

Vitamin D: active form of vitamin D inside human system is known as calcitriol that increases the concentration of serum calcium by increasing the absorption of calcium and phosphorus in the gastrointestinal tract, increase osteoclastic resorption and calcium resorption in the distal renal tubule. It promotes calcium resorption in the intestine through binding with vitamin D receptors present in the intestinal mucosal cytoplasm (“DrugBank: Perindopril”, 2016). As Audrey has a history of osteoporosis, recommending her with vitamin D dosage is highly beneficial. Nursing implications include reporting a drop in alkaline phosphatase in the serum as it signals initiation of hypercalcemia.

Metformin: it is used to treat type II diabetes mellitus. It reduces the level of blood glucose in the blood by reducing the production of hepatic glucose, intestinal absorption of glucose and developing sensitivity of insulin by increasing uptake of peripheral glucose and its utilisation. Audrey has a history of type II diabetes mellitus, therefore, recommending her with Metformin is beneficial. Nursing implications include monitoring reduced liver function, cardiopulmonary status where cardiopulmonary insufficiency might lead to lactic acidosis (Cameron, Forteath, Beall, & Rena, 2015).

Esomeprazole: it is a type of proton pump inhibitor which suppresses secretion of gastric acid by inhibition of H⁺ /K⁺-ATPase within gastric parietal cells (Bandar Aljudaibi, 2010). It is effective to treat Gastro-oesophageal reflux disease and thus significant to prescribe Audrey. Nursing implications include monitoring adverse effects of the central nervous system (depression, agitation and vertigo).  Periodic tests for liver function is also important.

Efexor: it is used to treat depression. It inhibits the reuptake of norepinephrine and serotonin but has reduced inhibitory effects on dopamine reuptake. Efexor is not active at alpha(1)-adrenergic receptors. Thus, controls the activity of central nervous system. Audrey is suffering from depression since last 5years, hence, recommending her with Efexor is significant. Nursing implications include periodic measurement of blood pressure and heart rate, monitoring lipid profile, excessive insomnia, nervousness and anxiety.

Caltrate: it reduces acid load within the gastrointestinal tract, increases gastric pH that reduces activity of pepsin, reinforces the gastric mucosal barrier and grows oesophageal sphincter tone. As Audrey suffers from heartburn and acid reflux prescribing her with Caltrate is effective. Nursing implications include recording amount of stool consistency, monitoring level of calcium and hypercalcemia (anorexia, confusion and headache). However, Audrey takes cardiac glycoside, so administration of Caltrate should be done cautiously.

Mylanta: it is a type of antacid that does not prevent production of acid but acts on existing acid inside the stomach. It is useful to treat heartburn and indigestion. Audrey had a history of Gastro-oesophageal reflux disease, which causes heartburn. Therefore, prescribing her with Mylanta is effective. Nursing implications include severe pain in the abdomen, along with renal failure and fever.

Pre-Operative Care

Arthroplasty will be performed on Audrey. Her pre-operative care plan includes minimisation of the infection related risks, stabilising patient in order to reduce discomfort, pain, reducing risk of peripheral neurovascular impairment, and inform the patient about the procedure.

Infection Related Risks

Nursing Care	Reasoning
Evaluating temperature, skin colour, integrity, presence of inflammation and intensity of wound	Provides early indications of infection and possibility of healing
Investigate alterations in pain characteristics	Dull, deep, aching pain in the fractured area may demonstrate the chance of forming joint infection. Once infection initiates in the joints, it cannot be reversed.
Noting the presence of chills	Temperature elevation is common but constant temperature for more than 3-4days may indicate the presence of infection such as sepsis, tissue necrosis and so on.
Administer antibiotic as prescribed	Used prophylactically to prevent infection (Toba, 2007).

 

Reduce Discomfort, Pain

Nursing care	Reasoning
Evaluate Audrey’s pain intensity (0-10), location and duration	Informs nurses based on what they monitor the efficiency of interventions.
Maintain proper positioning of fractured area	Lessens muscle spasm and undue pressure on surrounding tissues.
Examine reports of severe and sudden joint pain, muscle spasm, joint mobility, chest pain with restlessness and dyspnoea	Early indications complications such as pulmonary emboli that informs prompt intervention and prevention of serious complications.
Apply icepacks if recommended by the doctor	Promotes circulation to the affected muscles, reduces stiffness of joint, and relives spasms of muscle (Lucas, 2007).

 

Reducing Risk of Peripheral Neurovascular Impairment

Nursing care	Reasoning
Evaluating vital signs	Tachycardia and lessening blood pressure may demonstrate blood loss or hypovolemia or inform anaphylaxis associated with methyl methacrylate absorption by the systemic circulation.
Test peroneal nerve sensation by pinprick between the first and second toe	Length and position of peroneal nerve rise direct compression or injury by hematoma or tissue oedema.
Evaluate inflammation, calf tenderness	Primary identification of intervention and thrombus development may inhibit the formation of embolus.
Check indications of constant bleeding, oozing from fractured site	Sensitivity towards anticoagulants and depression of clotting give rise to bleeding, which could affect the level of red blood cell in the circulating volume.
Remove jewellery	Jewellery may restrict circulation if oedema occurs (Ko, Chu, & Lin, 2015)

 

Reduce the Risk of Impaired Gas Exchange

Nursing care	Reasoning
Handle fractured region gently	Prevents development of fatty emboli that is generally develops within first 12-72hr and closely related to fractures of long bones.
Monitoring respiratory effort and rate along with stridor, application of accessory muscles, growth of central cyanosis and retractions	Dyspnoea, tachypnoea indicate early respiratory insufficiency and development of pulmonary emboli.

 

Inform Audrey About the Procedure

Nursing care	Reasoning
Review process of disease, surgical method and further expectations	Provides patient with knowledge, based on which informed choices could be made.
Increase rest period	Conserves energy to prevent unnecessary fatigue, and stimulates stability

 

Post-Operative Care

Nursing priorities related to post-operative care for Audrey includes prevention of tissue injury, alleviation of pain, and prevention of complications and inform her with relevant information, diet, treatment needs and so on.

Reducing the Risk of Trauma

Nursing care	Reasoning
Maintain limb rest by providing joint support below and above fractured area, especially during turning and moving	Provides limb stability, diminish chance of disturbances, muscle spasms that increases healing.
Secure bed board under orthopaedic bed	Soft mattress may deform plaster cast and interfere with traction pull.
Support fractured area with pillow, maintain natural position with splints, trochanter roll	Prevents alignment disruption and unnecessary patient movement. Improper placement of support like pillows could increase pressure deformities.
Experienced professionals should be engaged in patients movement	Hip casts are extremely cumbersome and heavy. Failure of which could lead to cast break.
Patient positioning should be monitored to maintain proper pull on long bone axis	Promotes alignment of repaired bone and diminishes complications (Wylde, Maclean, & Blom, 2012).

 

Breathing Pattern

Nursing care	Reasoning
Perform stir-up	Deep ventilation breaks up secretions, inflates alveoli, increase transfer of oxygen, removes anaesthetic gases. Stir-up stimulates removal of section from pulmonary system.
Monitor excessive somnolence	Presence of muscle relaxants or narcotic-induced depression during respiration inside the system may reoccur, create sine-ware depression pattern. Additionally, Pentothal may absorbed in fatty tissues that improves circulation and redistributed through the bloodstream.
Administer oxygen supplement as directed	Increases uptake of oxygen that binds with haemoglobin instead of anaesthetic gases in order to increase removal of anaesthetic inhalants.

 

Altered Though Perception

Nursing care	Reasoning
Continuously reorient Audrey after coming from anaesthesia and confirm her that the procedure is successfully completed	As Audrey regains consciousness, she should be provided with assurance and support that would help in alleviate anxiety.
Interact in normal voice without screaming. Minimise negative discussion with patient and explain procedures	Providing patients with information helps in preserving dignity, eliminates chance of misinterpretation and promotes rapid recovery (Penning-van Beest et al., 2011).

 

Discharge Planning

Audrey’s discharge plan
Area	Specific steps
Medication reconciliation	Provide and explain medication list that includes OTC, prescription and herbal remedies. Involve clinical pharmacist. Evaluate pain and dosage modification, if required.
Nutritional information/patient instruction	Encourage increase in fluid intake, diet with high fibre and protein. Adequate nutrition and fluid support tissue perfusion, tissue healing and cellular regeneration.
Transition record	Completed written transition record according to facility procedures Reconcile discharge plan along with the clinical guidelines Handover the discharge plan to Audrey within 24hours of discharge
Medication Management	If required, develop new prescription with analgesics for management of pain, anticoagulant for PE/DVT prophylaxis and so on. Inform Audrey about the significance of compliance with medication instructions. Ensure that Audrey understand where to fill next prescriptions Discuss follow-up tests
Follow-up care	Made next appointment of Audrey’s follow-up with her surgeon and other relevant health care professionals. Provide physical therapy to Audrey. Provide name, address and contact number of the care professional, time and date of next follow-up, reason for visit in written format which would promote understanding for the patients as well as for any other care professionals. Inform Audrey that she should give her show her discharge plan to the care professionals involved in her care and recovery (Choi, 2013).

 

Conclusion

To conclude, it could be mentioned that the care professionals should also consider non-pharmacological interventions which include considering her psycho-social condition. Audrey stays alone at her home, which indicates a need to appoint a primary care provider, who could help her in her daily living activities. Hip replacement surgery may diminish her physical mobility, hence, she should be informed to walk with the support of clutch or walker in order to prevent the risk of fall. Thus, this assessment provides a through illustration of a case study of Mrs. Audrey Smith, a 75-years old Victorian female, who underwent left hip arthroplasty.

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