Critical Thinking in Nursing: Prioritizing Interventions for a Patient with Fractured Neck of Femur

This essay demonstrates skills related to critical thinking by analysing the case scenario of Mrs. Audrey Smith, a 75 year old female who came to the emergency department after a fall in the kitchen and prioritizes nursing intervention for Mrs. Audrey based on her health needs. The essay also examines the effect of 8 past medical diagnosis and past drugs provided to determine its impact on care provided now. As Mrs. Audrey is scheduled for a left hip arthroplasty, the essay also provides pre and post surgery nursing intervention and discharge plan for health and wellbeing of the client.

Nursing assignment
Name of the student:
Name of the University:
Author’s note

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Introduction:
Nursing is a systematic process involving the process of assessment, diagnosis, planning,
implementation and evaluation. Critical thinking skills can be applied in each of these stages to take best
decision for health and being of patient. This essay demonstrates skills related to critical thinking by
analysing the case scenario of Mrs. Audrey Smith, a 75 year old female who came to the emergency
department after a fall in the kitchen and prioritizes nursing intervention for Mrs. Audrey based on her
health needs. The essay also examines the effect of 8 past medical diagnosis and past drugs provided to
determine its impact on care provided now. As Mrs. Audrey is scheduled for a left hip arthroplasty, the
essay also provides pre and post surgery nursing intervention and discharge plan for health and well-
being of the client.
1. Assessing and prioritising nursing interventions:
Safety:. To reduce discomfort due to fracture and promote safety of patient, some nursing intervention
that has been prioritised for Mrs. Smith are:
1. As Mrs. Smith has been diagnosed with a fracture neck of femur (NOF), soft tissue injury and
bruising to her left shoulder, head to toe assessment can help to find any unusual findings where
focussed assessment would be necessary.
2. Neurovascular assessment will be necessary to access blood supply to the fractured legs.
3. Fall risk assessment will be essential to determine the need for mobility support, prevent fall
(Ambrose, Cruz & Paul, 2015).
4. Call bell should be near to the patient and height of bed should be low
5. As Audrey is allergic to Bactrim, red identification should be provided to avoid medication error
Hygiene & comfort:
The nursing intervention that needs to be prioritized necessary for Audrey’s health and hygiene includes:
1. Assess the client’s ability to engage in self-care activity to determine hygiene needs for client.

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2. Assessment of pain is also necessary so that no safety issue arise while meeting hygiene needs
of client (Carvajal Carrascal & Montenegro Ramírez, 2015).
3. Head to toe hygiene will be important to control infection. Changing bed sheets and supporting
client in dressing and toileting will be necessary too.
4. As Mrs. Audrey has mild to moderate urinary incontinence, use of urinary catheter is a priority
(Maher et al., 2012)
5. It will be necessary to change position of Mrs. Smith quickly to reduce risk of developing pressure
ulcers. Keeping the skin dry will be necessary to prevent bedsores too (McInnes et al., 2015).
6. Braden scale should be used to evaluate skin integrity.
Nutrition:
Nutritional screening as Mrs Audrey is a patient with anorexia. Input and output data of patients
should be recorded and dietician should be consulted regarding diet chart and eating routine for patient.
Nutritional consultation would also support the nurse to identify oral nutritional supplementation and fluid
balance necessary for optimal recovery from fracture and prevention of future fractures ( Maher et al.,
2018).
Elimination
In response to the issue of issue of chronic constipation in patient, assessment of eating habit
and pattern of elimination would help to identify characteristics of constipation and understand the cause
of constipation. Patient will be encouraged to take dietary fiber to make defecation easier. Laxatives need
to be provided to patient to soften stools and lubricate the intestinal mucosa (Huang, 2016).
Activity levels:
To achieve a functional and stable hip, the following nursing interventions are necessary for client:
 Maintain suitable positioning of hip to prevent stress
 Assist patient during position changes and transfer to reduce pain and discomfort

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 As Audrey is on bed-rest, providing pressure area care and assistance with daily life activities will
be necessary (Resnick et al., 2011).
Psychosocial needs:
Mrs. Audrey is worried about her dog; Rufus as she thinks no will be there to take care of Rufus when
her neighbour goes back to work. To reduce anxiety of patient, it is necessary to calm her and assure her
that suitable care for his dog will be taken. Mrs. Audrey is also at risk of psychosocial issues because of
fracture. She needs to be properly informed regarding the benefits of arthroplasty she accepts the
treatment with a positive approach .
2. Past medical history:
Atrial fibrillation: Atrial fibrillation is a condition associated with irregular and rapid heart rate and to
prevent risk of thrombotic events, patients like Mrs. Audrey need Warfarin or aspirin anticoagulation
therapy. However, as Mrs. Audrey is scheduled for arthroplasty, risk of wound drainage and hematoma
formation is high. Mrs. Audrey is also at risk of bleeding (Aggarwal et al., 2013). Regular assessment of
heart rate and blood pressure should be done to detect any abnormality.
Hypertension: Mrs. Audrey’s past medical history also reveals that she is hypertensive. Hypertension is
a condition that increases risk of stroke, heart failure and artery diseases. For patients going for surgery
like hip arthroplasty, hypertension can delay wound healing process and increase the likelihood of
infection (Ahmed et al., 2011). Low sodium diet and antihypertensive medication should be provided to
patient and blood pressure should be checked regularly.
Cerebrovascular accident: Mrs. Audrey had suffered from stroke in the past, which occurs due to the
interruption of the blood flow to the brains. Fall is one of the common consequences of stroke
(Andersson, Seiger & Appelros, 2013). To increase the degree of functional recovery for Mrs. Audrey, it
will be necessary to assess vitamin D status and use of anti-coagulants to reduce bone loss after stroke
(Ciobanu & Ciobanu 2017). She should be supported with every day exercise to overcome right side
shortcoming.

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Diabetes mellitus type 2: Diabetes is a metabolic disorder associated with hyperglycemia and insulin
resistance. As patients with diabetes are at risk of poor glycemic control and neuropathy, they are at risk
of surgical site infection and impaired wound healing. To enhance recovery and minimize complication for
patient, her blood sugar level should be monitored and she should be advised for diabetic diet ( Wukich,
2015). .
Gastro oesophageal reflux disorder (GERD): GERD is a condition where acid from the stomach leaks
up into the oesophagus and it leaves an unpleasant taste in the back of mouth. To prevent recurrence of
the symptoms in Mrs. Audrey, it is essential to review her medications, eating habits and lifestyle.
Appropriate dose of proton pump inhibitors like Omeprazole should be provided for effective care of Mrs.
Audrey (Chait, 2010).
Total hysterectomy: Mrs. Audrey had undergone a total hysterectomy which involved removal of uterus
and cervix. Long term effects of hysterectomy include bowel dysfunction and urinary incontinence
(Kocaay et al., 2017). Mrs. Audrey’s bowel function and urinary output must be monitored to provide
optimal care.
Osteoporosis: Mrs. Audrey’s fracture might also be attributed to diagnosis of osteoporosis. Osteoporosis
decreases bone density and increases risk of fracture. During Mrs. Audrey’s hospital stay, it is necessary
to evaluate her environment and prevent chances of any fall or injury in the hospital. Vitamin D
supplements can also be provided to minimize risk of fractures in the future (Masterson et al., 2016).
Depression: Depression is episodes of sadness, low moods and loss of interest in activities for a long
period. Mrs. Audrey’s anxiety and her worry for her dog may also cause depressive symptoms. Hence,
providing psychological and emotional support will be important to improve her emotional and mental
stability during hospitalisation.
3. Drugs:
To ensure that current medications provided to Mrs. Audrey do not have significant interactions with
the past drug she uses, reviewing the medications that she takes now and its impact on current treatment
is important.

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Digoxin: Mrs. Audrey takes Digoxin medicine. Use of Digoxin indicates that she is a patient with atrial
fibrillation problem. While taking this drug, it is necessary for nurse to observe for side effects like fatigue,
blurred vision, nausea and vomiting. The drug may also interact with other drugs like loop diuretics to
increase the risk of toxicity. The nursing implications are to avoid toxic effects in Mrs. Audrey while
providing other medications and to carefully assess her for conditions that increase toxic effects
(MacLeod-Glover et al., 2016). Mrs. heart rate should be checked before giving the medication and it
should not be given to her if the heart rate is less than 60.
Warfarin: It is an anticoagulant used to treat blood clot in veins to reduce risk of heart attack and strokes.
The nursing consideration before providing the medication is to check the range of IRN (between 2-3) to
prevent risk of bleeding. Right dosage for Audrey should also be considered (Forsman, Nordmyr
&Wahlbeck, 2011).
Coversyl: Coversyl is use to treat hypertension and reduce the risk of stroke and congestive heart failure
(Bansal et al., 2014). To provide safe and quality care to her, the nursing implication to look for side
effects of the drug such as diarrhoea, headaches and oedema. Blood pressure should be checked before
providing the medication to avert hypotension.
Vitamin D: Mrs. Audrey takes Vitamin D and this is given to manage bone disease and strengthen bones.
The adverse effects of Vitamin D includes dry mouth, nausea and vomiting. The nursing implication is to
check for daily intake of calcium and assess fall in serum alkaline phosphatise (Weaver et al., 2016). She
should be educated to avoid this drug in case of hypercalcemia.
Metformin: Metformin is used to treat diabetes. To promote safety of Mrs. Audrey, it is necessary to
observed for side-effects like headache, vomiting, abdominal pain and acidosis. Check for
cardiopulmonary status of patients throughout the therapy and provide the medication with food to avoid
gastrointestinal antagonistic effect (Palmer et al., 2016).
Esomeprazole: Mrs. Audrey used Esomeprazole indicating that she suffered from GERD in the past. The
nursing implication is to check for CNS effects like vertigo and agitation. There is also chance of diarrhea

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and constipation after taking the drug (Dhaliwal & Nwokolo, 2014). The medication should be provided in
empty stomach to prevent vomiting.
Mylanta: Mrs. Audrey’s drug history reveals use of Mylanta in the past. This indicates that the patient
might have suffered from stomach upset and gastric hyperacidity in the past (Hall, 2015). The adverse
effects of the drug include vomiting, diarrhea, hypotension and electrolyte imbalance. Nursing implication
is to evaluate the need for the drugs and educate patient regarding chance of constipation after reviewing
the drug.
Efexor: Use of Efexor suggests that Mrs. Audrey has suffered from depressive episode in the past. The
adverse effect of the drug includes increase in blood pressure and heart rate, fatigue and nausea. As she
has a history of hypertension and stroke, the nursing implication is to discontinue the medication to
prevent complication in patient (Hall, 2015).
Caltrate: Caltrate is a a calcium supplement. As Mrs. Audrey has been taking Vitamin D
supplementation, she might be taking the drug as a calcium supplement (Weaver et al., 2016). The
nursing implication is to check for bowel movement to determine the need for the drug for Mrs. Audrey.
4. Preoperative intervention
To prepare Mrs. Audrey for surgery, it is necessary for nurse to provide details about the surgery and
any safety issues and utility of the surgery. Providing such information is important because to fulfil
informed consent requirement and maintain the documentation process. This action of informing patient
about surgery is also in accordance with NMBA standards of nursing practice as standard 3 mentions the
responsibility of a registered nurse in providing the information and education to support patient’s control
over health (Nursing and Midwifery Board of Australia, 2016).
Reviewing nursing notes and history of treatment is essential to determine current medication and
restorative history of patient. This action can minimize any risk. Red band can prevent medication error
and remind nurse regarding her allergy with Bactrim.. Vital sign assessment will also be necessary to
ensure that patient’s physical condition is suitable to go ahead with the surgery (Akhtar, MacFarlane &
Waseem, 2013). Nurses also have a role in supporting Mrs. Audrey to physically prepare for the surgery

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by educating about meals to be taken or avoided on the day or surgery, removing any jewellery before the
surgery and education regarding proper diet to be maintained before surgery and the need to quit drinking
until surgery. This kind of physical preparation is essential to get positive outcomes after arthroplasty
(Pettersson et al., 2017). Before the operation, dressing her in theatre gown is essential as some
synthetic materials may respond with an electric current of the searing hardware. Her daughter should be
made aware regarding the arranged medical procedure for Mrs. Audrey.
5. Post-operative intervention
The nursing interventions that will be important after Mrs. Audrey returns to the ward post surgery are
as follows:
Assessment of patient: Checking vital signs, heart rate and SPO2 every 15, 30 and 60 minutes is
necessary. Neurological status should be check to assess proper blood flow to the affected legs. It may
also help to identify any complications or need for pharmacological intervention to stabilize patient’s
condition.
Post-operative care: To provide post-operative care, review of major body system will be necessary to
identify signs of discomfort and deterioration. Furthermore, pain assessment and assessment and care of
surgical site will be importance to prevent sepsis and provide relief to patient. Nurses also have the
responsibility to maintain fluid and electrolyte balance to replace unusual fluid losses due to surgical
drains. Any form of fluid imbalance need to be regularly checked to identify signs of hypovolemia or
sepsis.
Pain management: Post-operative pain can impair recovery process of Mrs. Audrey. Hence, nursing
intervention such as pain assessment and providing appropriate medications on time will be necessary to
provide pain relief and improve outcome of patient (Akhtar, MacFarlane & Waseem, 2013).
Dressing: Incision site should be checked during dressing to review progress in wound healing process.

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Drainage: Checking the color and location of drainage from the wound site and documenting them is
essential. Maintaining patency of drainage device will be essential to reduce the risk of infection
(Wagenaar et al., 2017).
6. Discharge plan
The discharge plan is to provide information Mrs. Audrey and her daughter about list of rehabilitation
centres to reduce their stress. They should be made aware about the indication timing, dose and side-
effects of each medication. This may help Mrs. Audrey or her daughter to report on time about any issue
faced after taking the medication. Information regarding wound care and incision care will be provided
and necessary precautions such as avoiding swimming and soaking incision in bathtubs need to be
provided. Precautions needed during sitting and sleeping and during mobility also needs to be provided.
Assessment of mobility needs and need for supportive devices should be done to understand patient’s
ability to mobilise independently at home. Diet chart should also be provided to ensure that patient does
not suffers from constipation and anorexia in the future. Provision for appointment with her medical doctor
and physiotherapist should also be done in the future
Conclusion:
The report summarized the care needs and nursing interventions needed for Audrey’s by the
review of her case history and diagnosis. It provided a discussion around impact of 8 diagnosis mentioned
in past medical history and drugs used by Mrs. Audrey in the past to determine its influence on current
treatment method. The medication history and nursing priorities helped to develop specific nursing
intervention before and after the surgery. This kind of comprehensive assessment and evaluation is
necessary to determine the best quality and safe care for clients with arthroplasty.

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References:
Aggarwal, V. K., Tischler, E. H., Post, Z. D., Kane, I., Orozco, F. R., & Ong, A. (2013). Patients with atrial
fibrillation undergoing total joint arthroplasty increase hospital burden. JBJS, 95(17), 1606-1611.
Ahmed, A. A., Mooar, P. A., Kleiner, M., Torg, J. S., & Miyamoto, C. T. (2011). Hypertensive Patients
Show Delayed Wound Healing following Total Hip Arthroplasty. PLoS ONE, 6(8), e23224.
http://doi.org/10.1371/journal.pone.0023224
Akhtar, A., MacFarlane, R. J., & Waseem, M. (2013). Pre-Operative Assessment and Post-Operative
Care in Elective Shoulder Surgery. The Open Orthopaedics Journal, 7, 316–322.
Akhtar, A., MacFarlane, R. J., & Waseem, M. (2013). Pre-Operative Assessment and Post-Operative
Care in Elective Shoulder Surgery. The Open Orthopaedics Journal, 7, 316–322.
http://doi.org/10.2174/1874325001307010316
Ambrose, A. F., Cruz, L., & Paul, G. (2015). Falls and fractures: a systematic approach to screening and
prevention. Maturitas, 82(1), 85-93.
Andersson, Å. G., Seiger, Å., & Appelros, P. (2013). Hip fractures in persons with stroke. Stroke research
and treatment, 2013.
Bansal, S., Chauhan, D. K., Ramesh, D., Barmare, S., & Chakraborty, S. (2014). Blood pressure control
and acceptability of Perindopril and its fixed dose combinations with Amlodipine or Indapamide, in
younger patients with hypertension. indian heart journal, 66(6), 635-639.
Carvajal Carrascal, G., & Montenegro Ramírez, J. D. (2015). Hygiene: basic care that promotes comfort
in critically ill patients. Enfermería Global, (40), 351.
Chait, M. M. (2010). Gastroesophageal reflux disease: Important considerations for the older
patients. World Journal of Gastrointestinal Endoscopy, 2(12), 388–396.
http://doi.org/10.4253/wjge.v2.i12.388

10
Ciobanu, N., & Ciobanu, S. (2017). Femoral neck fractures in patients with stroke sequelae. Retrieved
from: https://ibn.idsi.md/sites/default/files/imag_file/3_6_Femoral%20neck%20fractures%20in
%20patients%20with%20stroke%20sequelae_0.pdf
Dhaliwal, A., & Nwokolo, C. (2014). Commentary: daily pantoprazole vs. esomeprazole for
GERD. Alimentary pharmacology & therapeutics, 39(2), 226-226.
Forsman, A. K., Nordmyr, J., &Wahlbeck, K. (2011). Psychological interventions for the promotion of
mental and the prevention of depression among older adults. Health Promotion International,
26(suppl 1), i85-i107. doi:10.1093/heapro/dar074
Hall, J. E. (2015). Guyton and Hall textbook of medical physiology e-Book. Elsevier Health Sciences.
Huang, T. T. (2016). Effectiveness of Individualized Intervention on Elderly Residents with Constipation in
Nursing Home: A Randomized Controlled Trial.
Kocaay, A. F., Oztuna, D., Su, F. A., Elhan, A. H., & Kuzu, M. A. (2017). Effects of hysterectomy on pelvic
floor disorders: a longitudinal study. Diseases of the Colon & Rectum, 60(3), 303-310.
MacLeod-Glover, N., Mink, M., Yarema, M., & Chuang, R. (2016). Digoxin toxicity: Case for retiring its use
in elderly patients? Canadian Family Physician, 62(3), 223–228.
Maher, A. B., Meehan, A. J., Hertz, K., Hommel, A., MacDonald, V., O’Sullivan, M. P., ... & Taylor, A.
(2012). Acute nursing care of the older adult with fragility hip fracture: an international perspective
(Part 1). International Journal of Orthopaedic and Trauma Nursing, 16(4), 177-194.
Masterson,J., Woodall, T., Wilson, C. G., Ray, L., & Scott, M. A. (2016). Interprofessional care for patients
with osteoporosis in a continuing care retirement community. Journal of the American
Pharmacists Association, 56(2), 184-188.
McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015).
Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, (9),
1-119.

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Merten, H., Langelaan, M., Lubberding, S., Schoonhoven, L., & Wagner, C. (2018). Patient safety in older
hip fracture patients: results of a randomised controlled trial to test three patient safety
interventions. Patient safety and complex care for older hip fracture patients, 159.
Nam, D., Sadhu, A., Hirsh, J., Keeney, J. A., Nunley, R. M., & Barrack, R. L. (2015). The use of warfarin
for DVT prophylaxis following hip and knee arthroplasty: how often are patients within their target
INR range?. The Journal of arthroplasty, 30(2), 315-319.
Nursing and Midwifery Board of Australia 2016. Registered Nurse Standards for Practice. Retrieved from:
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards.aspx
Palmer, S. C., Mavridis, D., Nicolucci, A., Johnson, D. W., Tonelli, M., Craig, J. C., ... & Natale, P. (2016).
Comparison of clinical outcomes and adverse events associated with glucose-lowering drugs in
patients with type 2 diabetes: a meta-analysis. Jama, 316(3), 313-324.
Pettersson, M. E., Öhlén, J., Friberg, F., Hydén, L. C., & Carlsson, E. (2017). Topics and structure in
preoperative nursing consultations with patients undergoing colorectal cancer
surgery. Scandinavian journal of caring sciences, 31(4), 674-686.
Resnick, B., Galik, E., Boltz, M., Hawkes, W., Shardell, M., Orwig, D., & Magaziner, J. (2011). Physical
Activity in the Post-Hip-Fracture Period. Journal of Aging and Physical Activity, 19(4), 373–387.
Wagenaar, F. C., Löwik, C. A., Stevens, M., Bulstra, S. K., Pronk, Y., van den Akker-Scheek, I., ... &
Jutte, P. C. (2017). Managing persistent wound leakage after total knee and hip arthroplasty.
Results of a nationwide survey among Dutch orthopaedic surgeons. Journal of bone and joint
infection, 2(4), 202.
Weaver, C. M., Alexander, D. D., Boushey, C. J., Dawson-Hughes, B., Lappe, J. M., LeBoff, M. S., ... &
Wang, D. D. (2016). Calcium plus vitamin D supplementation and risk of fractures: an updated
meta-analysis from the National Osteoporosis Foundation. Osteoporosis International, 27(1), 367-
376.

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Wukich,D. K. (2015). Diabetes and its negative impact on outcomes in orthopaedic surgery. World
Journal of Orthopedics, 6(3), 331–339. http://doi.org/10.5312/wjo.v6.i3.331