NURSING 6 Case Study: Post-Operative Challenges of Sarah Blake

This case study focuses on Sarah Blake, a 76-year-old patient who underwent a right total hip replacement. The essay analyzes her post-operative vital signs, including a drop in blood pressure and rapid pulse, indicating hypovolemia. It explores the pathophysiology of her condition, considering factors such as blood loss and the impact of anesthesia and pre-existing conditions like hypertension and OSA. The study identifies three priority clinical problems: managing hypovolemic shock, addressing wound drainage, and controlling post-operative pain. Nursing goals and interventions are outlined for each problem, including frequent vital sign monitoring, blood transfusions, wound care, and pain management strategies like multimodal analgesia. The essay also details a comprehensive discharge plan, emphasizing medication education, movement limitations, and follow-up care to ensure continuity of care at home. The case study emphasizes the importance of critical thinking and problem-solving skills in nursing practice, providing a valuable resource for understanding and managing post-operative complications.

Running head: NURSING
Nursing
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Author’s note

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Surgical patients face various challenges in the post-surgical period as they are vulnerable
to various surgical complications. The complications may range from minor events which could
be managed by pharmacological intervention to serious events that may require multiple
interventions. To get better idea about the kind of challenges faced by surgical patient, this essay
will look at a patient with hip replacement surgery (Pinto et al., 2016). The essay will review the
case study of Sarah Blake, a surgical patient admitted to the hospital for a right total hip
replacement. The essay will look at the post-surgical vital signs and outcome of patient and
discuss about the pathophysiology of Sarah’s post operative hypovolemia. By the use of problem
solving and critical thinking skills, the essay will examine the three priority clinical problem,
nursing goals and nursing interventions for Sarah. In addition, based on the assessment of care
needs of Sarah post discharge, a discharge plan will be developed.
The case study is about Sarah Blake, a 76 year old retired pharmacist who has been
admitted for a right total hip replacement (THA). Based on the comparison of his pre and post-
operative assessment data, several changes in his vital signs was found. For example, his BP was
140/95 in the pre-operative period and post his operation, his blood pressure decreased to 100/54.
This form of decrease in blood pressure might be due to several causes such as bleeding, sepsis
or adrenal insufficiency. Relative adrenal insufficiency is another cause behind sudden
hypotension in the postoperative period. According to Doğu et al. (2014), decrease in systematic
vascular resistance (SVR) and arterial blood pressure is seen due to the induction of general
anaesthesia. Due to the stress conditions during surgery, inadequate cortical response takes place
which is defined as adrenal insufficiency. Thus, anaesthesia is one of the causeS behind
subsequent decrease in systematic vascular resistance. Patients who undergo THA are often
given spinal anaesthesia and one of the side effects of spinal anaesthesia is hypotension. There
are two main causes behind onset of spinal induced hypotension. One is the decrease in SVR and
other is the decrease in cardiac output (Hofhuizen et al. 2019). Hence, advanced hemodynamic
monitoring is crucial to detect post operative hypotension and reduce risk for Sarah.
The stress of surgery was clearly identified for Sarah as she was found to have an
estimated blood loss in the OT of 400 ml and this might be one of the causes behind hypolemic
symptoms in patient. There were many other symptoms that indicated that Sarah was suffering
from hypovolemic shock. This is evident from her vital signs observation post-operatively. His

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pulse rate was 116 bpm which is greater than the normal value of 100 bpm. She had respiratory
rate of 12/min shallow. Her right leg was cool to touch. According to Taghavi and Askari (2019),
symptoms of hypovolemic shock includes rapid heart beat, shallow breathing, feeling weak, low
blood pressure and cool clammy skin. In case of Sarah, hypovelemia due to blood loss is most
likely. The pathophysiology behind hypovolemic shock includes depletion of intravascular
volume due to blood loss. In response to this change, the body compensates with increase in
sympathetic tone. This pathophysiological change is associated with increase in heart rate,
peripheral vascular constriction and increase in cardiac contractility. The first change that is seen
as a result of such change includes increase in diastolic blood pressure and decrease in systolic
blood pressure. This change adversely impacts the delivery of oxygen to the vital organs and
oxygen demand of the organ is compromised. At this point, it is very important to correct
hypovolemia because cells switch from aerobic metabolism to anaerobic metabolism resulting in
diverted flow of blood to the organs and disruption of blood flow to the heart and brain. Hence,
tissue ischemia may occur and patient may suffer from worsening hemodynamic shock which
may even lead to death (Taghavi & Askari, 2019; Gulati, 2016). Thus, to prevent any further
complications to Sarah, implementation of active intervention is necessary.
Sarah’s past medical history might also be the cause behind adverse effect on patient. For
example, from the past medical history, it was found that she was suffering from hypertension,
obstructive sleep apnea (OSA), myocardial infarction, hypercholesterolemia and osteoarthritis.
Her history of hypertension is one area of concern as she is at risk of poor wound healing and
prolonged wound discharge because of hypertension. Prolonged wound discharge was observed
in case of Sarah too as her hip dressing had serous ooze with mild swelling. This may increase
risk of infection rate. Ahmed et al. (2011) supports that hypertension may delay wound healing
following THA and active pharmacological prophylaxis may be required to enhancing wound
healing process. Sarah’s medical history revealed that she is suffering from OSA and this can be
one of the factors that can increase risk of post operative cardiovascular complications in Sarah.
Thus, peri-operative measures like assessment of cardiac troponins was necessary to implement
appropriate intervention that could reduce cardiovascular complications for patient (Lyons et al.,
2016). Based on the review of the pathophysiology behind hypovolemia post THA, it can be
concluded that it is necessary to treat hypovolemic shock in post operative patient because if it is
left untreated, it may lead to ischemic injury of vital organs and result in multi-system organ

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failure. Before deciding appropriate treatment, it is critical for the medical team to identify
whether hemorrhage or fluid loss has resulted in hypovolemic shock. Appropriate interventions
can be planned accordingly (Taghavi & Askari, 2019).
The first clinical priority is to treat symptoms of hypovolemic shock in patient. This is an
important clinical problem because if this is not resolved, it may lead to organ failure and even
death of patient. The main goal of care for the first clinical priority will be to address signs of
hypovolemic shock and improve all the areas that are affected by hypovolemia. This is important
because of rapid respiratory rate of 12/min and BP of 100/54. The second high priority clinical
problem for Sarah is her wound drainage which should be immediately managed as wound
drainage is a sign of infection (Kim & Parvizi, 2017). The main goal of care for this problem is
to promote wound healing and prevent any purulent discharge from the surgical wound site. The
third high priority clinical problem for Sarah is her pain. Based on post-surgical observation of
Sarah at 2100, it was found that her pain score was 6 on a scale of 0-10. Hence, in the first 24
hours post surgery, management of pain is important to promote positive outcomes post surgery
and increase the likelihood of early mobility as well as surgical wound healing for Sarah. Thus,
the third goal of care is to engage in post operative pain management of Sarah and promote
recovery and early mobility.
To address the first clinical problem of adverse vital signs due to hypovolemic, it is
important to regularly check vital sign and temperature of Sarah after every four hours. The
significance of this assessment is that it can help to identify cardiovascular status of patient and
detect signs of hypovolemia, excessive bleeding and fluid volume deficit at an early stage. Vital
sign is also important because Sarah has a history of hypertension and myovcardial infarction
which may further complicate her conditions. According to Mori, Hagemandd and Zimmerly
(2017), after patient is transferred to the PACU, nurse need to closely monitor vital signs as it
can give idea about patient’s current medical status and inform nursing staffs about clinically
worsening symptoms that could further increase risk of adverse events. Post surgical patient are
vulnerable to blood loss and vital sign can help to identify this too. In addition, as hypovolemia
occurs due to blood loss and such issue was found for Sarah, it is necessary to consider blood
transfusion for patient. Average estimated blood loss post surgery is about 273 ml. However,
Sarah was found to have a blood loss of 400 ml. Thus, early use of blood can reduce

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hemorrhagic shock in patient. Another advantage of blood transfusion using 1:1:2 of plasma to
platelets to packed red blood cells are that it can improve homeostasis process post surgery
(Taghavi & Askari, 2019; Carling et al. 2015).
To address the second clinical problem of wound drainage and risk of infection for Sarah,
it will be necessary to wound care measures as well as prophylaxis for treating infection. To
reduce purulent discharge from wound, it is will be crucial to use appropriate dressing and
change dressing after every 4-5 hours. This intervention is important for the mitigation of
infection post surgery. According to Chen et al. (2017), infection is one of the serious
complications seen in patient with THA. If this is not treated well, many patients are at risk of
revision surgery too. Hence, nurse must choose the best wound dressing so that wound healing is
promoted any chance of contamination is eliminated. The dressing should be such that they can
protect the incision area from contamination as well as maintain moist environment for proper
wound healing. As Sarah has exuding wounds, absorbent dressings like Primapore and Mepore
can be used directly over the surgical wound. This can be combined with the use of prophylactic
antibiotic so that any surgical site wound infection can be prevented (Johnson et al., 2013). This
pharmacological intervention is most important for the prevention of deep wound infection and
nurse can collaborate with clinicians to decide the best antibiotic prophylaxis for Sarah.
To address the third clinical problem of high pain score for Sarah post operatively, it will
be crucial to engage in pain management process. Pain management is crucial because it will
have an impact not only on surgical outcomes but also on the days of hospitalization. Thus,
regular administration of pain medications such as analgesia can help to reduce the intensity of
pain. According to De Luca et al. (2018), intensive pain management is a part of post surgical
rehabilitation process which helps in recovery and maintaining patient’s complete movement. In
contrast, if proper analgesic treatment is not initiated post surgery, it may lead to infection and
thromboembolic disorders which may delay discharge and increase overall health care cost too.
Acute pain can be a source of emotional and psychological distress for Sarah too. Thus,
multimodal analgesia can be provided to Sarah. This intervention involves providing analgesics
with different mechanism of action. It is a gold standard approach of pain management which
reduces opioid consumption and leads to early initiation of rehabilitation. Some examples of
multimodal analgesics include acetaminophen and use of nonsteroidal anti-inflammatory drugs

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(NSAIDs) drug. As this intervention targets several steps of the pain pathway, it can lead to
better pain control for patient with fewer side-effects too (Min et al., 2016).
After the above three clinical problems are addressed, Sarah will be ready for discharge.
However, she may have to continue with many medications and wound care. So, discharge plan
will involve educating Sarah about ways to maintain continuity of care at home. Post operatively,
Sarah may have to continue with many of the medications such as simvastatin, atenolol,
morphine and aspirin. Hence, written discharge sheet will give her education on use, purpose,
timing and side-effects of each drug. This education is likely to improve Sarah’s adherence to
medication regime as she will have clear understanding regarding why all medications has been
prescribed to her and when she should report about any issues to the doctor (Wiznia et al., 2019).
The second important discharge education will be to educate her about her limits related to
movement at home. For example, Sarah is allowed to move with walker if she feels discomfort
lying. In addition, she cannot take bath for two weeks unless her incision heals. To avoid
discomfort, Sarah will be advised regarding not sitting for more than 30-45 minutes and not
leaning forward while sitting. Sarah needs to refer to a physical therapist too so that she could be
assisted in movement by moderate exercise. This will help her to recover fast and gain her usual
mobility at an early stage (Madara et al. 2019). Moreover, for her incision care, Sarah is advised
to check the skin around the area and clean the wounds using aseptic technique (Bechstein,
2018). By following the above discharge plan, Sarah is likely to continue her care at home and
recover fast post her surgery.
Based on the analysis of post-operative outcomes of Sarah, it can be concluded that she
was suffering from signs of hypovolemic shock, acute pain and risk of infection due to wound
drainage. To treat hypovolemic shock, regular vital sign assessment along with use of blood
transfusion therapy was proposed. To reduce rate of infection, use of appropriate dressing and
dressing change was suggested. Furthermore, pain management was suggested by means of
multimodal analgesia. During the discharge period, the discharge plan gave education on wound
care, mobility limits, medication regime and rehabilitation needs of Sarah at home. Use of such
comprehensive approach can facilitate proper post-operative care of patient with THA.

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References:
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. https://doi.org/10.1371/journal.pone.0023224
Bechstein, W. O. (2018). Towards Simpler and Reliable Wound Care. Deutsches Ärzteblatt
International, 115(13), 211.
Carling, M. S., Jeppsson, A., Eriksson, B. I., & Brisby, H. (2015). Transfusions and blood loss in
total hip and knee arthroplasty: a prospective observational study. Journal of orthopaedic
surgery and research, 10(1), 48.
Chen, K. K., Elbuluk, A. M., Vigdorchik, J. M., Long, W. J., & Schwarzkopf, R. (2017). The
effect of wound dressings on infection following total joint arthroplasty. Arthroplasty
today, 4(1), 125–129. https://doi.org/10.1016/j.artd.2017.03.002
De Luca, M. L., Ciccarello, M., Martorana, M., Infantino, D., Letizia Mauro, G., Bonarelli, S., &
Benedetti, M. G. (2018). Pain monitoring and management in a rehabilitation setting after
total joint replacement. Medicine, 97(40), e12484.
https://doi.org/10.1097/MD.0000000000012484
Doğu, B., Öksüz, H., Şenoğlu, N., Yavuz, C., & Gişi, G. (2014). Postoperative Sudden
Hypotension Due to Relative Adrenal Insufficiency. Turkish journal of anaesthesiology
and reanimation, 42(5), 283–287. https://doi.org/10.5152/TJAR.2014.33254
Gulati, A. (2016). Vascular endothelium and hypovolemic shock. Current vascular
pharmacology, 14(2), 187-195.
Hofhuizen, C., Lemson, J., Snoeck, M., & Scheffer, G. J. (2019). Spinal anesthesia-induced
hypotension is caused by a decrease in stroke volume in elderly patients. Local and
regional anesthesia, 12, 19–26. https://doi.org/10.2147/LRA.S193925
Johnson, R., Jameson, S. S., Sanders, R. D., Sargant, N. J., Muller, S. D., Meek, R. M., & Reed,
M. R. (2013). Reducing surgical site infection in arthroplasty of the lower limb: A multi-

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disciplinary approach. Bone & joint research, 2(3), 58–65. https://doi.org/10.1302/2046-
3758.23.2000146
Kim, T. Y., & Parvizi, J. (2017). Wound Complications. In Complications after Primary Total
Hip Arthroplasty (pp. 27-36). Springer, Cham.
Lyons, M. M., Bhatt, N. Y., Kneeland-Szanto, E., Keenan, B. T., Pechar, J., Stearns, B.,
Elkassabany, N. M., Memtsoudis, S. G., Pack, A. I., & Gurubhagavatula, I. (2016). Sleep
apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk
stratification: an exploration of feasibility. Biomarkers in medicine, 10(3), 265–300.
https://doi.org/10.2217/bmm.16.1
Madara, K. C., Marmon, A., Aljehani, M., Hunter-Giordano, A., Zeni, J., Jr, & Raisis, L. (2019).
PROGRESSIVE REHABILITATION AFTER TOTAL HIP ARTHROPLASTY: A
PILOT AND FEASIBILITY STUDY. International journal of sports physical
therapy, 14(4), 564–581.
Min, B. W., Kim, Y., Cho, H. M., Park, K. S., Yoon, P. W., Nho, J. H., Kim, S. M., Lee, K. J., &
Moon, K. H. (2016). Perioperative Pain Management in Total Hip Arthroplasty: Korean
Hip Society Guidelines. Hip & pelvis, 28(1), 15–23.
https://doi.org/10.5371/hp.2016.28.1.15
Mori, C., Hageman, D., & Zimmerly, K. (2017). Nursing Care of the Patient Undergoing an
Anterior Approach to Total Hip Arthroplasty. Orthopaedic Nursing, 36(2), 124-130.
Pinto, A., Faiz, O., Davis, R., Almoudaris, A., & Vincent, C. (2016). Surgical complications and
their impact on patients’ psychosocial well-being: a systematic review and meta-
analysis. BMJ open, 6(2), e007224.
Taghavi, S., & Askari, R. (2019). Hypovolemic Shock. In StatPearls [Internet]. StatPearls
Publishing.
Wiznia, D. H., Swami, N., Nguyen, J., Musonza, E., Lynch, C., Gibson, D., & Pelker, R. (2019).
Patient compliance with deep vein thrombosis prophylaxis after total hip and total knee
arthroplasty. Hematology reports, 11(2).

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