Clinical Case Study for Postoperative Management and Nursing Consideration

Running head: CLINICAL CASE STUDY
Clinical case study
Name of the student:
Name of the university:
Author note:

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CLINICAL CASE STUDY
Table of Contents
Introduction......................................................................................................................................2
Case description:..............................................................................................................................2
Systematic assessment:....................................................................................................................3
Nursing consideration and safe administration:..............................................................................5
Legal, ethical and professional issues:.............................................................................................8
Conclusion:......................................................................................................................................9
References:....................................................................................................................................11

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CLINICAL CASE STUDY
Introduction:
Critical postoperative management can be defined as the process of providing an
integrated, patient cantered, and specialized care program to a patient after a surgery (Murakami
et al., 2013). A very important concern for providing post-operative care program to a patient by
a nursing professional is to take into consideration systematic assessment, medication
management, and legal, ethical, and professional issues that may overlap while providing care to
the patient under consideration. Hence, it is imperative for the student nurses that are
translationing into practice to have a clear idea of the nursing assessment, medication
management and nursing consideration, and the impact of legal ethical and professional issues
that arise in practice so that they can develop the skills and expertise with respect to the exact
requirement for optimal and safe care delivery (Mukhopadhyay et al., 2018). This assignment
will attempt to emphasize on patient assessment using a systematic assessment framework,
nursing consideration the safe administration of three medications that has been provided to the
patient, along with legal ethical and professional issues that are prevalent in the patient case
scenario of taking the help of a case study. The patient is an 83 year old man named Walter
Williams who had suffered a fall injury and had to go through a total hip replacement surgery
and had been recovering and sent to the post anaesthetic care unit and then returned to the
orthopaedic surgical inpatient unit where I am working as a registered nurse for the patient. The
patient had been conscious and able to answer questions but had been falling back asleep when
he is not being talked to but had been complaining of pain.
Systematic assessment:
The process of patient assessment is fundamental to the relationship of a nurse and client
and is an imperative component of the entire clinical decision making procedure. It is a step-by-

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CLINICAL CASE STUDY
step procedure that helps the new nursing professionals understand the process of diagnosis and
care delivery (Thim et al., 2012). For this particular case study assignment the systematic
assessment framework that is going to be applied in here is the A to G assessment framework
followed by an additional focused assessment. The A to G assessment has been considered as
one of the most abundantly used and trusted systematic assessment framework for assessing
recovering patients, especially in the post anaesthetic care unit. According to Munroe et al.
(2013), it is one of the easiest and simplest assessment framework with extensive applicative
benefits that can be used in any clinical emergency. Hence, it has been chosen as the systematic
assessment framework for this case study assignment as well.
First element of this assessment framework is airway, where the patient is assessed for
any airway obstruction that can be partial or complete. If the patient is able to respond in a
normal voice when asked question then it is considered to be patent of a patient, which is the
case for Mr Williams as well. However, as the level of consciousness is considered to be an
indication of partial obstruction of the airways, the possibility cannot be ruled out either. Hence,
the next step of this assessment is to listen for any adventitious breathing sounds such as stridor,
paradox, respiration, or gurgling (Elliott & Coventry, 2012).
Second elements of this assessment is breathing in which the patient's respiratory rate
and thoracic movements along with presence of any cyanosis, distended neck veins, and
lateralization of the trachea is identified. The patient had been exhibiting vital signs of 14 breaths
taken per minute. According to standard protocol, an adult person at rest taking 12 to 20 breaths
per minute is considered normal. The next element of the systematic assessment framework is
circulation where the circulatory functioning, pulse rate and capillary refill time after patient is
assessed. In this case the skin colour and integrity is also inspected which can give indication of