Critical Analysis of Nursing Management in Mrs. Grace's Case Study

This case study analyzes the nursing management of Mrs. Grace, an 80-year-old woman admitted to the Emergency Department (ED) following a fall, resulting in a hip dislocation. The analysis includes a thorough assessment of the patient's condition, vital signs, and medical history. It explores the pathophysiology of hip dislocation, identifying the presenting problems and deviations from normal findings that require immediate attention. The study discusses essential nursing interventions, including managing the risk of peripheral dysfunction, controlling pain, and addressing potential complications. Furthermore, it examines the pharmacokinetics and indications of prescribed medications such as Rivaroxaban, Thyroxine, Panadol, Amiodarone, Neurofen, Metoprolol, and Morphine, highlighting nursing considerations for safe and effective administration. The case study emphasizes the importance of comprehensive patient assessment, prompt intervention, and vigilant monitoring to ensure optimal patient outcomes. This assignment, contributed by a student, is available on Desklib, a platform offering AI-powered study tools and resources for students.

Running head: CASE STUDY ANALYSIS
CASE STUDY ANALYSIS
Name of the student
Name of the university
Author’s name

1CASE STUDY ANALYSIS
Introduction
As per this case study, Mrs Grace, an 80 year old woman who was admitted to the
Emergency Department (ED), had an unwitnessed fall and was later found on the floor. She was
not able to stand up. When she was brought to the ED, her right leg was found to be shortened
and internally rotated and was in excruciating pain. From the above medical condition, it can be
clearly understood that Mrs Grace had encountered hip dislocation characterised by legs
shortening and internally rotated. Mrs Grace also had other medical conditions like bruising is
noticed on her face and in the right arm and her lower arm has a laceration of 4 cm, which
indicates that she must have come across any injury. There is a strong need for conducting an
overall assessment of the patient including medical history and collecting information on the use
of past medications. The “old aged” people are more susceptible to hip dislocation compared to
that of the yon or middle aged adults. The rate of occurrence of hip fracture and hip dislocation
increases with age.
Discussion
Nurses in the Emergency Department needs to be highly skilled and experienced to
accurately perform a comprehensive assessment of the patient by monitoring several health
aspects and identifying the urgency of treatment of the patients. It is important to recognise any
potential hazards involved with the patient that seeks immediate clinical attention. Current
medical condition along with the historical factors of the patient that indicates the patients being
either injured or chronically ill and has the potential to deteriorate the situation determines the
urgency and demands for urgent medical intervention. Assessing medical history and collecting

2CASE STUDY ANALYSIS
data on important health information of the patient, past medical history including the use of
medications and collecting information on whether the patient has undergone any surgery or
other treatments after admitting to the ED, is considered to be a crucial factor before
commencing the treatment. It should be the responsibility of the nurses to collect functional
health patterns of the patients and also consider their health perception, their involvement in
daily activities or exercise. To deliver a quality care and treatment for a better health outcome of
the patient, the nurses must carry out a thorough assessment of the patient including collecting
certain information related to health and the current medical condition (Dawson-Amoah et al.,
2018). Along with the above stated information, it is also essential to check and analyse the
cognition level of the patient. After the patent has admitted to the ED, a thorough analysis of the
current medical condition is done along with obtaining data regarding the area of injury or the
current position of the injury. It is also important to note the Integumentary data of the patients
whether they have skin lacerations, cool or warm or bluish skin. Upon patient admission,
cardiovascular, neurologic and musculoskeletal assessments are also done (Masiewicz&
Johnson, 2019). The cardiovascular assessment evaluates whether a patient has reduced or absent
pulse distal to injury, delayed capillary pill or has a low skin temperature. The neurologic
assessment covers information on parenthesias, hypersensation and decreased or no sensation.
The Musculoskeletal assessment is a crucial step in the diagnosis of the above medical condition
as it gives information on the affected or injured part of the body and gives an interpretation of
the physical condition related to the medical condition by identifying local bony deformities,
shortened or rotated physical features, if any.

3CASE STUDY ANALYSIS
Pathophysiology of the above medical condition
The medical condition identified in the above case study is hip dislocation characterised
by excruciating pain, where the limb gets shortened and internally rotated. Disruption in between
the femur and pelvis joint leads to dislocation of hip. The symptoms usually includes agony and
movement restriction of hip and unable to stand and walk. The above medical condition can lead
to further complications like avascular necrosis of the hip and injury to the sciatic nerve, or even
arthritis (Masiewicz& Johnson, 2019). Hip dislocation usually occurs when the internal structure
of the hip including the capsule, muscles, bones, labrum, ligaentumteres and the mechanical
anatomy are overruled by a large amount of energy transmitted through the joint. The patient
has developed a condition called Posterior hip dislocation characterised by the amount of pain
stimulated as well as the inability to walk or stand. A physical deformity is usually noticed in
these patients associated with limbs and hip (Masiewicz& Johnson, 2019).
Nursing considerations for the above condition
Managing the risk of peripheral dysfunction- The patient with hip dislocation are likely to
develop symptoms of peripheral neurovascular dysfunction that includes a terrible pain near the
affected area, parenthesias, pain on moving the “body parts” therefore unable to stand or walk,
weakness, a lower temperature, pallor and diminished or reduced pulses. Therefore, the nurses
must take serious actions to prevent further complications through monitoring and accessing
these since they are at a potential risk of developing peripheral dysfunction related to nerve
compression. The nurses must know the ways to control and manage such situation by several
interventions like applying ice on the affected areas to reduce pain and provide comfort to the
patients. Notifying the physicians straightaway if the patient complains of an increased pain

4CASE STUDY ANALYSIS
unrelieved by drugs since the situation can indicate neurovascular impairment that can result in a
significant injury if not treated and relieved.
The development of acute pain associated with edema, the movement of bone
fragments and muscle spasms- The nurses should deal with these patients by taking into
consideration the current medical condition of the patient. Any discrepancy can lead to serious
injury of the patient making the situation worse. The nurse should therefore carefully and gently
position the fractured extremity to minimise pain and prevent displacement of bone. The nurses
should apply some support to the affected extremity and apply ice in order to reduce edema and
provide comfort. To relieve the patient from a great deal of pain, nurses gives analgesics or
muscle relaxant of indicated doses to promote comfort and muscle relaxation. The nurses must
be alerted and gives serious attention to the pain not diminished even after administering an
analgesic as it may indicate an impending compartment syndrome (Dawson-Amoah et al., 2018).
Pharmacokinetics of the prescribed medications in ED and their indications
Rivaroxaban 15 mg Bupivacaine + fentanyl femoral block- Rivaroxaban, an anticoagulant, is
usually prescribed for patients with hip dislocation and has undergone hips or knee replacement
for the prevention of venous thromboembolic events (VTE). It is also used to treat blood clots
and used to prevent blood clots from forming again. It is used to prevent stroke and prevent
systemic embolism in the patients who has nonvalvular arterial fibrillation. It is prescribed as a
treatment of deep vein thrombosis (DVT) and also pulmonary emblism (PE) and to reduce the
risk of recurring DVT or PE (McHorney, 2017). It is sometimes prescribed with a combination
of aspirin to reduce the risk of cardiovascular events in the patients who have a risk of
cardiovascular disorder. It is prescribed along with fentanyl nerve blockers to reduce the pain in

5CASE STUDY ANALYSIS
these patients. Rivaroxaban inhibits free clot bound factors ‘factor Xa’ which is needed for
activating the prothombin (factor II) to thrombin (factor IIa) (Reddy & Rao, 2016). Upon oral
administration of the drug, it is readily absorbed and reaches the plasma saturation point within
2-4 hours. The bioavailability of the given dose (15 mg) is lower if taken during fasted state and
therefore, must be taken along with food. However, metabolism of Rivaroxaban can be reduced
once combined with Bupivacaine (Drugbank.ca, 2019).
Thyroxine 50 mcg- It is used mainly to treat hypothyroidism, a condition characterised by the
inability of the thyroid gland to produce enough quality of hormones for thyroid. The condition
can lead to symptoms of hypothyroidism like fatigue, depression, an increased heart rate,
memory impairment, muscle cramps, dry skin, constipation, poor tolerance to cold temperature
and weight gain. It is indicated as a replacement therapy for primary, secondary as well as
tertiary acquired or congenital hypothyroidism and also considered as an adjunct to the surgery
and radioiodine therapy for managing thyrotropin-dependent and well-differentiated thyroid
cancer. It is incompletely absorbed from the gastrointestinal tract and almost bound to the
plasma proteins completely. The maximum proportion is taken up by the liver (Drugbank.ca,
2019).
Panadol 1 g-Panadol is a paracetamol used as an analgesic and antipyretic agent. It resembles
particularly the selective inhibitors COX-2. It is preferred because of having better tolerance. It
prevents the COX-1 and COX-2 inhibitors by metabolising the peroxidase function of the
isoenzymes that leads to the inhibition of phenoxyl radical creation from excessive tyrosine
which is crucial for the cyclooxygenase action of COX-1 and COX-2 and prostaglandin (PG)
production. It has selectivity for the inhibition of synthesis of PGs and other related factors

6CASE STUDY ANALYSIS
during low levels of arachidonic acid and peroxides availability. However, it has a little activity
on the arachidonic acid and peroxidesin at substantial levels. Panadol sometimes show selectivity
for cox-2 that is often exposed by its poor anti-platelet activity and a better gastrointestinal
tolerance (Graham et al., 2013).
Amiodarone 100mg–Amiodarone is protein bound strongly and has the plasma half-life of 50
days. However, the half-life usually varies with an individual patient. High doses should be
administered for achieving effective tissue levels rapidly. Considering the half-life of the drug,
sufficient time should be allowed for achieving a new distribution equilibrium between the dose
adjustments. If it is given orally, the loading dose should be mg/kg/day for 7 days (Drugbank.ca,
2019).
Neurofen 400 mg-It is an anti-inflammatory and non-steroidal drug derived from propionic acid.
It is commonly used as an analgesic, anti-pyretic and anti-inflammatory. Due to the activity of
Neurofen against prostaglandin, it is attributed to alter platelet function and the duration of
gestation and labor. It is considered as a non-selective inhibitor of cyclooxygenase, enzyme of
prostaglandin and thromboxane (stimulators of blood clotting) synthesis through the arachidonic
acid pathway (Drugbank.ca, 2019).
Metoprolol 25 mg-It is a beta-1selectiveinhibitor utilized as the succinate and tartrate
derivatives dependent on the formation designed. It is usually prescribed for the cure of angina,
myocardial infarction, hypertension, heart failure, atrial flutter , and atrial fibrillation. It is a
receptor inhibitor specific to the cardiac cells and has insignificant effect on beta 2 receptors. The
inhibition has the capacity to decrease the cardiac output producing negative cronotropic and

7CASE STUDY ANALYSIS
inotropic effects without presenting activity towards membrane stabilization or intrinsic
sympathomimetic. The half-life of metaprolol is about 3-7 hours (Drugbank.ca, 2019).
Morphine 5 mg-Morphine is an alkaloid first obtained from the poppy seeds. It is prescribed to
manage chronic and severe pain. Morphine has the ability to effectively manage pain if used for
a short time. The use of morphine needs to be monitored since usage of opioids for a longer time
can develop and increase a physical dependence, drug abuse and addiction disorder. Morphine
and the metabolites acts like agonists of the mu and kappa opioid receptors that develops into
analgesia (Drugbank.ca, 2019).
Nursing management and considerations for Medication prescribed
If the doses of Morphine exceeds, it can lead to many complications. The nurses should
therefore observe and identify any symptoms indicating an overdose of morphine they should
immediately report to the doctor and take immediate actions. Nurses must not exceed the amount
of morphine more than 99 mg/kg to avoid further complications. The symptoms includes
abdominal pain, vertigo, drowsiness, lethargy, nausea, vomiting, unconsciousness, CNS
depression, metabolic acidosis, convulsions, headache and other related symptoms. Morphine is
contraindicated in- Hypersensitivity, patients diagnosed with hypersensitivity, postoperative pain
(extended/sustained-release), significant respiratory depression (extended-release), acute or
severe bronchial asthma (extended-release), and paralytic ileus (extended-release) should avoid
products which consist of tartrazine, bisulfites, or alcohol.
Overdose of metoprolol can lead to bradycardia, hypotension, bronchospasm, and cardiac
failure. Therefore, nurses should be aware of the doses and give it to the patient accordingly. In
case of overdose, nurses must report it to the doctor and the necessary treatment should be given.

8CASE STUDY ANALYSIS
Metoprolol is contraindicated in- Uncompensated HF, Pulmonary edema, cardiogenic shock,
Bradycardia, heart block, or sick sinus syndrome (in the absence of a pacemaker).
The adverse effects of Neurofen includes vomiting, nausea, heartburn, dizziness, oedema,
epigastric pain, intraventricular haemorrhage, hypocalcaemia, respiratory infection, GI disorders,
hypoglycaemia, ulceration and perforation ad therefore several considerations needs to be taken
into account while prescribing this. Contraindications include- hypersensitivity, active peptic
ulcer; Neonates with congenital heart disease, suspected necrotising enterocolitis and active
bleeding (parenteral). Nurses should collect history on whether the patient is allergic to neurofen.
The adverse effect of rivaroxaban includes dizziness, diarrhoea, abdominal pain, blister
and other related symptoms. It can lead to further complication. It is not recommended acutely
with pulmonary embolism or with hemodynamic instability or who may receive thrombolysis or
pulmonary embolectomy.
Nursing interventions for the above medical condition
The long term effects includes cardiovascular disease, myocardial infarction,
intraventricular haemorrhage, hypoglycaemia, CNS depression, metabolic acidosis and even
death. Therefore proper follow up is needed. The medications must not exceed the prescribed
dose. It is the responsibility of the nurse to provide information and educate the patient on hip
surgery. The nurse should access and answer patient’ question and responds to the concerns she
is having. The nurse should ensure that the patient wears compression stocking and SCD device
regularly to decrease or avoid DVT development. The nurse should teach the patient to correctly
use trochanter roll to help align hip properly. The nurse should tell and educate the patient on
changing positions properly to relieve pressure without having uh pain. The nurse should also

9CASE STUDY ANALYSIS
educate the patient on the use of trapeze bar while transferring on bed (Masiewicz& Johnson,
2019).
Conclusion
For the management of such conditions like that of Mrs Grace, nurses needs to have a
thorough knowledge on the medical condition and the impacts that can have on the patient’s
health if precautions not taken. Patients suffering from such disorders such as hip dislocation,
fractures and other related medical condition, needs constant care and monitoring. It is evident
from the above scenario that the patient has hip dislocation and needed immediate care. Nurses
here, plays an important role both in the aspects of delivering care to the patient as well as
assessing and collecting important health information of the patient after admitting to the ED.
The nurses should possess the skill set required to act in such circumstances, particularly in the
Emergency situations for finding out interventions for a particular issue. Besides, delivering an
appropriate care for these patients through assessments and monitoring and giving proper
medications, the nurses should also include in their care plan to educate the patients about their
current medical condition and what measures these patient needs to take in order to promote an
improved health outcome.

10CASE STUDY ANALYSIS
References:
Dawson-Amoah, K., Raszewski, J., Duplantier, N., & Waddell, B. S. (2018). Dislocation of the
hip: A review of types, causes, and treatment. Ochsner Journal, 18(3), 242-252.
Drugbank.ca. (2019). Amiodarone - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB01118
Drugbank.ca. (2019). Ibuprofen - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB01050
Drugbank.ca. (2019). Levothyroxine - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB00451
Drugbank.ca. (2019). Metoprolol - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB00264
Drugbank.ca. (2019). Morphine - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB00295
Drugbank.ca. (2019). Rivaroxaban - DrugBank. Retrieved 3 August 2019, from
https://www.drugbank.ca/drugs/DB06228
Graham, G. G., Davies, M. J., Day, R. O., Mohamudally, A., & Scott, K. F. (2013). The modern
pharmacology of paracetamol: therapeutic actions, mechanism of action, metabolism,
toxicity and recent pharmacological findings. Inflammopharmacology, 21(3), 201-232.

11CASE STUDY ANALYSIS
Masiewicz, S., & Johnson, D. (2019). Posterior Hip (Femur) Dislocation. Retrieved 3 August
2019, from https://www.ncbi.nlm.nih.gov/books/NBK459319/
McHorney, C. A., Ashton, V., Laliberté, F., Germain, G., Wynant, W., Crivera, C., ...& Peterson,
E. D. (2017). Adherence to rivaroxaban compared with other oral anticoagulant agents
among patients with nonvalvular atrial fibrillation. Journal of managed care & specialty
pharmacy, 23(9), 980-988.
Reddy, E. D., & Rao, B. D. (2016). Comparative study of efficacy of femoral nerve block and IV
fentanyl for positioning during femur fracture surgery. International Surgery Journal,
3(1), 321-324.