Transition to Professional Practice Essay Example

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13Transition to Professional Studies


Case Introduction

Joan (not her real name), presented to the Small 9 Community hospital emergency department on July first, 2016 on a transfer for pain management due to confirmed right knee periprosthetic fracture. She is a 76-years old female, with a past history of smoking as well as light drinking. She reported due to an acute right knee pain, as well as the inability to carry weight after a slip and fall incident. This report enumerates Joan’s history leading to her current illness, as well as relevant medical history. Further, it will assess the patient’s medical and nursing interventions, validating the interventions applied, as well as expounding on the laboratory and diagnostic measures used in planning management. Further, the role of the interdisciplinary team used in her care is explained, in addition to presenting a discharge plan. Finally, a relevant article to the patient’s case is disseminated as evidence for the efficacy of care given.

The patient is a widow, her husband being dead for an excess of twenty years. She has a daughter who lives in Sydney, however, who is very supportive and visits her mother on many occasions. Being a retired teacher, Joan is independent in her ambulation by use of a walking stick. Further, she enjoys gardening as well as shopping. For the past 12 years, Joan has been a teetotaller, while she also quit smoking 15 years ago. Joan reports having had a slip and fall accident, resulting in an acute pain in the right knee, as well as rendering useless her ability to bear weight. From her medical records, the patient also suffers from hypertension, gastro-oesophageal reflux disease (GORD), as well as osteoarthritis, in addition to being obese. The patient’s admission to the ED followed a confirmed diagnosis of right knee periprosthetic fracture, requiring orthopaedic care.

Patient Medical history

Joan’s medical history indicates that she suffers from hypertension necessitating medication with lercanidipine, which acts as a calcium-channel blocker. The drug’s effect of regulating calcium movement in the muscles causes a deficiency, inhibiting muscle contraction while dilating the blood vessels causing reduced blood pressure (Triggle, 2007, p 5). Olmesartan/hydrochlorothiazide is also used in managing her hypertension, where it blocks the constricting actions of angiotensin II through selective blockage of angiotensin II to its receptor in the smooth muscle. Joan has a high risk for developing secondary conditions such as heart attack as well as stroke, given her hypertension as well as obesity conditions, thus explaining her medication with Rosuvastatin. The drug acts by managing cholesterol as well as triglycerides while improving high-density lipoprotein (Hausenloy & Yellon, 2008,p 710). The patient also suffers from gastroesophageal reflux disease (GERD) and is on docusate medication. The drug functions by softening stool as well as easing bowel movements. However, the drug is known to invoke severe allergic reactions including hives and breathing difficulties (Grassi, et al., 2011, pp 660-663). Joan’s osteoarthritis is compounded by her history of knee replacement, advancement in age as well as her obesity. Non-pharmacological interventions form the basis of osteoarthritis therapy, with actions such as patient education, exercise as well as weight loss recommended in Joan’s case. Anti-inflammatory medicines such as trolamine salicylate and Acetaminophen are also recommendable in this patient’s case management. The patient has also undergone a previous TKR, (Total Knee Replacement) which replaced her knee joint with artificial prostheses. She is treated with enoxaparin in preventing deep vein thrombosis, as well as buprenorphine in managing pain. Finally, the patient has a known allergy to contrast dye, which causes her hives with severe rashes over the body.

Diagnosis and Medical Management of Joan’s right knee Periprosthetic fracture

Knee periprosthetic fracture; Pathophysiology

Periprosthetic fractures present immense difficulty in patient management as well as recovery. Further, the correction and management of these fractures are arduous, especially given the existence of previous implants. Periprosthetic fracture in the elderly is devastating, occasioning increased morbidity as well as mortality. Among major risk factors for periprosthetic fracture include; osteoporosis, inflammatory arthritis, corticosteroid use, age progression, being of a female gender as well as previous revision arthroplasty (McGraw & Kumar, 2010). The patient manifests almost all the predicting factors for periprosthetic fracture, given her age, sex as well as suffering from osteoarthritis. The fracture can involve the distal femur, proximal tibia or the patella, and are classified into three dependent on the pattern of the fracture. Extra-articular or supracondylar fractures relate to when the fracture does not extend to the knee. Partial-articular or condylar fractures signal a fracture extending to the knee joint line with the condyles attached. Complete articular fractures relate to fractures extending to the knee joint line with the condyles removed from the femur shaft (Chettiar, et al., 2009, p 983).

Peri-implant fractures are caused by trauma, occurring even after low energy episodes such as a simple fall. Axial and torsional forces collaborate in fracturing the prosthesis, just as is the case in normal fractures. Risk increases for patients with compromised bone strength, following conditions such as osteoporosis and corticosteroid use. Stress exacerbation is another postulated cause for peri-implant fractures, particularly, notching of the anterior cortex. Notching of the cortex reduces bone density integrity, thus predisposing fracture.


Diagnosis of knee periprosthetic fracture bases on radiological results, where a right knee replacement is observed. Further, an abnormal that lucency is evident in the proximal anterior tibia, disrupting the cortex. The lucency’s extension is in line with periprosthetic fracture, given that it appears related to the distal part of the prosthetic tibia. Apart from notable effusion of the knee, lateral imaging shows the humeral prosthesis in a mildly posterior position to the tibial prosthesis (see appendix 1). Prior to her private appointment with Dr. Webb, the primary examination has established her need for X-rays taken on the right knee in revealing the extent of damage to the prosthetic. Further, the general practitioner is advised to monitor the patient’s use of medications such as rosuvastatin and meloxicam, given the possible contraindications possible on the patient following their use in her condition. Further, the treating team is advised to follow up on the patient’s supplementation of vitamins, minerals as well as keeping to medication. Prior to her appointment with orthopaedics specialist, the patient is to avoid all weight-bearing on the affected knee through the application of a zimmer frame. Management with enoxaparin for the non-weight bearing status is proposed, for
prevention of deep vein thrombosis (Chalidis, et al., 2007, p 718). Acute pain is managed through the use of oxycodone since effective management of pain leads to faster recovery while reducing the risk for complications. Thrombosis also contributes to pain, and its occurrence is avoided by use of enoxaparin. The nurse is also advised to elevate the leg as much as possible, where the feet are higher than the hips. Keeping the legs in an elevated position lessens the amount of pain suffered by the knees.

ISBAR Patient Clinical Assessment

The patient handed over is Joan, a 76-year-old female with a diagnosed periprosthetic fracture of the knee. Pain management is a central aspect of the care for prosthetic fracture patients, necessitating Joan’s admission to Small 9 community hospital. Pharmacologic intervention includes buprenorphine patch therapy, as well as oxycodone tablet medication for acute pain. Assessment of the presence of prosthetic fracture examines symptoms such as the history of a recent fall, severe pain and swelling as well as inability to bear weight. X-ray imaging confirms the diagnosis, while also informing on a suitable treatment. The patient is recommended for a scheduled follow-up X-ray session, with assisted mobility as well as pain management prior to surgical intervention.

Psychosocial / Environmental / Economic aspects of Joan’s Care

Several variables are pertinent in planning optimum care for Joan, especially in consideration of her social and environmental circumstances. Empirical studies show that an increasing number of periprosthetic fractures are due to increased patient longevity, as well as increasingly demanding activity levels into old age (Chalidis, et al., 2007, p 721). While Joan is fairly advanced in her age, she lives alone in a single unit, implying that she takes care of most of her daily activities of living. Further, her condition of being obese also detrimental to her health, in this case increasing the risk for fractures due to excess weight bearing. Ensuring she has assistance with most of her activities, as well as taking measures against her obesity facilitate uneventful rehabilitation of her knee prosthetics.

Nursing Care for the Patient’s Periprosthetic fracture of the Knee

Nursing priorities intended including cessation of further bone and tissue injury, minimise pain as well as prevent complications possible from the fracture. Joan’s care will hinge on the results of her X-ray, as well as recommendations due on her next scheduled visit to the hospital. If the fracture suffered is stable and nondisplaced, she may only require a cast or brace in addition to protected weight bearing. However, as is the case with most periprosthetic fractures, the patient might require surgical stabilization of the joint, as well as possible replacement of the prosthetic. Post-treatment early ambulation would be emphasized for the patient, in avoiding respiratory complications, pressure ulcer as well as disuse osteoporosis (Chettiar, et al., 2009, p 982).

Education Needs of Patient

Other than providing basic care for the patient, a nurse is also required to ensure a patient I properly educated on issues likely to affect their health. Foster (2015) explained patient education as a crucial element in ensuring positive outcomes including improvement in the quality of life especially after discharge from the hospital. Joan received education on different issues including the various steps she can take to prevent any other falling incidents as well as how she can improve her overall health while at home. Joan learnt the importance of exercise in preventing future falls. Joan was, however, cautioned against attempting any exercises before consulting her physician. She was also educated on the importance of vitamin D in ensuring bone health as well as the need for her to start using proper footwear, which would help prevent any falling incidents. Joan also received education on what she should do in case she experienced a fall in the future. She received education on the importance of a safety alert button, a device that would summon help in the event of a fall.

Discharge Planning

Discharge planning is an integral element in provision in many coutries. Discharge planning aims at reducing the amount of time a patient spends in the hospital as well as preventing and reducing instances of readmission (Shepperd, et al., 2009, p. 6) Joan’s discharge planning involved providing her with instruction on when to take pain medication. Joan will also require follow up her physician or a bone specialist to ensure her knee is healing properly She was also informed on the importance of asking questions during her visit with to her health care provider. Joan discharge planning also involves education on how to take care of her cast, as well the various ways she could ensure self-care. Before discharge, Joan learnt the importance of resting, using ice and elevating her leg in ensuring quick healing of her knee (Michel, et al., 2012). Joan will also require a physical therapist’s services to ensure she goes back to her normal mobility. The discharge planning also involved education on when she should contact her care provider.

Establishing the Evidence Supporting Current Practice

Periprosthetic fractures are quite common among the elderly, a phenomenon that has resulted in increased research on management techniques. Pain is quite common among individuals suffering from periprosthetic fractures; therefore, a need for effective pain management. Afilalo, et al. (2010) reviewed the efficiency of both oxycodone and tapentadol in managing pain after a knee injury. The randomized study reported both drugs to be efficient in pain management. According to Afilalo, et al. (2010), using either oxycodone or tapentadol resulted in pain reduction in a high percentage of patients involved in the study. The study also involved a study of the drugs side effects, with Afilalo, et al. (2010) reporting both oxycodone and tapentadol to have minimal impact on the gastrointestinal health of the patient. Pain management in Joan’s case involved the use of oxycodone, which was also meant to ensure fast recovery and increased comfortability.

Knee injuries are often associated with an increased risk of clot development, which may result in thrombosis. Joan care plan also involved the use of enoxaparin to help prevent the occurrence of thrombosis. Lassen, et al. (2009) compared the effectiveness of enoxaparin against apixaban in preventing thrombosis. According to Lassen, et al. (2009) there lacks an optimum strategy for preventing thromboprophylaxis, with existing strategies reporting mixed results with varied side effects. The study revealed enoxaparin more effective as compared to apixaban in preventing the formation of clots. Despite its effectiveness, enoxaparin was reported to result in increased risks of bleeding, as compared to apixaban, which resulted in reduced instances of bleeding. Other drugs that may help in preventing thrombosis include Rivaroxaban, which Lassen, et al. (2008) reported to be superior to Enoxaparin. Lassen, et al. (2008) however reported both drugs to have similar side effects including the same bleeding rates. These studies showed a need to for constant observation of the patient’s injury to ensure the two drugs do not result in over bleeding.

The use of medication is one way of preventing and reducing knee pain as a result of the fracture. Other pain management techniques do not involve the use of medication. In Joan’s case, elevating her feet to a position higher than her hips was alternative non-medical pain management strategy chosen. Toms et al., (2009) investigated the various pain management techniques used in patients who have undergone knee surgery including total knee replacement. Pain management should entail the use of a multi-disciplinary team composed of physicians, physiotherapists, and nurses (Toms et al., 2009). The interdisciplinary team should aim at early pain management to help prevent overuse of analgesic and pain medication. A strategy that helps in early prevention of pain is simply keeping the foot in an elevated position. Toms et al., (2009) explained elevating the foot to a higher level than the hip resulted in reduced pressure to the knee; therefore, minimal pain. Toms et al., (2009) also explained elevating the foot as the cheapest method of pain management it involves using pillows to ensure the foot is raised. The pain management technique can also be practiced at home, as well as the hospital.

Knee fractures often take a long time to heal due to the constant movement of the leg. Joan’s knee rehabilitation involved the use of a Zimmer-split whose main purpose was to allow immediate weight bearing. Pujol et al. (2015) explained the need for patents to start weight bearing exercises at the beginning of the rehabilitation program. According to Pujol et al. (2015), the use of a Zimmer-split also helps to immobilise the knee; therefore, promote fast healing of the fracture. Immobilization of the knee also helps to reduce the amount of pain experienced by a patient during motion.

The health care field is constantly changing, with new nursing care methods emerging. Hirschmann et al. (2011) conducted a review of emerging trends in pain diagnosis among patients who have undergone total knee arthroplasty. The article identified SPECT/CT imaging as the most effective strategy for pain diagnosis. The use of SPECT/CT imaging is also crucial in establishing the pain management technique chosen for specific patients (Hirschmann et al., 2011). In Joan’s case, SPECT/CT imaging would have provided an alternative pain diagnosis procedure. Joan’s treatment also involved the prevention of thrombosis using enoxaparin. Lassen, et al. (2008) conducted a comparison of Rivaroxaban and enoxaparin, two drugs meant to prevent deep vein thrombosis. The study revealed Rivaroxaban as more effective that enoxaparin. Rivaroxaban would have made an effective alternative for enoxaparin.

Summary and Conclusion

The paper involved a discussion of Joan’s case, an elderly female patient who had suffered from a periprosthetic fracture on her right knee. Joan was first rushed to the emergency department but was transferred to Small 9 Community hospital for pain management. During her stay at the facility, I was appointed as her care provider. Provision of care involved giving Joan pain medication, educating her on the best strategies to avoid pain and teaching her on how best to avoid future falls. The various intervention strategies chosen for Joan’s case aimed at meeting both short-term and long-term goals of the treatment. Short-term goals involved immediate alleviation of pain, which was achieved by prescribing pain medication for Joan. The long-term goals of the treatment aimed at ensuring full recovery and return to mobility for Joan. Some of the strategies chosen to ensure achievement of the long-term goals included patient education, physiotherapy, as well as the use of devices such as the Zimmer-split, which promote quick healing of the fracture. Working with Joan was a useful learning experience as it allowed proper understanding of how an interdisciplinary team works, as well as how one can use evidence to ensure proper care to patients.


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