Casestudy – Medicine

Adele Cambridge is an 82 years old lady booked for an elevetive hip replacement. She has a history of coronary artery bypass grafts and a trial fibrillation. Her medications are Avapro, Dignoxin and Warfarin. She lives alone and independently, she is a Jehovah Withness.

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As Adele Cambridge is a Jehovah Witness, she would not agree to blood transfusion. This is poses a critical limitation to her treatments both during the surgery and after the surgery. Her refusal of blood transfusion can cause unwanted complications. Furthermore, with the history of coronary artery bypass grafts and atrial fibrillation and the medication used, Adele Cambridge can face potential death threat.

The use of medicines Avapro, Dignoxin and Warfarin may also interfere with her pain management medications after the surgery. Patients having hip replacement surgery are at high risk of venous thromboembolism, and appropriate assessment and interventions need to be in place. Venous thromboembolism (VTE) is the blocking of a blood vessel by a blood clot. It includes both deep vein thrombosis (DVT), a blood clot in a deep vein, and pulmonary embolism (PE), a blood clot that breaks off from the deep veins and travels through the circulation to block the pulmonary arteries. Hip replacement surgery is a high-risk surgery for VTE. It is calculated that without the use of prophylactic measures the risk of VTE is 44% for patients having Hip replacement surgery (National Collaborating Centre for Acute Care, 2007).

Patient risk needs to be assessed by nursing staff using a tool such as the Autar DVT risk assessment scale (Autar, 2007). A review of the evidence shows that a mechanical method of prophylaxis, i.e. graduated compression stockings, such as anti-embolism stockings, intermittent pneumatic compression devices or foot impulse devices is used alongside low molecular weight heparin or fondaparinux (an injection to inhibit coagulation) for 4 weeks after surgery (National Collaborating Centre for Acute Care, 2007).

This will have implications for Adele Cambridge on discharge as she will be needing help to remove and reapply her graduated compression stockings. As the details clearly state that she lives alone, she will need to be taught how to perform subcutaneous heparin injection and will need routine round visits by the doctor or nurse.

Adele Cambridge may need several months for recovering completely from the surgery, although she will be mobile from the day after her operation. At 10 years after surgery, approximately 90–95% of patients with a hip replacement surgery are still pain free and functioning well. Some hip replacements require removal and a replacement of prosthesis inserted; this is known as revision surgery. The most common indications for revision surgery are aseptic loosening and infection. Her checkup nurses should be aware of the symptoms associated with these complications. Adele Cambridge will have to be fully prepared for such possible complications through pre-operative knowledge.

Patients undergoing these procedures need skilled nursing care so that they can recover from surgery and enjoy the benefits of their new joint. However, as Adele Cambridge lives alone with no primary care, the immediate recovery period (first 5–7 days) should be spent within the hospital. Nursing management in this phase consists of facilitating safe recovery from the anesthetic and surgery, and the initial stages of rehabilitation. Hip replacement surgery may be carried out using a variety of anesthetic techniques, depending on the patient’s medical condition, the anesthetist’s skills and patient preference.

Adele Cambridge may have a general, spinal or epidural anesthetic, or a combination of these depending upon her past medical history (Royal College of Anesthetists, 2008). Each carries its own risks, which patients should be aware of. For those having general anesthesia the risk of death for a healthy person is 1 per 100 000 general anesthetics; for those having spinal or epidural anesthesia, less than 1 in 100 000 suffer significant permanent nerve damage resulting in the loss of use of their legs (Royal College of Anesthetists, 2004).

As it is recommended for Adele Cambridge to spend the immediate recovery period after surgery with the hospital, nurses have a responsibility to ensure that they play their part in promoting recovery after anesthesia and surgery through the use of early warning systems (EWSs), in which acceptable parameters for physiological signs, such as heart rate, are set; any deviations from these are managed according to an agreed protocol with early medical involvement (Cullinane et al, 2005). The past history of Adele Cambridge with coronary artery bypass grafts and a trial fibrillations puts her at a higher risk of complications.

Infection can occur at the time of surgery, while the wound is healing, or in the longer term. In the last case, it occurs through haematogenous seeding, when bacteria from a distant infection travel to the joint replacement via the bloodstream. Infections occur in approximately 0.2–1.1% of hip repayment prostheses (Phillips et al, 2003). While, nurses within primary and secondary care are key in detecting early and late infection, which manifests as physical symptoms (discharge, redness, swelling, pain) and through abnormal blood results (high white cell count, erythrocyte sedimentation rate and C-reactive protein) (Della et al, 2004), in Adele Cambridge, if the infection develops in the later stages of recovery then, she will have to seek medical attention on her own. Infection that cannot be eradicated can lead to loosening of the prosthesis. Both aseptic loosening and loosening caused by infection may mean that the prosthesis has to be removed and a revision replacement implanted.

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