NAME: __________________ CLASS: __________________ DATE: _______________ 1

Case Study
All questions apply to this case study. Your responses should be brief and to the point. When
asked to provide several answers, list them in order of priority or significance. Do not
assume information that is not provided. Please print or write clearly. For every question,
please support your answer using reference to a source (i.e.: textbook), including in-text
citations and a reference page in APA format.

Scenario
Mrs. Jones is a 69-year old female coming in for her annual check-up visit with her primary care
provider, Dr. Spencer. She is accompanied by her daughter. The nurse takes the following
measurements on Mrs. Jones before bringing her into the patient room.

Height: 5’1”
Weight: 150 lbs.
Pain: 0/10
Blood Pressure: 170/102
O2Sa: 92%
Respirations: 20 rpm
Pulse: 78 bpm
Temperature: 98.9 F

As the nurse reviews Mrs. Jones’s chart, she notes the following pre-existing diagnoses:

Type II diabetes mellitus (DM) for 11 years

Chronic obstructive pulmonary disorder (COPD) for 17 years
Hypertension (HTN)
Atrial fibrillation
Hypothyroidism for 32 years
Osteoporosis
Depression for 2 years

The following are assessment findings by the nurse:

Extremities:
2+ pitting edema in lower extremities bilaterally

Abdomen:
Liver palpable 3 cm below right costal margin
Non-tender to palpation
Bowel sounds present x4 quadrants
 2

Respiratory:
Wheezing
SOB upon exertion, none at rest

CVS:
No jugular distention
Normal S1/S2
Cap refill <3 seconds
No clubbing
Skin cool to touch

Neuro:
No localized or sensory deficits
Patient appears sad, with trouble sleeping

Acting holistically, the nurse recognizes the importance of taking a thorough patient history:

Mrs. Jones has smoked 1ppd for over 25 years. She occasionally has an alcoholic beverage like
red wine 2-3 times per week in social settings. She tells the nurse that she tries to go on walks,
but does not like to go alone so has only gone occasionally. Mrs. Jones had a hysterectomy at
age 50, but has no other surgical history. She states no food or medication allergies. Mrs. Jones
is a recent widow. Her husband of 47 years passed away 8 months ago from a severe stroke.
Mrs. Jones has been living alone since her husband’s death in the house that they have owned
together for the past 25 years. Her daughter, Mrs. Nader, lives 10 minutes away and checks in
on her mother daily by phone and visits every few days to help with housework. Mrs. Jones still
has her driver’s license and is able to take trips to the store independently. She particularly
enjoys attending her Baptist Church every Sunday and takes part in the choir. Mrs. Jones has 2
other daughters who have recently moved to different states, and she mentions that it has
been difficult adjusting to her children moving away. Mrs. Jones says that she has been feeling
sad lately and has been having difficulty sleeping at night. She does not know what to do
without her husband, and is still grieving the loss. Her daughter mentions that Mrs. Jones used
to play bingo with a group of friends every Tuesday, but she is no longer attending the
gatherings. The daughter, Mrs. Nader, is concerned about her mother’s emotional and
psychological well-being.

During the admission interview, the nurse makes a list of all the medications Mrs. Jones takes
at home.
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Medication List
Zestril (lisinopril) 40 mg PO qd
Combivent (ipratropium bromide and albuterol sulfate): 2 inhalations qid
Advair Diskus 250/50: 1 inhalation q2d bid
Synthroid (levothyroxine) 112 mcg PO qd
Glucophage (metformin) 500 mg PO bid
Coumadin (warfarin) 5 mg PO qd

Question:
Fill out the following table regarding Mrs. Jones’s medication list 1

Mechanism of
Medication Class Use Side Effects
action
Hyperkalemia, hypotension,
Reduce BP. renal insufficiency,
Cardioprotective. angioedema, dizziness,
ACE competitive
Zestril Reno-protective vertigo, dry cough, angina,
antihypertensive inhibitor, bradykinin
(lisinopril) in diabetics. taste changes / anorexia,
degrader
Hydrophilic, constipation, Nausea,
bypasses liver. vomiting, diarrhea (N/V/D).
Flushing.
Prophylaxis of
venous
Inactivates Vit. K,
thrombosis / PE, Hemorrhage (GI, CNS).
Coumadin preventing clotting
anticoagulant complications of Bruising. Cramping, nausea,
(warfarin) factors II, VII, IX,
aFib, and skin necrosis (purple toe).
and X.
thromboembolic
sequelae after MI.
Dysrhythmias, anaphylaxis,
Ipratropium –
paradoxical bronchospasm.
muscarinic COPD, asthma.
Hypokalemia. Closed-angle
Anti-asthmatic / antagonist Intubation
Combivent glaucoma. CNS stimulation.
bronchodilator Albuterol – Short enhancer. Asthma
Dizziness, nausea,
Acting β2 Agonist exacerbation.
oropharyngeal irritation /
(SABA)
dryness. Urinary retention.
Dysrhythmias. Adrenal
Fluticasone –
Anti-asthmatic / insufficiency. Hyperglycemia.
immune
Advair Diskus corticosteroid / Asthma. COPD. Oral candidiasis. Dysphonia.
suppression.
adrenergic Cough / pneumonia.
Salmeterol – LAβ2A
Osteoporosis. Glaucoma.
↑ BMR (protein
Synthroid Tachycardia. Dysrhythmias.
Hormone synthesis,
(levothyroxine Hypothyroidism. Headache. N/V/D. Insomnia /
replacement gluconeogenesis,
) irritability.
etc.)
Lactic acidosis.
Glucophage Biguanide
↓ gluconeogenesis DM2. PCOS /
Hypoglycemia. Prolonged
& intestinal glucose weight loss (off
(metformin) antidiabetic QTc. Bloating; N/V/D;
absorption. label).
constipation. ↓ B12 / pernicious
1
All drug information gathered from Davis’s Drug Guide for Nurses, 15th ed. and student’s previous coursework.
 4

anemia.

Question:

Mrs. Jones goes on to ask whether there is anything else she should do to help with her HTN.
She asks, “Do I need to lose weight?” Look up her height and weight for her age on a body mass
index chart.
A. What is her BMI? 28.3
B. Is she considered overweight? Overweight
C. What would your response to her question be? Yes. This would be helpful both for
your blood pressure and diabetes. It also improves heart function and muscular function,
both of which can help with your leg swelling. Moreover, exercise and sunshine improve
both mood and sleep. Perhaps some of your friends or fellow parishioners could be
walking buddies and help you be accountable for getting in more steps?

Question:
What nonpharmacologic lifestyle alteration measures might help someone like Mrs. Jones
control her blood pressure? (List two examples, explain fully and cite your source.)
1. Vigorous aerobic exercise (40 minutes, 3-4x/week) such as walking, swimming, biking,
aerobics, etc.
2. DASH diet: reduced sodium, increased vegetables, whole grains, and low-fat protein
sources. Reduced intake of red meat, processed foods (soups, pizza, etc.), & sugars. (Oza
& Garcellano, 2015)

Question:
What is Type II DM?
Diabetes mellitus II (DM2) is a metabolic disorder in which hyperglycemia develops from
insulin resistance and/or reduced insulin secretion. It accounts for over 90% of diabetes
incidence in adults, affecting nearly 9% of the adult population (though only half of that
population is aware of their condition). DM2 is the fifth leading cause of death globally, and
reduces lifespan by 20 years on average. (Khan, et al., 2019)

A. What are some of the risk factors Mrs. Jones has for this diagnosis? Overweight,
sedentary lifestyle, depression all put her at risk metabolically and in terms of lifestyle
choice problems (esp. regarding diet).

What is COPD?
Chronic Obstructive Pulmonary Disease (COPD) is an air-space disease where patients
experience chronic airflow restriction. It comprises two distinct disease processes, chronic
bronchitis and emphysema; however, many patients display elements of both. Bronchitis is
inflammation of the bronchioles such that there is productive cough and irreversible airway
restriction. Emphysema is the destruction of the parenchyma leading to loss of elasticity and
surface area in the alveolar structure; lung hyperinflation, airflow limitation, and air trapping
follow with bullae as common sequelae. (Wise, 2018)
 5

A. What are some of the risk factors Mrs. Jones has for this diagnosis? Inhalational
exposure (via tobacco smoking) is the only known modifiable risk factor.

What is HTN?
Hypertension is the sustained elevation of blood pressure (BP). BP equals cardiac output
(CO) x total peripheral vascular resistance (TPR). An increase in either is able to produce HTN,
though both are commonly involved. Secondary HTN is the result of another pathological
condition (commonly hyperaldosteronism, sleep apnea, renal disease, and endocrine disorders).
Primary HTN is not caused by a single factor and is idiopathic. HTN is clinically diagnosed by at
least 3 consecutive measurements with elevated systolic or diastolic pressures. (Bakris, 2019)

A. What are some of the risk factors Mrs. Jones has for this diagnosis? Smoking, elevated
BMI, age, sedentary lifestyle, and diabetes. Given her comorbidities, her diet is also a
likely factor.

Question: Fill out the following chart for the stages of hypertension. (Bakris, 2019)

Systolic (mmHg) Diastolic (mmHg)

Normal <120 <80

Prehypertension 120-129 <80

Stage 1 Hypertension 130-139 81-89

Stage 2 Hypertension ≥ 140 ≥ 90

Hypertensive Crisis ≥ 180 ≥ 120

A. What stage of hypertension does Mrs. Jones’s blood pressure fall into? Stage 2

Question:
The nurse notes that Mrs. Jones has a persistent, dry cough throughout the assessment. What
from Mrs. Jones’s history could potentially be causing this?
Her COPD, smoking, and medication (esp. the lisinopril).

A. Why is COPD a less likely cause? Chronic bronchitis has a productive cough; ACE
inhibitors commonly cause dry cough.

Question:
The nurse is making a holistic care plan for Mrs. Jones that includes an assessment of
developmental, psychosocial, spiritual, physiological, and cultural variables. Describe some of
Mrs. Jones’s strengths and stressors related to these variables.
 6

Strengths Stressors

Developmental Successful parent. Still independent. Widow

Social interactions, esp. with church. Widow. Grandparenting at a distance.

Psychosocial Daughter nearby. Recent isolation.

Spiritual Church membership Loss of husband

Newly single status. Responsibility

Cultural Still independent. Capable of self-care. consolidated in her after husband’s
death.

Still mobile. Overseen by PCP. Smoking. Overweight. HTN, aFib, DM2,

Physiological Moderate wine consumption COPD, hypothyroidism. Osteoporosis.
(cardioprotective). Largely sedentary.

Case Study Progress

Mrs. Jones’s primary care provider Dr. Spencer reviews her history. He orders a complete blood
count (CBC), chemistry panel, a screening lipid panel, and a urinalysis (UA). He also prescribes 2
new medications.
New medications added:
Microzide (hydrochlorothiazide) 12.5 mg PO qd
Zoloft (sertraline) 50 mg PO qd

Question:
What is the purpose of taking these labs annually? What do they screen/check for?
 7

Test Purpose
Monitor for anemias, leukocytosis, and possibly infection /
Complete blood count (CBC)
atopy. Important benchmark reference.
Electrolytes, metabolic byproducts, imbalances in
excretion. Hypothyroidism, osteoporosis, and renal
Chemistry panel
dysfunction as well as her medications can cause
electrolyte imbalance, esp. for K & Ca.
Pt is at increased risk for dyslipidemias due to metabolic
disorders. Important benchmark for mitigating worsening
Screening lipid panel
HTN and cardiac disease. Hypothyroidism predisposes to
dyslipidemia.

Screens for end-organ damage from HTN & DM2.

Urinalysis (UA)
Asymptomatic UTIs common and can be opportunistic.

Question:
Fill out the following table regarding the new medications prescribed by Dr. Spencer

Medication Mechanism of
Class
Use Side Effects
Action
↑ Na, K, Cl, Mg, &
Anti- Hypokalemia, hypercalcemia,
Microzide bicarb excretion in
hypertensive / HTN, edema dehydration, dizziness, acute angle
(HCTZ) distal tubule,
diuretic glaucoma
causing H2O loss
Serotonin syndrome, neuroleptic
Major
SSRI, increasing malignant syndrome, suicidal
Zoloft depression,
Antidepressant serotonin activity in ideation. Drowsiness, insomnia,
(sertraline) social anxiety,
synapse headache, fatigue, tremor, N/D,
panic disorder.
appetite change.
Question:
What lab tests would you expect to be monitored for Mrs. Jones related to the new order of
hydrochlorothiazide, and why?
CBC and chem panel to monitor for thrombocytopenia, hematocrit elevation
(dehydration), and electrolyte disorders (hypercalcemia, hypokalemia, hypomagnesemia,
hypochloremia, hyponatremia, acidosis).
Question:
A few days later, Mrs. Jones calls the office and tells the nurse that she is having even more
trouble sleeping. She continually wakes up throughout the night to use the bathroom, and is not
able to get uninterrupted sleep.

A. What may be contributing to her nocturia? Medication changes: diuretic, potential

increased water intake due to dry mouth from anticholinergics.
 8

B. What education should the nurse provide Mrs. Jones to help solve this problem? Limit
water intake at night. Take HCTZ in mid to late afternoon. Elevate feet / use compression
stockings. Void completely before bed. Exercise before late afternoon. Practice good sleep
hygiene (dark & quiet room, regular schedule, no exercise of blue-light within an hour of
bed, temperature regulation, bed-clothes). Limit caffeine & alcohol, esp. 4-6 hours before
bed. Obesity increases risk 2-3 times. Consider a bedside commode or clear path to
bathroom to prevent enuresis & falls. (Leslie, D'Andrea, Sajjad, & Singh, 2019)

Case Study Progress

5 days after her primary care visit, Mrs. Jones is brought into the ER by ambulance with a
fractured right hip. She states that she became dizzy and fell one afternoon while making lunch
in her kitchen. She immediately felt a ‘pop’ in her right hip as she hit the ground. She was
unable to get up to reach the phone so she laid on her floor for a few hours. Mrs. Jones’s
daughter found her when she came to visit her mother later that afternoon.

After arriving to the hospital by ambulance, the emergency department physician orders an x-
ray, contacts an orthopedic surgeon, and gets ready to send Mrs. Jones to the OR.

Question:
What could be cause(s) for the dizziness that led to Mrs. Jones’s fall?
Her antihypertensives predispose her to dizziness by hypotension and hypovolemia, as
well as normal ADE. Combined with her COPD, she could easily become hypoxic. Her new
SSRI can cause drowsiness and her ongoing sleep issues are a factor as well. Polypharmacy
always requires careful monitoring after adjustments.

Question:
What are some of the clinical manifestations of a hip fracture?
External rotation of ipsilateral leg, inability to bear weight, deformity (if displaced),
decreased leg length. In Mrs. Jones case, there is also likely ecchymosis from the fall & her
anticoagulated state.

Question:
Describe each lines of defense by Neuman. Which line of defense is/are invaded at this point for
Mrs. Jones?
The lines of defense are conceptualized as
physical, psychosocial, developmental, spiritual,
and physical barriers that maintain homeostasis,
avoid stressors, and resist the impact & infiltration
of stressors. These lines protect the balance of the
core, which is the basic structure of the person
(their anatomy, physiology, and ego/psyche). The
flexible line maintains balance by routine
functions, avoiding stressors, and buffering
stressors from further invasion. It is the most
 9

modifiable line and can be significantly expanded by wellness-promoting behaviors. The flexible
line is also the most immediately situationally dependent line of defense. The normal line is a
reflection of the general state of wellness the individual has. It is the result of their core, stressors
(past & present), and their prior experience with stressors & buffers. When the normal line of
defense is breached, the person experiences a stressor which provokes a reaction to activate or
protect the basic core. The stressor is resisted at the Line of Resistance where there is a response
to maintain balance for the core. (Barrett, Wilson, & Woollands, 2019)
In this case study, each of Mrs. Jones lines of defense were breached and she sustained an
insult which brought about dysfunction. Her general health (normal line) had been compromised
due to her increasing age and chronic diseases. Her recent medication changes, sleep deprivation,
depression, and losses had retracted her flexible line to the point that she couldn’t resist the
stressor. She was unable to resist the dizziness or gravity. When she landed, her porous bones
were unable to resist the stress of the impact.

Question:

Fill out the chart by listing 3 nursing diagnoses for potential postoperative problems for Mrs.
Jones related to her pre-existing medical conditions and current state.

A. Include possible interventions for each diagnosis.

Nursing Diagnosis 1:
Risk for constipation.
Nursing Diagnosis 2:
Risk for infection
Related To
Opiod & anaesthesia;
immobility.
Invasive procedure
Chronic health condition
(diabetes & hypothyroid slow
wound healing)
Interventions
Instruct on proper use of opiates.
Instruct on hydration and fiber
intake. Instruct on use of
laxatives. Teach enema
avoidance to prevent electrolyte
imbalance. Explain Valsalva
avoidance, re aFib. Refer for
bedside commode to ease quick
response. (Andrews, 2017)
Instruct on proper wound
dressing & care. Instruct on
signs of infection and instruction
to return. Teach or refer to RD
for nutritional support for
wound healing. (Curchoe, 2017)
 10

Nursing Diagnosis 3: Immobilization of hip Request consult for PT/OT.

Impaired transfer ability
(complicated by overweight)
Teach client MD’s instructions
for weight-bearing. Assess fall
risk w/ pt and local daughter.
Involve social worker for in-
home assistive devices. (Makic,
2017)

Case Study Progress

The previous labs ordered by Mrs. Jones’s primary care doctor at her annual visit had not yet
been drawn, so they are drawn before surgery and come back as the following

Na+: 139 HbA1c: 8.5%

K: 3.9 LDL: 131
Cl+: 9.4 PT: 22
Albumin: 4.1 Platelets: 190,000/mm3
Creatinine: 0.9 BUN: 15
Hgb: 14g/dl Glucose: 142
INR: 3.5 RBC: 4.5 million/mm3
Cholesterol: 224 WBC: 6,200/mm3
Triglycerides: 160 Hct: 39%
HDL: 37 UA: clear, yellow urine; no
proteins, ketones, glucose, blood

Question:
What specific lab values should the nurse immediately notify the surgeon over before surgery?
Prothrombin time! Pt is also hypochloremic.

Question:
What could be the reason for this abnormal lab value?

Because this was an emergency surgery, the patient did not have time to stop taking her
Coumadin for 5 days to prepare for the procedure.

A. What does this put Mrs. Jones at risk for? Severe hemorrhage during and after.

Question:
What will be done so that Mrs. Jones’s surgery can continue?
Vitamin K will be administered to restore dependent clotting factors.

Question:
 11

After the nurse notifies the surgeon, the nursing student asks about the other lab results. The
nurse points out what other values that are not WNL?

Cl+, cholesterol (total, LDL, & triglycerides elevated), A1c elevated, BG elevated

A. What does do these abnormal lab values mean?

The dyslipidemia and A1c/BG are expected from her PMH and medication list. The Cl+ seems
dangerously low, but the usual symptom in acidosis which there’s no indication she’s
experiencing. Her PCP should consider further adjustments to her DM2 meds or lifestyle
adjustments. A statin is not warranted at this time, but enhanced counseling on lifestyle
modification should be included in discharge.

Case Study Progress

Mrs. Jones has her coagulation labs redrawn the next day and values are WNL. She has a right
hip repair using a hip compression plate and bone screws. After surgery, Mrs. Jones is admitted
to PACU with an abduction pillow between her legs, two peripheral IV catheters, a self-suction
drain from the hip dressing, and an indwelling urinary catheter. The nurse looks up the
physician’s orders to find the following:
Vital signs per PACU routine
Dextrose 5% in 0.45 normal saline at 100ml/hr
Morphine via patient-controlled analgesia 1 mg q6min (30 mg max in 4 hr) for pain
Advance diet as tolerated
Incentive spirometer qhr x 10

Question:
The nurse notices that Mrs. Jones’s O2sat has dropped to 87% and there are crackles in the
lower bilateral lobes. Mrs. Jones’s respirations are slightly decreased and shallow. What could
be causing this?

Respiratory complications are common with COPD pts recovering from anesthesia. Additionally,
she has been known to be fluid overloaded (diuretic Rx), so clearing secretions may be difficult.

A. What are some interventions that the nurse could do to improve Mrs. Jones’s breathing
and prevent further respiratory complications?

Incentive spirometry is called for in the MD’s orders. Coughing & deep-breathing exercises
should be included in PACU as well.

Case Study Progress

2 days post-op, Mrs. Jones is getting ready to go home. Her daughter is planning on staying with
her mother for a few weeks to help with wound care, ADLs, and medication administration.
 12

Question:
What are a few priority teaching interventions that should be done before discharge for hip
repair surgeries?

Recognition of infection. Mobility and transfer techniques and aids. Strategies for pain control.
Risk for fall; home inspection for fall prevention. Social resources for assistive equipment.
Constipation risk from opioids. OT/PT follow up & importance of activity restrictions / schedule
per MD. Wound care. Types of assistance for ADL (self-care / hygiene / toileting) during
recovery. Signs of DVT; prevention (mobility / compression / anticoagulation).

Question:
The nurse also reviews Mrs. Jones’s labs prior to discharge. What discharge teaching should be
done regarding the lab results taken before surgery (p. 9)?

Lifestyle modification regarding diet and exercise for A1c and hyperlipidemia. Regular BG
monitoring / logging for PCP review of metformin dosing. Resumption of anticoagulants after
surgery. Prevention of DVT during lapse of anticoagulation medication.

Case Study Progress

2 weeks post-discharge, Mrs. Jones is brought in to her primary care doctor by her daughter.
Her incision is not healing and she has noticed fluid leaking from the bandage with a strong,
foul odor. Her hip and upper thigh is warm to the touch and noticeably swollen. Dr. Spencer is
concerned that her hip repair has become infected. He sends her to the ER for stat blood work.

As the blood work is being analyzed, the nurse takes Mrs. Jones’s vitals.

Pain: 7/10
Blood Pressure: 139/103
O2Sa: 90%
Respirations: 30 rpm
Pulse: 96 bpm
Temperature: 101.9 F

The lab work comes back with the following results:

Na+: 139 PT: 12

K: 3.9 Platelets: 220,000/mm3
Cl+: 9.4 BUN: 15
Albumin: 4.1 Glucose: 350
Creatinine: 0.9 RBC: 4.5 million/mm3
Hgb: 14g/dl WBC: 12,200/mm3
INR: 1.1 Hct: 39%
 13

Question:
What is your analysis of these findings?

Her RR, HR, and temp. are all elevated, consistent with infection. At 2 weeks, her pain should be
well controlled but she’s reporting 7/10. WBC have begun to elevate. BG shows her DM2 is very
poorly controlled (whether from non-compliance, cortisol release, or infection is unknown).

Case Study Progress

Mrs. Jones returns to surgery. The wound over her fracture site has become necrotic with
purulent drainage. The wound is debrided and cultured. Mrs. Jones returns to her hospital
room with odors for wet-to-moist dressing changes. The physician suspects osteomyelitis and
orders ciprofloxacin (Cipro) and nafcillin (Unipen).

Question:
What are the two medications ordered for?
Ciprofloxacin is a fluoroquinolone with outstanding efficacy against Gram-negative organisms
(common in deep surgical wound infections) and good distribution to skin & bone/joints.
Nafcillin is a β-lactamase resistant penicillin with broad spectrum activity against both Gram+/-
organisms and is the drug of choice for methicillin-susceptible staphylococci.

Question:
Which of Mrs. Jones’s underlying chronic health issues could delay wound healing? Why?
Diabetes is a risk factor for delayed wound healing. It causes neuropathy and microvasculature
sclerosis, leading to a lack of blood supply to the wound. Additionally, sugar is highly
inflammatory and increases oxidative stress. This leads to both inflammatory cytokine release
and neutrophil activation. (Rubin, Rubin, & Strayer, 2015)

Question:
As Mrs. Jones is assessed over the following days, what will you look for to determine the
antibiotics are effectively treating the infection?

Decrease in temperature, pain, swelling, erythema. Drainage should become clear. There should
be no streaking. Her WBC should return to normal levels. I would also watch for signs of
hypersensitivity to the antibiotics.

Question:
What discharge instructions should you teach Mrs. Jones about preventing further infection?

Aseptic wound care techniques and bandage changes. Importance of washing hands. Importance
of completing any course of antibiotics. Importance of controlling BG during recovery.
 14

A. What nutritional instructions should she follow?

Ongoing nutritional support of immune system and wound healing (Vit. D, Vit. C, protein).
Focus on fresh vegetables, leafy greens (with cautions about kale & spinach for Vit. K / clotting).
Improve quality of carbohydrates (incl. whole grains, eliminate sugars / refined / processed
foods).

B. Will there be any changes to her medication dosages during the healing process?
She will likely have modified warfarin under MD’s orders. She may have route changed while
she has IV access.

Case Study Outcome

Mrs. Jones stayed in the hospital for another 5 days until her labs indicated no infection. Her
wound began healing properly and she was discharged home. Mrs. Jones followed up with her
primary care doctor routinely until her hip repair had completely healed. She completed
physical therapy and now has normal ROM and is back to her independent way of living.

Test questions
Write two test questions using the information provided in class, your textbook, and
PowerPoints. Be sure the Bloom level is at least application. Provide the answer and the
explanation for the question.

1. A nurse is completing preoperative education for a patient who is scheduled to have hip
arthroplasty. Which of the following should the nurse include in the teaching plan?
(Select all that apply.)
A. Sit in a low reclining chair.
B. Use an abductor pillow when turning the patient.
C. Instruct patient to roll onto the operative hip.
D. Perform isometric exercises.
E. Use a straight backed armchair.
F. Use a raised toilet seat.
G. Bend at the waist when putting on socks.

A – No. This increases risk of hyperflexion and is difficult to transfer.

B – Yes. This prevents dislocation of the hip.
C – No. Avoid pressure to prevent dislocation.
D – Yes. This prevents blood clots and maintains muscle tone.
E – Yes. His decreases the risk of hyperflexion and is easier to transfer.
F – Yes. This prevents hyperflexion / dislocation risk.
 15

G – No. This increases risk of hyperflexion.

(Roberts, et al., "Perioperative Care", 2017)

2. A nurse is reviewing risks for hyperglycemic hyperosmolar state (HHS) in patients with
diabetes mellitus type 2. They include: (Select all that apply.)
A. Age 69.
B. Takes hydrochlorothiazide.
C. Takes metformin.
D. Recent pneumonia.
E. Estimated glomerular filtration rate (GFR) of 58 mL/min/1.73 m2
A – Yes. Heightened risk of DM2 complications accompany age. Older clients are less likely to
realize they are dehydrated.
B – Yes. This increases the risk of dehydration and electrolyte imbalance.
C – No. Metformin aids in reducing glucose production & absorption.
D – Yes. Infection or injury increases HHS risk due to cortisol and aldosterone excretion
following insult.
E – Yes. Renal function is compromised, indicating that the kidney cannot effectively filter
blood glucose into the urine.
(Ballinger, 2012)

Simulation
Write a simulation using the template below. The simulation should last about five minutes
and represent a portion of the case study. Be sure it is as realistic as possible.

Simulation Name: Discharge education (post-operative)

Objectives:
1. The student nurse should be able to identify, organize, and convey priority education
around the discharge of a post-operative patient.
2. The student nurse will resource family / caretakers with needed referrals.
Scenario:
Edward Jacobs is an73 y/o white male who has had a rotator cuff repair to his left shoulder. He
lives with his wife (62) and has adult children in the city. He has kept physically and mentally
active since retiring, playing golf and participating in the Service Corps of Retired Executives,
Rotary Club, and church activities. He has preschool and elementary school age grandchildren.
 16

PMH includes HTN controlled with Bystolic (nebivolol), HLD controlled with Vytorin
(ezetimibe and simvastatin), and osteoarthritis of the right shoulder and left knee treated with
celecoxib & glucosamine chondroitin sulfate. His labs are normal and he reports pain controlled
as 3/10.
Equipment needed to make the simulation realistic: Discharge education papers, sling and arm
pad, clipboard, pen, resource folder, computer terminal, hospital room with bed, chairs, & table.
Scenario Progression Outline

Timing Patient Actions Expected Interventions May Use the Following Cue

Expresses readiness Nurse will review HCP prepared / “I’m a little spacey from
to leave and “get on auto-generated discharge those drugs. Am I supposed
2 mins with life.” instructions. to remember all this?”

Wife asks “He’s left-

Demonstrate adjustment of sling,
Receives instruction; handed. How is he
2 mins. use of pillows & pads to stabilize
asks questions. supposed to put that sling
joint.
on?”

Refer patient to PT. Emphasize

“How long till I’m “The doc said something
1 min. MD clearance before resumption
back on the green?” about exercises?”
of normal activities.

Roles

Primary Nurse
Handles discharge by reviewing printed instructions, prescriptions, and showing new nurse
location for resource binder. Provides PT referral. Discusses modified ADLs.

New nurse who is off orientation tomorrow

Demonstrates proper use of the sling & wound care. Witnesses signatures.

Family member
1. Asks questions about what she’ll need to do for him while he recovers. Demonstrates
sling use after being shown how.
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Observer
Write your findings on a separate sheet of paper.
1.

Works Cited

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