Running head: CLINICAL CASE SCENARIO 1

Clinical Case Scenario:

Expansion on Key Components of Concept Map

Jody Dawson

October 26, 2014

CLINICAL CASE SCENARIO 2

Clinical Case Scenario: Expansion on Key Components of Concept Map

In order to ensure safe, competent, and ethical nursing practice, it is essential that

entry-level Registered Nurses (RNs) demonstrate critical inquiry and evidence informed

decision-making (College of Nurses of Ontario [CNO], 2014). Creating a concept map is

an excellent way to facilitate critical thinking through complex health-care situations.

Concept maps allow nurses to synthesize information from diverse sources of knowledge

and use this information to prioritize their nursing interventions. The following is an

expansion of the key components of the concept map created for the care of Mrs. S.B,

which can be found in the Appendix.

Patient Profile

Mrs. S.B. is an 89-year-old woman who was admitted to the hospital with end-

stage osteoarthritis of her right hip. She was scheduled for the surgical intervention of

total hip arthroplasty [THA]. Mrs. S.B. had two secondary diagnoses of hypertension and

hyperlipidemia, which were controlled by medications. She lived in a two-story home

with her husband, and their children and grandchildren all lived nearby.

Pre-operative Nursing Interventions

Prior to her surgery, it is essential to ensure that Mrs. S. B. has made an informed

decision regarding her plan of care. Mrs. S.B. had a pleasant discussion with her

physician where she was fully informed about the risks and benefits of the surgery, and

she made an informed decision about her resuscitation care plan where she elected to

have the health care providers allow natural death in the event that her heart stopped

beating.

CLINICAL CASE SCENARIO 3

Along with completing an assessment of Mrs. S.B’s functional capacity and

allergies prior to her surgical intervention, it is important to address any socio-economic

issues that may affect Mrs. S.B. in her recovery. For example, patients with low income

and low education have been shown to be at increased risk for post-operative

complications such as infection and poorer functional outcomes (Santaguida et al., 2008;

Matar et al., 2010). Using a social determinants approach allowed us to address issues

such as financial concerns Mrs. S.B. had regarding her plan of care, and also allowed us

to ensure she had access to resources and information that would support her in her

recovery. In our pre-operative assessment with Mrs. S.B. we also took the opportunity to

integrate any preferences that were important to her physical, emotional, and spiritual

health into her plan of care. Culture care preservation is an effective approach to

promoting client centered and culturally sensitive care, and promotes positive health

outcomes (College of Nurses of Ontario, 2009).

Post-operative Nursing Interventions

While THA is well known as being a highly effective intervention for patients

suffering from severe arthritis of the hip, it is still associated with general risks. Older

women as well as individuals with comorbidities are associated with having worse

functional outcomes and increased risks of complications (Santaguida et al., 2008;

Basilico et al., 2008). Mrs. S.B.’s age, gender, comorbidities and procedure in general

pre-disposed her to various potential post-operative complications. The following is a

discussion of these complications in order of priority for nursing interventions.

Ineffective Tissue Perfusion

CLINICAL CASE SCENARIO 4

Joint replacement surgery is associated with significant blood loss, and elderly

patients presenting for THA tend to already have disorders in hematopoiesis associated

with ageing (Conlon, Bale, Herbison, & McCarroll, 2008). On the day following her

surgical procedure, Mrs. S.B. began presenting with symptoms of anemia. These

symptoms included low serum levels of hemoglobin [Hg] (83g/L), low serum levels of

hematocrit [Hct] (26%), pallor, increased fatigue, and shortness of breath on exertion. In

treating Mrs. S.B. for symptomatic anemia, the physician ordered two units of a red blood

cell IV transfusion, as well as 300mg of ferrous gluconate to be taken orally, twice daily.

Prior to administering the blood transfusion, we explained the procedure to Mrs. S. B.

and obtained her informed consent. We then monitored her throughout the entire

transfusion for signs and symptoms of adverse reactions. Mrs. S.B.’s transfusion was

effective with no adverse reactions. Her Hg and Hct returned to normal levels, her skin

colour returned to normal and she was soon able to carry out appropriate activities

without shortness of breath.

Risk for Delayed Recovery

Higher levels of post-operative pain following THA are associated with increased

length of stay, delayed ambulation and long-term functional impairment (Morrison et al.,

2003). Adequate pain management for elderly individuals is complicated by comorbid

diseases, increased risks of adverse drug reactions, and physician reluctance to prescribe

opioid analgesics (Mercadante, 2010). Patient controlled analgesia [PCA] has been

demonstrated to be effective for older patients, and the use of PCA greatly reduces the

risk of overdose (Mercadante, 2010). Mrs. S.B.’s pain relief was complicated by a

knowledge deficit regarding the use of PCA. Once Mrs. S.B. received sufficient

CLINICAL CASE SCENARIO 5

education regarding the use of her PCA device that infused 0.4mg of morphine every 15

minutes if she pressed her button, she was able to receive adequate pain relief by this

intervention.

Risk of Increased Sedation and Respiratory Depression

Knowing Mrs. S.B.’s increased risk of sedation and respiratory depression when

taking morphine, I monitored Mrs. S.B.’s respirations and oxygen saturation closely and

provided continuous oxygen therapy while she received the opioid analgesic. I also

completed frequent checks with my preceptor of the parameters of the PCA to ensure that

the device was not infusing at a basal rate and that the lock-out interval and demand dose

were consistent with the physician’s order.

Risk of Neurovascular Dysfunction

Orthopedic surgeries in general predispose patients to risks of neurovascular

dysfunction, for example, pulmonary embolus, thrombophlebitis, and vascular

complications (Jain, Guller, Pietrobon, Bond, & Higgins, 2005). The risk of postoperative

neurovascular complications is increased when patients possess preoperative

cardiovascular risk factors such as hypertension and hyperlipidemia (Dy, Wilkinson,

Tamariz, and Scully, 2011). Due to her surgical operation, edema, immobility and

comorbidities, Mrs. S.B. was at increased risk for neurovascular dysfunction.

In order to address this risk, I continuously monitored Mrs. S. B. by assessing the

circulation, sensation, and movement in her affected right extremity compared with her

left. I assessed for deep venous thrombosis by assessing Homans’ sign, and I assessed for

pulmonary embolisms by looking for signs of respiratory distress. Mrs. S.B.’s physician

ordered 24-hour telemetry monitoring for her so that we could be quickly made aware of

CLINICAL CASE SCENARIO 6

any issues such as ischemia, arrhythmias, and infarction. I educated Mrs. S.B. about the

importance of foot pumping and mobilization, and assisted her in ambulating multiple

times throughout the day in order to prevent vascular complications. Also, I administered

her prescribed anticoagulant as prophylactic treatment for potential vascular

complications.

Risk for Infection

Wound infection is a devastating complication and a leading cause of morbidity

following THA (Matar et al., 2010). The risk of infection is increased for patients who

are older than 75 years, who have received an allogenic blood transfusion, and who are

administered a low-molecular-weight heparin, which can result in hematoma formation,

reoperation, and subsequent infection (Matar et al., 2010). Having required an allogenic

transfusion of two units of blood, being prescribed dalteparin for prophylactic control of

deep vein thrombosis, and because she is 89 years old, Mrs. S.B. was at increased risk for

infection. The provision of prophylactic antibiotics has been shown to be an effective

method of reducing the incidence of post-operative wound infection (Matar et al., 2010).

Mrs. S.B. was prescribed with 3 doses of cefazolin IV. We completed dressing changes

with aseptic techniques, and educated Mrs. S.B. about monitoring for signs and

symptoms of infection.

Role Performance Altered

There are many aspects of a patient’s experience that cannot fully be captured by

standardized assessment tools and screening instruments, and can only be uncovered

through shared moments of intentional relations that enable deeper connections. There

was a moment where Mrs. S.B. began to express to me her worries about her husband

CLINICAL CASE SCENARIO 7

and sadness for being apart from him. Through relational inquiry, I discovered that

feelings of guilt were causing Mrs. S.B. significant spiritual distress. She was concerned

about her ability to take care of herself when she returned home let alone continue

cooking for and taking care of her husband. In identifying these concerns, we were able

to assist Mrs. S. B. and her family by connecting them with appropriate resources such as

the Community Care Access Center, meals-on-wheels, physiotherapy and assistive

devices.

Conclusion

Using evidence gathered from multiple sources of knowledge, nurses can promote

safe, competent, and ethical nursing care that reflects the principles of relational practice

and critical thinking. A concept map is a useful tool to illustrate the integration of

evidence-based knowledge into holistic nursing processes and interventions based on

prioritized nursing care. By creating a concept map for the case of Mrs. S.B., the complex

individual components of her experience were linked in a comprehensive, effective, and

clarifying visualization.

CLINICAL CASE SCENARIO 8

References

Basilico, F., Sweeney, G., Losina, E., Gaydos, J., Skoniecki, D., Wright, E., & Katz, J.

(2008). Risk factors for cardiovascular complications following total joint

replacement surgery. Arthritis & Rheumatism, 58(7), 1915-1920. doi:

10.1002/art.23607

College of Nurses of Ontario. (2014). Competencies for entry-level Registered Nurse

practice. Retrieved from

http://www.cno.org/Global/docs/reg/41037_EntryToPracitic_final.pdf

College of Nurses of Ontario. (2009). Culturally sensitive care. Retrieved from

http://www.cno.org/Global/docs/prac/41040_CulturallySens.pdf

Conlon, N., Bale, E., Herbison, G., McCarroll, M. (2008). Postoperative anemia and

quality of life after primary hip arthroplasty in patients over 65 years old.

Anesthesia & Analgesia, 106(4), 1056-1061. doi:

10.1213/ane.0b013e318164f114.

Dy, C., Wilkinson, J., Tamariz, L,. & Scully, S. (2011). Influence of Preoperative

Cardiovascular Risk Factor Clusters on Complications of Total Joint

Arthroplasty. The American Journal of Orthopedics, 40(11), 560-565. Retrieved

from http://hosp.gcnpublishing.com/fileadmin/qhi_archive/ArticlePDF/AJO/

040110560.pdf

Jain, N., Guller, U., Pietrobon, R., Bond, T., Higgins, L. (2005). Comorbidities increase

complication rates in patients having arthroplasty. Clinical orthopedics and

related research, 435, 232-238. doi: 10.1097/01.blo.0000156479.97488.a2

Matar, W., Jafari, S., Restrepo, C., Austin, M., Putrill, J., & Parvizi, J. (2010).

CLINICAL CASE SCENARIO 9

Preventing infection in total joint arthroplasty. Journal of Bone & Joint

Surgery, 92, 36-46. doi:10.2106/JBJS.J.01046

Mercadante, S. (2010). Intravenous patient-controlled analgesia and management of

pain in post-surgical elderly with cancer. Surgical Oncology, 19, 173-177. doi:

10.1016/j.suronc.2009.11.013

Morrison, R., Magaziner, J., McLaughlin, M., Orosz, G., Silberzweig, S., Koval, K, &

Sui, A. (2003). The impact of post-operative pain on outcomes following hip

fracture. Pain, 103(3), 303-311. doi: 10.1016/S0304-3959(02)00458-X

Santaguida, P., Hawker, G., Hudak, P., Glazier, R., Mahomed, N., Kreder, H., Coyte, P,

& Wright, J. (2008). Patient characteristics affecting the prognosis of total hip

and knee joint arthroplasty:A systematic review. Canadian Journal of Surgery,

51(6), 428-436. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2592576/

Running head: CLINICAL CASE SCENARIO 10

Appendix