INTRODUCTION In this critical thinking scenario

Etudes

INTRODUCTION
In this critical thinking scenario, I demonstrate to analyse my knowledge on Mrs. Audrey smith who is lying down on the kitchen floor and suffering from fractured left NOF (neck of femur), soft tissue injury and bruising to her left shoulder as well as a small haematoma to he left shoulder. Here I’m going to present basic nursing needs for Mrs. Smith and provide information about her past medical history and diagnosis. I also deal with the pre and post operative management which compliment to surgical treatment. Lastly I’m talking about rehabilitation, discharge planning and what kind of nursing intervention require for Mrs. Smith for early recovery. This case also highlight the holistic approach to patient care, require the support of multidisciplinary team approach. I also ensure that continuity and maintenance of the care provided, records of data represent the main tool for communication. This information should be clear, objective, so that the member of the healthcare team easily understand.

CRITICAL THINKING SCENARIO
1) prioritise nursing intervention:
? SAFETY
• First assess safety needs of Mrs. Smith.
• Mrs. Smith is not able to perform her activity so monitor for any fall risk and applied fall risk intervention for her safety.
• For client safety access the infrastructure (including staffing, facilities and environment.)
• Prevention of infection is also included in safety needs.
• Mrs. Smith is suffering from depression so monitor for self harm behaviour.
• Keep the patient bad near to nursing station and apply side rails for prevention of fall.

? HYGIENE AND COMFORT
• Mrs. Smith has right sided weakness so maintaining hygiene and comfort is necessary for prevention of infection.
• She is 75 years old so skin is appear flaky and rough that’s why proper nursing intervention needed to maintain skin integrity.
• Apply protective ointments, provide back care and encourage for fluid intake.
• Also give other hygiene care like bathing, oral care, hair care, eye care, etc…( Berry, A. M., Davidson, P. M., Masters, J., ; Rolls, K. 2007 )
• Provide adequate comfortable device like pillow, air matters, back rest for prevention of pressure ulcer.

? NUTRITON
• Mrs. Smith suffering from anorexia so proper nursing intervention need for maintaining fluid and electrolyte balance.
• First perform the nutrition assessment and screening.
• Encourage for sufficient fluid intake.
• Regular exercise strengthen abdominal muscle and stimulate peristalsis.
• Provide smaller meals and supplements snacks.
• Provide choice for patient selective and her choices food.
• Give vitamin D and calcium rich diet for strengthen bone.

? ELIMINATION
• Mrs. Smith is suffering from constipation and urinary incontinence. There are many factor responsible for impaired elimination pattern but, for Mrs. Smith medication, surgery, depression and anxiety is responsible for that.
• Encourage for regular exercise that helps to improve bowel and urinary function.
• Check out usual dietary habits, eating habits and liquid intake.
• Administer medication like laxative and enema.

? ACTIVITY LEVEL
• Assess activity level of Mrs. Smith.
• Arthroplasty scores take into pain, function, walking and range of motion.
• Encourage for participation in mild activity such walking that helps to improve body function.
• Participate in exercise program that helps to strengthen bones and body muscles.

? PSYCHOLOGICAL NEEDS
• Psychological needs assisting client to meet their basic needs include their emotional and mental well-being.
• Mrs. Smith is suffering from depression and anxiety so she need psychological support. She is also concern about dog.
• Discuss any fears the client has associated with living alone.
• Encourage for participate in social activity.
• Informs her daughter to visit Mrs. Smith regularly for alleviate loneliness.

2) past medical history:
? ATRIAL FIBRILATION (AF)
• AF is the most common abnormal heartbeat or arrhythmia.
• AF is strongly associated with other cardiovascular disease. For Mrs. Smith hypertension contributed to the AF.( Atrial Fibrillation Association Australia, 2018)
• Diabetes mellitus may contributed to the development of AF by leading to inflammation of atria.
• Also alcoholism is another risk for development of AF in Mrs. Smith. Its working as metabolic stressor.

? HYPERTENSION
• Heart disease is one of the biggest silent killer on global scale.
• In my case age contributed for development of hypertension.
• If person maintain poor diet, drink excessively, fatty and sugar foods that also contributed to development of hypertension.
• Also medication side effect, diabetes, hormonal changes and stress is responsible for development of hypertension in Mrs. Smith.

? L CVA – 2008
• Cerebrovascular accident is the medical term for stroke. Blood flow to the part of brain stopped either by a blockage or rupture of blood vessel.
• Diabetes, high cholesterol, age, hypertension, poor diet, obesity, alcohol consumption and use of illicit drug are directly or indirectly responsible for stroke.

? T2 DM – 2008
• Diabetes mellitus is linked to the many health problem. (vijan. S, 2010)
• In my scenario Mrs. Smith is 75 years old so according to age and hormonal changes due menopause is leading to diabetes.
• Hypertension is one another risk for development of diabetes mellitus.

? GORD
• Gastro oesophageal reflux disorder is usually caused by the ring of muscle at the bottom of the oesophagus becoming weakened.
• There are many risk factor GORD but, for Mrs. Smith alcoholism is main risk for GORD. Because these may relax the muscle at the bottom of oesophagus.
• Some medication like NSAID and antihypertensive medication also responsible for development of GORD.

? OSTEOPOROSIS
• Osteoporosis is common disease affecting over 1 million Australians. Osteoporosis occurs when bones lose minerals such as calcium.
• Women are greater risk of developing of osteoporosis because of the rapid decline in oestrogen level during menopause. When oestrogen level decrease, bone loss calcium and other minerals at much faster rate. (Osteoporosis Australia,2015 )
• Low calcium intake and low vitamin D levels are also responsible for development of osteoporosis.
• For Mrs. Smith all these reason is responsible for development osteoporosis.

? TOTAL HYSTERECTOMY – 1995
• A total hysterectomy means both uterus and the cervix removed.
• There are many reason for behind hysterectomy like fibrosis, heavy or irregular menstrual periods, severe period pain, prolapsed, endometriosis and many other. ( The department of health and human services, state government of Victoria, Australia )
• But, according to me in my patient it’s because of menopause and irregular periods.
? DEPRESSION
• There are number of factor behind the development of depression like family history, personality, serious medical condition, drug and alcohol use and some life events like loss most loving person and loneliness. (Australian Psychological society, 2016)
• For Mrs. Smith it’s because of reaction to loss and number of illness. Mrs. Smith loss their husband in 2010 and now she is living alone.

3) Medication history
? DIGOXIN 62.5 mcg OD (NPS medicinewise, 2017)
• Indication for use : used for treat arterial fibrillation (AF) and CCF
• Nursing implication :
? check heart rate
? must be ;60 to give and check for apical pulse
? look for sign of toxicity, bradycardia and changes for halos around lights
? look for nausea and vomiting
? weight each day under standard conditions, report weight gain ;1 kg
• Its use for Mrs. Smith because she has arterial fibrillation and help to relieve the symptoms of AF and increase the contractility of heart muscle.

? WARFARIN 2 mg (INR result 2.0 in ED)( Drug.com, 2017)
• Indication for use : minor bleeding, severe bleeding ,brain hemorrhage
• Nursing implication :
? Monitor patient for fever, diarrhoea, rash.
? Monitor for haemorrhage like bleeding gums, tarry stool, haematuria, epistaxsis and blood test for INR.
? Report for bleeding and administer the tablet same time each night.
? Monitor closely adult, psychotic and alcoholic patient because they present serious noncompliance problem.
• It’s prescribed for L CVA and help in prevention of clot formation.

? COVERSYL 5mg OD
• Indication for use : treat hypertension, heart failure
• Nursing implication :
? Monitor for blood pressure and vital sign.
? Monitor for renal function and angioedema.
? Maintain adequate fluid intake and avoid salt substitutes with k+.
? Place patient in a supine position if hypotension develop.
• It used to treat hypertension.

? VITAMIN D 1000 UNITS OD
• Indication for use : playing role in bone and calcium homeostasis, help in absorption of calcium
• Nursing implication :
? Monitor for toxicity.
? Effectiveness of therapy depends on adequate daily intake of calcium. So, monitor for calcium intake.
• Mrs. Smith is not getting appropriate sunlight and diet so it help in maintain bone strength and helps in absorption of calcium.

? METFORMIN 500mg BD (BSL 5 @ 1200)
• Indication for use : Diabetes
• Nursing implication :
? Check sugar level and lipid profile periodically.
? Monitor for side effect like nausea, upset stomach and diarrhea.
• Maintain sugar level and improve tissue sensitivity to insulin, increase glucose transport to skeletal muscle and helps in lowering the blood glucose level.

? ESOMEPRAZOLE 40 mg OD
• Indication for use : treat GORD
• Nursing implication :
? Monitor for sign and symptoms of adverse CNS reaction.
? Monitor INR with current use of warfarin.
? Report for any changes in urinary elimination such as pain and discomfort.
? Take tablet before 1 hours of eating.
• Relieve symptoms of GORD.

? EFEXOR 150 mg OD
• Indication for use : Depression
• Nursing implication :
? Monitor for cardiovascular status.
? Monitor for neurological status and report for anxiety, nervousness and insomnia.
? Monitor for suicidal ideation.
? Assess safety, as dizziness and sedation are common.
• Prescribed for depression and help to relieve anxiety because of surgery.

? CALTRATE 600 mg OD
• Indication for use : Treat osteoporosis
• Nursing implication :
? Note number and consistency of stool.
? Lab test of serum and calcium weekly.
? Record for hyper/hypocalcemia.
• Use as a calcium supplement so it relieve the symptoms of osteoporosis. Effectively relieve the symptoms of acid indigestion.

? MYLANTA 15-30 mLs prn (Drugs.com, 2018)
• Indication for use : gastritis, GORD and hiatal hernia
• Nursing implication :
? Monitor for constipation and stool consistency
? Monitor for renal function
? Report for epigastric and abdominal pain
? Inform doctor if indigestion accomplish by shortness of breath, sweating, or chest pain.
• It’s reduces gastric acidity by neutralizing action. Reduce acid concentration and pepsin activity by raising ph of gastric and intraoesophageal secreations.
4) pre operative care (B Lucas, 2008)
• Pre operative assessment is require for identification of post operative complication.
• I Perform pre operative assessment of Mrs. Smith.
• Psychological preparation for Mrs. Smith because she is suffering from depression and anxiety and also concern about her dog.
• I develop good therapeutic relationship with client for identification of needs and desire.
• I given time to Mrs. Smith to analyse information and express question and concern about surgery.
• I ensure that for informed consent prior surgery.
• Send blood and urine sample for laboratory testing. And check blood sugar level.
• Keep the patient NBM for 8 hrs.
• Encourage for deep breathing exercise.
• Identified level of pain by using pain assessment tool.
• Remove all jewellery and clipping operative area
• Double check all document prior to surgery and review and sign pre operative checklist.
• I Placed identification belt and allergy belt prior to surgery.
• Check cardiac function of Mrs. Smith because she is suffering from atrial defibrillation and hypertension.
• Administer pre operative medication.
• Marked operative area by doctor prior surgery.
• Review and signed pre-operative checklist.
• Provide appropriate clothing.

5) post operative care
• After surgery when Mrs. Smith returns to the ward at 2000, first I received the patient in bed and take the over from theatre staff about patient condition.
• Check vital sign of patient like
? Temperature
? Pulse
? respiration
? Blood pressure
? Oxygen saturation

• Monitor condition of wound like dressing, drainage and blood loss.
• Assess and monitor level of pain and provide pain relief medication and applying pharmacological and non-pharmacological.
• Provide comfortable position.(N Aresti, 2017)
• I specially taking care of pressure point for prevention of pressure ulcer.
• Given catheter care for prevention of infection.
• Monitor elimination pattern for constipation.
• Follow the safety precaution for prevention of infection.
• Monitor the activity level and encourage for exercise like ROM.

6) Nursing intervention to prepare Mrs.
Smith for rehab facility
• Explain what is rehabilitation facility and Provide information about rehabilitation team member and inform about services of centre.
• Explain how staff is helping her in their activity like moving from bed, helping in mobilization and encourage for self independent and help to learn some tips like how to move part of body have surgery.( Bistolfi, A., Federico, A. M., Carnino, I., Gaido, C., ; Rold, I. D. 2016)
• Given information about the treatment provide by member of rehabilitation centre and they are also teaches patient about performing daily activities like bathing, dressing and toileting. And also helping to relieve pain after surgery.
• I explain they are supporting her with their depression and anxiety and also arrange some group activity for supporting her.

CONCLUSION
This case study illustrate and provide information about basic prioritise needs of patient. Provide explanation about past medical history of Mrs. Smith and also discuss the medication history like indication for use, nursing implication and how they effect in care. provide detailed knowledge pre and post operative care require for arthroplasty operation and what kind of intervention need to apply for arthroplasty. Provide appropriate nursing intervention taken by nurse to prepare Mrs. Smith for rehab facility. And also discuss how multidisciplinary team helping the patient for improving the quality of life and day to day function of daily living. This case study examine how in the field of practice, the work process of nursing combining scientific knowledge to the technique. It also helps nurses to contributed in the visualization of care played by the nursing staff.

REFERENCES
Atrial Fibrillation Association Australia, (2018), Drug information, retrieved from: http://www.heartrhythmalliance.org/afa/au

Australian Institute Of Health and Welfare, (2017), Retrieved from: http://www.aihw.gov.au

Australian Psychological society, (2016), Information about Depression, Retrieved from: https://www.psychology.org.au/for-the-public/Psychology-topics/Depression

B Lucas, (2008), Pre Operative Care Arthroplasty, Retrieved from: https://www.ncbi.nlm.nih.gov;pubmed

Berry, A. M., Davidson, P. M., Masters, J., ; Rolls, K. (2007). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16(6), 552-562.

Bistolfi, A., Federico, A. M., Carnino, I., Gaido, C., ; Rold, I. D. (2016). Rehabilitation and Physical Therapy before and after Total Knee Arthroplasty: A Literature Review and Unanswered Questions. Int J Phys Med Rehabil, 4, 356.

Charnley, J. (1972). The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. The Journal of bone and joint surgery. British volume, 54(1), 61-76.

Warfarin, (2017). The complete drug reference. Retrived from: https://www.drugs.com/warfarin.html

Mylanta, ( 2018). The complete drug reference. Retrieved from: https://www.drugs.com/cdi/mylanta.html
Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., ; Radford, M. J. (2001). Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. Jama, 285(22), 2864-2870.

Gastro-oesophageal reflux disease (GORD), (2018), Retrieved from: https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/gastro-oesophageal-reflux-disease-gord

Health direct Australia, (2017), Total Hysterectomy, retrieved from: https://www.healthdirect.gov.au/hysterectomy.

NPS Medicinewise, (2017), Digoxin, Retrieved from: http://www.nps.org.au;medical-info/medicine finder

NPS Medicinewise, (2018), All Drug information retrieved from : http://www.nps.org.au;medical-info/medicine finder

N Aresty,(2017), Primary care management of postoperative shoulder, hip, and knee arthroplasty, Retrieved from: https://www.bmj.com/content/359/bmj.j443

Osteoporosis Australia, (2015), Information retrieved from: https://www.osteoporosis.org.au/

Parsley, B. S., Engh, G. A., ; Dwyer, K. A. (1992). Preoperative flexion. Does it influence postoperative flexion after posterior-cruciate-retaining total knee arthroplasty?. Clinical orthopaedics and related research, (275), 204-210.

The Department of Health ; Human Services, State Government of Victoria, Australia, retrieved from: https://www.betterhealth.vic.gov.au/
Vijan, S. (2010), Type 2 diabetes. Annals of internal medicine, 152(5), ITC3-1.