Clinical Case Study: Post-operative Care, Medication & Assessment

This clinical case study focuses on the post-operative care of Walter Williams, an 83-year-old male who underwent a total hip replacement surgery. The study emphasizes systematic patient assessment using the A-to-G framework, followed by focused pain assessment (PQRST). It details nursing considerations and safe administration protocols for three medications: cefazolin (antibiotic for surgical prophylaxis), heparin (anticoagulant for thromboembolism prevention), and fentanyl (opioid analgesic for pain management). The study highlights the importance of adhering to the 10 rights of medication administration, monitoring for potential side effects, and addressing legal, ethical, and professional issues, including the registered nurse's standards of practice and code of ethics. The importance of continuous monitoring and adapting care based on patient response is also highlighted.

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

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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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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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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

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any circulatory problem 50 colour changes sweating and decrease level of consciousness
(Macaluso & McNamara, 2012). As Mr Williams already had slightly reduced level of
consciousness the chances of decreased perfusion are considerable and hence heart escalation
and electrocardiography monitoring is implemented to check for any cardiac abnormalities. As
the heart rate of the patient had been 81 beats per minute and the blood pressure had been 103/55
mmHg, which can be considered that a patient has slight tachycardia with hypotension. The next
element of the assessment Framework is the disability where the level of consciousness is
assessed. For this patient, he had executed slightly reduced level of consciousness, hence,
Glasgow Coma score can be an excellent method of assessment.
The fifth element of the assessment framework is exposure, where as a registered nurse
attending the patient any signs of trauma, bleeding, skin reaction, and needle marks will be
observed of the patient keeping in mind the dignity and choices are preferential of the patient
(Thim et al., 2012). There had not been any signs of trauma or skin reactions on the patient
however the body temperature have been 35.1 degree centigrade indicates at slight hypothermia.
The second last or 6th element of the assessment framework is fluid, where observation
of the fluid charge, fluid input output, losses from all drains and the consistency and colour of
the patient's urine and urine analysis results are taken into consideration along with any complain
from the patient regarding thirst and presence of skin turgor. The last element of this assessment
framework is glucose, where the blood glucose levels signs of low glucose including confusion
and decreased conscious state and hypoglycaemic chart including complaints of thirst and lack of
orientation is assessed (Thim et al., 2012). As Mr Williams has reduced conscious state and had
been sleeping in and out of consciousness why being spoken to his chances of having low
glucose is high and hence this assessment is extremely useful for him.

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For further focused assessment of the patients, an expensive pain assessment is needed to
be taken. The patient has been suffering from pain which had been neglected by the previous
shift nurse which is a fundamental violation of the registered nurse standard for practice of
NMBA and code of ethics. In this case the pain assessment that I will be incorporating for the
patient will be PQRST where the provocation, quality or quantity, region or radiation, severity,
and timing of the pain will be assessed and documented as per the standard protocol based on
which analgesic medication will be provided to the patient (Elliott & Coventry, 2012).
Nursing consideration and safe administration:
The first chosen medication is cefazolin 2 grams intravenous BD. This medication has
been given to the patient as an antibiotic for surgical prophylaxis after the hip replacement
surgery. Although, this is one of the most commonly administered antibiotic medication for post-
surgical prophylaxis against any bacterial infection, there are certain contraindications and for
this medication along with no side effects for which the nursing consideration should apply
before administration of this medication. First and foremost, the nurse will have to be very
careful regarding how to implement the 10 rights of medication administration in order to be able
to ensure safe administration of the medication. Exploring further, it has to be mentioned that the
6 rights of medication administration includes right drug, right patient, right dose, right route,
right time and frequency, right documentation, right patient history assessment, drug approach
and right to refuse, right drug interaction and evaluation, and right education and information
(Elliott & Liu, 2010). Hence, the nurse will have to go through each of the steps of the rights of
administration and adequately document it before administering the medication. Next
requirement is to check whether the patient has any allergic reactions to this class of medication
from the patient history and also as this medication made react with vitamins and additional

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supplements. It is very necessary for the nursing professional to check whether the patient had
pain and any vitamin supplements and if there are any pro-vitamins that are prescribed to the
patient in the post-surgical unit as well. Along with the other researchers of the opinion that
patients that are more than 65 year olds when taking cefazolin have higher risk of side effects
than other patient populations; hence, as Mr Williams is more than 65 years old the most
common possible side effects are the patient can have in clothes diarrhoea severe allergic
reaction, sore throat, nausea, unexplained bleeding, seizures, and random pain. The registered
nurse will also need to be very careful of the side effects and cease administration of medication
immediately if any of the side effects are exhibited and take adequate measures to manage the
severity of the side effects. Furthermore the registered nurse will have to be very careful about
the diarrhoea that the patient diet encounter and report and take adequate measures to manage the
diarrhoea as it can lead to the onset of life threatening condition of pseudomembranous colitis
(Till et al., 2017). As the patient had not been exhibiting the signs of any of the side effects, I
would continue to administer the medication to avoid any chances of the patient acquiring any
infection.
The next medication is the heparin 5,000 units which is generally used as anticoagulant in
the surgical prophylaxis stage for postoperative thromboembolism (Wuring et al., 2014). For this
medication as well, the registered nurse will have to follow the 10 rights of medication
administration as well. Next, there are certain side effects and contraindications associated with
administering heparin to elderly patients and there are certain nursing consideration that is
applicable to this scenario. First of all as a registered nurse, I would have to assess whether the
patient has any hypersensitivity towards heparin and heparin derivatives. In the next phase, it is
very important to be extremely cautious regarding the dosage and time during the administration

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of heparin. As the patient is an elderly patient the most possible side effects that may occur
include slight fever, headache, chills, nausea, vomiting, constipation, epistaxis, skin necrosis,
urticaria, and even rhinitis. Hence, the registered nurse will have to be careful of the patient
exhibiting any of the above mentioned side effects and take adequate measures to prevent and
manage it. For safe administration of heparin, the nurse will have to check for peripheral
perfusion and carry out stool guaiac test or PPT or any other blood population test or platelet
count along with renal functional tests (Wurnig et al., 2015). Furthermore it can also be very
crucial for the next to check compatibility after medication and use heparin lock needle to avoid
repeated injections as it may lead to severe bleeding. Regarding the clinical decision of
continuing or withholding the medication, it has to be mentioned that the anticoagulants have to
be administered to patients after a hip replacement surgery for at least 10-14 days (Whitbread et
al., 2013). Hence, I would also like to continue administering the medication.
The next medication is fentanyl 50 mcg IV/IM which has been prescribed to Mr Williams
as analgesia for the post-operative surgical site pain. It is an opioid based analgesic which is
commonly used in post-surgical unit for moderate to severe pain; however, as Mr Williams is an
elderly patient of 81 years of age, the administration of opioid is associated with many possible
complications (Mickhael, Zekry & Elrazek, 2016). I would have to follow the 10 rights of
medication administration for this medication diligently as well. Furthermore, as this is an opioid
analgesic, I would have to ensure that the patient is not an allergic to opioid analgesics before
administering the medications. The patient is allergic to morphine but as fentanyl is
phenylpiperidine, which is not essentially a morphine derivative, there is no immediate need for
withholding the medication. Hence, I would take the clinical decision of continuing the
medication for pain management after undertaking the adequate pain assessment, until the

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patient is exhibiting any risk of exacerbation by taking the medication (Mickhael, Zekry &
Elrazek, 2016). Next the most common side effects of this medication include sedation,
euphoria, dizziness, diaphoresis, and conversion along with hypotension. It has to be mentioned
in this context that the patient has already been initiated reduced conscious state and had low
blood pressure at 103/55 mmHg, hence the dosage needs to be very any further deterioration of
the patient condition (Nadeem, Kazi & Janjua, 2012). A registered nurse is also needed to
monitor the vital signs and observe the patient for any science of skeletal of thoracic muscle
rigidity and weakness, respiratory depression and its duration as well. In case the consciousness
of the patient, respiration or blood pressure deteriorated any further, the analgesia will need to be
withheld and non-opioid based analgesics will need to be administered to the patient (Rastogi et
al., 2013).
Legal, ethical and professional issues:
The case study has a potential care delivery issue which could have been extremely
detrimental to the health and safety of Mr Williams. Before the handover chart was given to me,
the previous shift registered nurse has completely ignored the complaint of the patient that he
had been feeling pain and assumed that he is not feeling enough pain as he had already been
administered analgesia which had been fentanyl 50 mcg IV/IM dose. It has to be mentioned in
this context that fentanyl is an opioid based analgesic which is generally avoided for patients
who are elderly due to the enhanced risk of side effects of opioids. As fentanyl is a
phenylpiperidine, it will not invoke morphine allergy; but being an opiate based medication it
can be harmful to the patient. In this case the previous shift nurse did not take any systematic
focused assessment for the pain that the patient has been feeling which could be due to surgical
site infection and went on assuming that the fentanyl prescribed to the patient will be enough to

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relieve the patient of the pain. Hence, this is a violation of legal, ethical, and professional
principles of nursing practice (Parahoo, 2014). Exploring the legal issue, not undertaking a
proper pain assessment of the patient and infection risk assessment as well after the patient had
been complaining of pain is a legal issue undoubtedly; however, it does not fall under the
spectrum of therapeutic goods act. Although, it has to be mentioned that the previous registered
nurse had not performed the risk management and safety assessment of the medication before
providing into the patient and considering the situation of the patient, it can be considered a
broad violation of the therapeutic goods act (Legislation.gov.au, 2018).
On the other hand, there are a few ethical concerns with the issue that has been presented
in the case study. According to the six key ethical principles of nursing practice, not paying
attention to the patient's wishes and preferences is considered to be a violation of autonomy
(Healthdirect.gov.au, 2018). According to this ethical principle the nursing professional is
supposed to respect the wishes and demands of the patients with integrity and dignity even when
not agreeing with the concern. In this case registered nurse completely ignores the plea of the
patient of feeling pain violating the ethical principle of autonomy. Similarly, according to the
standard 4 of NMBA registered nurse standard of practice, a nurse is supposed to use a range of
assessment techniques to systematically collect relevant accurate information in order to inform
practice. The nurse has also had violated this by not taking any assessment even after the patient
had been complaining of pain. According to the code of ethics of NMBA as well, a nurse is
supposed to respect the dignity and autonomy of the patients and take a patient centred and
compassionate approach to care while respecting and prioritising each wish and demand
expressed by the patient. While not taking into consideration the complaint of pain of Mr

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Williams the registered nurse the previous shift has also violated code of professional ethics of
NMBA (Nursingmidwiferyboard.gov.au, 2018).
Conclusion:
On a concluding note, the preliminary or initial requirement for any care program to be
designed is proper and systematic assessment of the patient that is going through the disease
sufferings. Around with that a nursing professional who is providing care program to the patient
is also needed to be very cautious about the nursing considerations and indications while
administering any medication whether it is oral or intravenous. There also are a certain set of
additional protocol and precautionary measures that are needed to be taken by the nursing
professional regarding the legal, ethical and professional requirements of the role of a care
provider. This essay discussed all three above mentioned elements of safe and effective care
delivery and it had been an excellent opportunity for me to understand care planning and
delivery which will be an astounding help for me in the future.

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Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview. British
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