Running head: CLINICAL CASE SCENARIO
Clinical Case Scenario:
Expansion on Key Components of Concept Map
Jody Dawson
October 26, 2014
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CLINICAL CASE SCENARIO
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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 endstage 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.
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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
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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
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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
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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
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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
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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/0401105
60.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
CLINICAL CASE SCENARIO
Matar, W., Jafari, S., Restrepo, C., Austin, M., Putrill, J., & Parvizi, J. (2010).
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/
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Running head: CLINICAL CASE SCENARIO
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Appendix
esent Illnesses
Ferrous
Gluconate
300 mg PO
BID
Amlodipine: 5mg bedtime
Acetylsalicytic Acid: 81mg PO QD
Hydrochlorothiazide: 18.75mg PO q
morning
Ramipril: 15 mg PO q morning
Atorvastatin: 20mg PO bedtime
Pt Hg 83 g/L,
Pt Hct 26%, pallor, increased fatigue,
SOBOE
1. Ineffective Tissue Perfusion
r/t blood loss during surgery and
complicated by disorders in
hematopoiesis associated with aging
Obtain consent, administer blood
products, Pt teaching re:
administration of blood products,
promote adequate rest and nutrition
Ferrous
Gluconate
300mg BID
Hypertension
Hyperlipidemia
Anemia
Two Units Packed
RBCS
Pt demonstrates no S/S adverse
reaction to transfusion Pt’s Hgb
returns to normal level (120-156
g/L), , Pt’s Hct returns to normal level
(35-46%), pt’s skin returns to normal
colour, pt able to carry out goals with
minimal fatigue/SOB
Pre-op assessment:
?Allergies
? Functional
Capacity
? Socioeconomic
concerns
Pt teaching re: foot pumping, &
extremity mobilization
2. Risk for Delayed Recovery
r/t ineffective pain management
Convey empathetic understanding of
patient’s incisional and arthritic joint
pain; educate patient re: PCA;
maintain affected joint in aligned
position, and maintain extremity
mobilization
Morphine, PCA, SC
Basal Rate = 0
Demand dose = 0.4mg
Lock-out interval = 15 min
Boluses/hr = 4
Volume: 15 ml bag
Pt demonstrates understanding of PCA,
Pt rates pain < 4/10
Present Illnesses
Pt’s PPP, pt denies
numbness/tingling, pt completes
> 4 walks/day,
-ve Homans’ sign
★ End –Stage Osteoarthritis
Right Hip
Acute Pain
Elective Surgery:
Total Hip
Arthroplasty
5. Risk for Infection
r/t invasive procedure and
disruption of skin integrity
WBCs elevated (12), T 36.5°C
Respirations 10,
SpOs = 89%
3. Risk of Increased
Sedation and Respiratory
Depression
r/t adverse effect of opioid
narcotic
Apply 2 L O2 ; monitor RR
and SpO2, monitor PCA
parameters
Pt maintains adequate resps,
SpOs > 92%
Nursing Assessment
Dalteparin
5000 units,
SC, QD
? Adequate circulation,
? Adequate sensation,
? Adequate movement
? Homans’ sign
Telemetry monitoring for
? Ischemia, ? Arrhythmias,
? Infarction
Admitting Diagnosis:
Pt rating pain 6/10, facial grimacing
Patient teaching re:
healthy lifestyle
modifications
4. Risk of Neurovascular
Dysfunction
r/t immobilization, potential
vascular obstruction in surgery,
edema, comorbidities
Mrs. S. B.
★ Age: 89
★ Gender: Female
Allergies: NKA
Resuscitation Status:
Allow Natural Death
Social: Lives with husband
in 2-story home
HR = 82,
BP = 134/89
Nursing Diagnoses
Pt is concerned because she is care
provider for husband.
Promote good hand hygiene;
use aseptic techniques when
changing dressings; Pt
teaching re: S/S infection
6. Role Performance Altered
r/t compromised mobility
Address concerns of patient by connecting with
appropriate resources ie. CCAC, meals on wheels,
physiotherapy, and assistive devices.
Pt denies any concerns re: discharge. Pt has support
systems in place to assist she and her husband during
her recovery. Pt shows confidence and increased selfefficacy with discharge plan
Nursing Interventions
Pharmacological Therapy
Cefazolin 2g, IV, q8H,
3 doses
Pt’s WBC count returns to normal (510x109 /L), wound site shows no redness,
swelling, purulent drainage, odor, pt
remains afebrile
Expected outcomes
★ Known Risk Factors