This case study is based on Mr Ivan Jankovic who is 78 years old. He is admitted for a left total hip replacement. He undergoes surgery and is now three days post-operative, in the orthopaedic ward.

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Caring for a patient post-operatively with arthritis and multiple co-morbidities.

Setting the scene

Background- social:

Mr Jankovic is 78 years old and has enjoyed good health over his lifetime.

He moved to Australia in his late teens following the communist uprising in his home country in Eastern Europe in the late 1950s. His education was disrupted, and he has worked in a variety of skilled and semi-skilled jobs that have required manual labour at times, retiring 12 years ago. He says his English is good.

Ivan lives independently with his wife in a retirement living unit. His wife Marla is 74 years old and is in good health but recently had a fall and suffered a # wrist that required surgery. She is unable to drive for 8 weeks. They have 2 children – one daughter lives a fair distance away and works full time in a high-pressure job. Their son lives interstate and visits infrequently. They report having a lot of friends and social contact in the retirement village, but their friends are all elderly and are unable to assist at all.

Epidemiology / pathophysiology of disease processes

The National Health Priority Areas (NHP) of Arthritis and Musculoskeletal conditions, Mental Health Disorders, Cardiovascular Disease, and Injury Prevention and Control were established with the aim of improving health outcomes in these areas. They were established in response to the World Health Organization’s global strategy of Health for all by the year 2000. They are also the areas with the highest economic and health burden for Australians; this assessment considers the following NHP areas in relation to a case (Ivan Jankovic):

• Musculoskeletal conditions are conditions of the bones, muscles and their attachments (e.g. joints and ligaments). Osteoarthritis, rheumatoid arthritis and osteoporosis are the most commonly occurring musculoskeletal conditions. They have substantial influence on a person’s quality of life and impose a heavy economic burden on the community (AIHW, 2018).

• Injuries are adverse effects on the human body. They are a significant source of preventable illness, disability and premature death in Australia (AIHW, 2018).

• Mental Health Disorders relate to behaviours and conditions which interfere with social functioning and capacity to negotiate daily life. They can occur acutely at times of illness (AIHW, 2018).

• Obesity is when the energy consumed from food and drink is greater than the energy used, fat is deposited on the body, which over time can lead to obesity. Obesity increases the risk of many other chronic and potentially lethal diseases (AIHW, 2018).

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Your Task:

Use the Clinical Reasoning Cycle (CRC) on the following pages to review the nursing priorities in relation to the care of Ivan.

Consider the CRC on the following pages and following your work on the modules that encompass the NHP and National Health and Quality Safety (NHQHS) Standards, you should be able to answer the workbook questions. This task will assist you to critically think about typical clinical situations that will arise when you are a Registered Nurse and you will be required to assess and make clinical decisions for your patients.

When you have done this, answer the questions at the end of this workbook and submit into Turnitin in the provided template.

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Now we shall step through the CRC in relation to Ivan’s’ case to prepare you for the workbook assessment questions.

Watch the video –At home

Gain an initial impression of your patient

Consider Ivan’s situation, both socially and health wise. What is your initial view of this patient?

Consider Ivan’s osteoarthritis and obesity and how these may be linked.

Ivan is at risk of injury – both at home and when he comes to hospital. Consider why and what can be done in these settings to prevent injury.

Further background information

Mr Jankovic is 78 years old and has enjoyed good health over his lifetime. He has gained a lot of weight over the past few years and has severe osteoarthritis in his hips. He also has had resection of a prostatic cancer that has no current treatment and has residual prostatamegaly. He has occasional angina, high blood pressure and obstructive sleep apnoea, using a CPAP machine infrequently as it dries his mouth and nose and the noise annoys his wife.

Past medical history

• Osteoarthritis (diagnosed 10 years ago)

• Mild left cardiac failure and occasional angina (diagnosed 2 years ago)

• Hypertension (diagnosed 5 years ago)

• Frequent gout

Surgical history:

• Internal fixation left tibia and fibula following motor cycle accident at age 21years

• Appendectomy at age 23 years

• Resection prostatic carcinoma (7 years ago)

Medications:

• Omeprazole 20mg nocte

• Frusemide 20mg mane

• Isosorbide Nitrate 60mg mane

• Atorvastatin 40mg mane

• Prazosin 5mg mane

• Panadol osteo tds

• Brufen 400mg mane

• Glycerol Trinitrate 5mg S/L prn

• Colchicine 0.5mg prn

• Allopurinol 300 mg mane

Now watch the videos of Mr Jankovic-

1. Waiting room:

2. Pre-operative preparation – checklist:

3. Pre-operative preparation – medication:

4. Patient’s conversation after pre-operative checklist

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(a) Review current information

(b) Gather new information

(c) Recall knowledge (A&P, ethics, law, cultural safety)

Consider the pre-operative phase.

What are the issues here with the communication?

What may be contributing to this?

Ensure you understand the co-morbidities Ivan has presented with and how they may complicate a surgical recovery.

Now watch the video below and review the clinical documents for Mr Jankovic.

Day 3 post-operative Handover

Nursing Documents:

1. Pre-operative checklist [document link]

2. Nursing Notes [document link]

3. Med Chart [document link]

4. Observation chart [document link]

5. Neurovascular obs [document link]

For your convenience a transcript of the handover is provided at the end of this workbook.

Interpret data – what does it all mean?

It is important to consider the potential inter-relationships between mental health, cardio vascular, obesity, musculoskeletal problems and injury prevention.

What are the general nursing problems for patients undergoing major orthopaedic surgery?

What do you anticipate may be post-operative complications for this gentleman given his co-morbidities?

Synthesize all information that has been collected and processed.

You need to consider Ivan’s priority problems and any actual or strong potential problems he may experience while in hospital, based on your assessment of him and your knowledge of the pathophysiology of his presenting condition and co-morbidities.

Consider the pre-operative, acute post-operative and recovery phase.

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As a nurse, what are your desired outcomes for Ivan?

Now you have identified his problems, you need to identify your goals of care for each problem using the SMART acronym.

What action/interventions will you do?

The next step is to consider what you will do and ensure your nursing interventions suit the context and are evidence based.

Assess the effectiveness of actions

Now think about your interventions and how you will evaluate them.

What have you learned from this experience?

Now consider what you have learnt and what you need to follow up with.

References:

AIHW, (2018), Australia’s health 2018, Retrieved 4/12/18 https://www.aihw.gov.au/reports/australias-health/australias-health-2018

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Workbook Questions

Complete the following questions in the provided template following the instructions in your task booklet.

• Do NOT replicate the questions, just identify by number.

• You must attempt all questions, incomplete papers will be asked to resubmit

• References must be provided – remember no reference provided = 0 marks.

• Include a reference list at the end.

• Word count is up to 2000 words; responses beyond this will not be marked.

• You will be awarded 10 marks (total) for academic writing and quality of references and reference formatting- see CRA in your task booklet.

1. Mr Jankovic has presented with severe osteo-arthritis requiring a hip replacement. Discuss briefly the pathophysiology of obesity and its link to Ivan’s arthritis. (2 marks)

2. When you watch the pre-operative videos, what communication issues do you observe? Critically analyse the situation and consider both the patient and the nurse perspective and what may have contributed to this? (4 marks)

3. Explain the importance of the pre-operative checklists and how these link to patient safety and the NSQHS standards? (2 marks)

4. State 3 risks to Mr Jankovic linked to his obesity pose when having a General Anaesthetic? Support your answer with contemporary literature. (3 marks)

5. You realise that Ivan has been given incorrect medication. He received the medication for the person in the next bed and has incorrectly received

• Metformin 500mg

• Gliclazide 5mg

• Aspirin 100mg

• Omeprazole 20mg

What are your immediate responsibilities as an RN to ensure Ivan’s safety? (1 mark)

What responsibilities do you have in regard to medication administration? Discuss this incident with relation to 2 of the NSQHS Standards. (4 marks)

6. Ivan becomes very confused and a little aggressive in the immediate post-operative period. He does not have a history of dementia or confusion. This is quite distressing for his wife, Marla.

Discuss what is happening here in relation to the case study patient and outline briefly 2 key areas of nursing management linking to the evidence.

(4 marks)

7. Effective and accurate clinical assessment skills are imperative for the nurse working with Ivan at all times. State 3 priority nursing problems and justify for Ivan in the acute post-surgical phase. Following left total hip replacement. Phrase your problem statements as “Problem related to cause” (3 marks)

8. For each problem state a goal in SMART format.

(no reference required for this response) (3 marks)

9. For each problem above, state 2 nursing interventions to address these and briefly justify. These interventions can be independent or collaborative. (6 marks)

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10. Based on the clinical priorities of care and short-term goals, state 2 means you would use to evaluate the outcomes of each intervention.

Justify with links to the evidence to support your answer. (6 marks)

11. Ivan is having difficulty voiding post-operatively. He is demanding to get out of bed post his hip replacement. He passes 120mLs into the urinal with difficulty. What further two assessments should you perform and state 2 nursing actions that may assist him? (4 marks)

12. On day 3 the nurse handover says that Ivan does not greet his wife Marla when she arrives to visit and she reports she can’t understand him. He appears confused and when you investigate further, he is quite drowsy, has slurred speech and does not give comprehensible answers to your questions, you can’t decide if he is orientated or not.

There are several possibilities for this – review the documentation provided and state one possible reason for this

List and briefly justify 3 further assessments that should be done? (4 marks)

13. Ivan’s wife, Marla discloses that she is very worried about Ivan’s return home and that she is concerned how they will cope.

Outline the importance of discharge planning and 3 realistic strategies that could be put into place for this elderly couple. (4 marks)

Transcript of nursing handover (video 5)

Situation: Mr Jankovic is a 74 year old and is day 3 post-operative left total hip replacement. He has an IV cannula still in place in his left hand.

Background: Ivan has a history of osteoarthritis, prostatic malignancy resected, hypertension and mild left heart failure with infrequent angina. He also uses CPAP infrequently for sleep apnoea. Post-operative he has not been himself and was a bit aggressive and confused.

Assessment:

His neurovascular obs are intact. The toes of that left leg have been pink and warm with full movement and sensation, pulses normal.

His left hip wound remains intact with no strike-through.

He has been doing deep breathing and leg exercises. He has been resting quietly.

At 1400 hours vital signs: BP 174/80 mmHg; HR 96 BPM; RR 18 BPM; O2 sats 98%; Temperature 36.9 degrees.

I noticed that he wasn’t very responsive to his wife, Marla, this morning and he refused his tablets, so I think he is still confused. His wife just told me she is having trouble understanding him. I have not got round to calling the doctor yet.

Recommendations: I think you should do a more comprehensive assessment on him and call the doctor. I am a bit concerned but I have been too busy to do a full assessment.

 

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