Case Studies 9.2 & 9.3
Jessica Gragert
Lakeview College of Nursing
N309 Nursing of the Gerontological Client
July 16, 2012

Case Studies 9.2
Given the described scenario Pearl is in need of pain management if she is still in severe pain, and with assessment completed and informed consent obtained Morphine Sulfate can now be administered in her IV.  She also needs to be given Potassium Chloride in her IV line, as her low serum level is indicative of hypokalemia.  Regular Insulin should be given via a subcutaneous injection and the needed dose would be determined by a sliding scale.  With Pearl requiring surgery, she should be started on Cefazolin IV for surgical prophylaxis but her elevated BUN and creatinine levels indicating possible renal insufficiency, it should be used with extreme caution and at a low dose.  Coumadin should not be given as this increases the risk of surgical bleeding (Collins Abrams, Barnett Lammon, & Smith Pennington, 2009).
Approximately three hundred thousand hip fractures occur in the United States every year (University of Chicago Medicine, n.d., para. 8).  Some of the age-related physiological changes that can increase the risk of hip-fractures are vision changes, neurological changes, cognitive changes, and reduced muscular strength.  An elder may suffer from disease or disorder that affects physical and/or cognitive ability or awareness (e.g. dementia), increasing the likelihood of injury.  Adverse effects of some medications for many common disorders (e.g. dizziness from antihypertensives) may also put one at risk.  Any one of these factors may increase the risk of falls which can cause a fractured hip (Mauk, 2010).  
The use of preoperative traction has been shown in some research studies to have no effect on pain reduction in patients with hip fracture and effectiveness of immobilizing the fracture was inconclusive.  There is also a possible increased risk of infection, pressure sores, and additional pain from using such devices.  With this lack of evidence, some researchers believe that traction should not be used routinely (Handoll, Queally, & Parker, 2011, p. 4).  
Patients face a risk of developing complications after surgery.  There are various interventions that are used in order to prevent them.  To minimize risk of atelactasis, patients may be encouraged to utilize incentive spirometers and encouraged to cough in order to prevent fluid buildup in their lungs.  To prevent the development of pressure sores patients would be turned regularly and assisted in maintaining of skin integrity through proper hygiene and skincare.  The risk of deep vein thrombosis can be reduced by the administration of anticoagulant medications, passive leg exercises, and the use of compression devices or stockings on the unaffected leg (Taylor, Lillis, LeMone, & Lynn, 2011, Chapter 30).  Some measures that can be used to avoid abduction of the effected hip are using a pillow between the legs to allow proper placement, and educating the patient not to cross their legs, bend excessively while in a sitting position, or lie on the affected hip until allowed by their physician (Mauk, 2010, p. 432).
	When the nurse asks Pearl about any recent alcohol consumption, she is assessing for history of alcohol use, signs of possible alcohol dependency, and other symptoms of delirium.   Given the fragile state Pearl is in while healing from the fracture and surgery, she is at a risk for  delirium and her visions show troubling signs that she may be developing this.  An important aspect of treating delirium is to establish and treat the underlying cause. Pearl’s admitted regular use of alcohol raises the possibility that she may be experiencing withdrawal symptoms that may be causing or contributing to the symptoms of delirium (Mauk, 2010). 
Individuals that return home after a hip replacement will likely require certain modifications after their surgery.  Walking will require assistance, at least initially, with devices such as walkers or canes.  Installing safety bars in bathrooms can reduce the risk of falls, as can the use of elevated toilet seats, handheld showers, or bedside commodes. Using devices that assist in reaching objects can reduce this risk as well (National Association of Orthopaedic Nurses [NAON], 2009, p. 12).  Approximately twenty percent of patients who suffer from a hip fracture die within one year of their injury (University of Chicago medicine, n.d.).  

Case Study 9.3
	A fall is “an event which results in a person unintentionally coming to rest on the ground or another lower level” that was not caused by a medical issue or environmental obstacle (Mauk, 2010, p. 461).  Some of the results of falls are “injury, loss of independence, reduced quality of life, and death” (Mauk, 2010, p.461).  The total cost of these events in the year 2000 was nineteen billion dollars (Mauk, 2010, p. 462).  These costs are expected to increase to over forty-three billion dollars by the year 2020 (Mauk, 2010, p. 462).  
	The first step that Susan should do to prevent future falls is to “modify the environment” that her mother is in (Mauk, 2010, p. 464).  However, given the geographical separation of Susan from her mother, this is likely not possible.  As such, she chose to contact a local agency in order to facilitate this step.  During the resulting assessment, the nurse is able to determine that the medications Susan’s mother is taking may put her at increased risk for suffering from a fall.  The antihypertensive metoprolol can cause dizziness and orthostatic hypertension.  The medications pioglitazone and glimiperide that she takes for diabetes may also cause blood sugar to fall too low and this can result in dizziness and weakness as well (Hamilton County Fall Prevention Task Force, n.d.).  
	Mary’s complaint of fatigue is understandable given the lengthy drive she takes every day to visit her husband.  Some things that may help make this less taxing on her would be to inquire with her church, VA, or other local agencies for transportation services that may be available so that she may reduce or eliminate the time she has to spend driving.  Also, making sure that she is getting proper rest and eating properly can reduce fatigue.  Reducing visits from daily to a few times a week can cut down on her travel time, if she is willing to do so.  Educating Mary in ways to reduce the risk of driving such as eliminating distractions, taking routes with reduced traffic, and driving during daylight hours can also take away some of the stresses of this daily drive (Mau, 2010).  
	Older adults can stay connected to others in times of emergencies by using an “emergency response system (ERS)… which consists of the subscriber wearing a small help button as a necklace or wristband” (Mauk, 2010, p. 565).  This device can be used in an emergency and when activated connects to an emergency response center that can send appropriate help when needed.  Also, establishing a support network through her church or local organizations may allow her to set up home visits from volunteers, care providers, or even local emergency services that can provide regular wellness checks.  
Various factors in Mary’s home place her at risk for falls.  Some of these factors can be easily addressed. Reducing the clutter in Mary’s home, securing loose carpet, using nonskid wax on floors, using extra lamps and brighter lightbulbs, clearing staircases of objects or rugs, and modifiying handrails and steps to make them safer are all ways that she can improve the safety of her home environment (Mauk, 2010, p. 465).  These improvements could be made by volunteers or hired help, as Mary could not safely complete these steps on her own.  Another environmental factor that could cause falls is a slippery tub surface, and installing nonskid material to the tub bottom could reduce this risk.  
To further reduce the risk of future falls, Mary could begin an exercise program to increase her strength and balance.  Mary could be educated to the benefits of joining a structured training program at her local senior center. If group exercise is not possible, she should be educated to how to begin an exercise program at home.  Gently stretching before beginning exercise is important to prevent injury.  After warming up, she should engage in low intensity exercise such as walking or swimming. She should start slowly but should aim to exercise for thirty minutes at a time, if this proves too difficult, three separate ten minute sessions would also be beneficial.  She should aim to exercise most days of the week, if not every day, if she is sticking to lower intensity levels of exercise (Mauk, 2010, pg, 314).  In order to ensure that she adhere to a program such as this, it would be important to highlight all of the benefits of regular exercise such as increased muscle strength and cardiovascular fitness.  Also, it would be important to stress to Mary not to overdo it, especially at first, in order to prevent injury while beginning a new exercise program.  

References
Collins Abrams, A., Barnett Lammon, C., & Smith Pennington, S. (2009). . In Clinical Drug Therapy (9th ed., ). : Wolters Kluwer Health| Lippincott Williams & Wilkins.
Hamilton County Fall Prevention Task Force. (n.d.). Medication and fall prevention . Retrieved from http://www.fallpreventiontaskforce.org/falls_medication.htm
Handoll, H., Queally, J., & Parker, M. (2011). Pre-operative traction for hip fractures in adults: Review. The Cochrane Collaboration. Retrieved from http://www.thecochranelibrary.com/SpringboardWebApp/userfiles/ccoch/file/CD000168(1).pdf
Hip fracture. (n.d.). Retrieved from http://www.uchospitals.edu/online-library/content=P08957
Mauk, K. L. (2010). Gerontological nursing: competencies for care (2nd ed.). Sudbury, MA: Jones and Bartlett.
National Association of Orthoepedic Nurses. (2009). Total hip replacement. NAON Patient Education Series. Retrieved from http://www.orthonurse.org/Portals/0/images/PDF/TotalHipReplacement-FINAL.pdf
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2011). . In The Fundamentals of Nursing (7th Ed., ). : Wolters Kluwer Health| Lippincott Williams & Wilkins.
University of Chicago Medicine. (n.d.). Hip fracture. Retrieved from http://www.uchospitals.edu/online-library/content=P08957