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Posted: September 6th, 2023

Surgical Case Study Assessment

ASSIGNMENT 1: Written Assessment based on a surgical case study
Due date: Wednesday 29/03/2023 at 1400hrs Weighting: 50% Length and/or format: 2000 words +/- 10% Purpose: This is a written essay based on a surgical case study. Students will appraise an individual’s holistic health care needs and subsequent interventions and management to assist with the application of theory into practice. An excerpt of clinical notes and charts are provided in the NRSG258 LEO site to provide the clinical information for the patient — Maisie Wilson. Using the information on LEO answer all the following: • Identify and discuss all 6 of Maisie’s presurgical risks. What investigations does she need prior to surgery? Explain how they are linked to her surgical risks. (400 words) • Discuss what is required for legal consent. With reference to the relevant legislation, explain why or why not Maisie can provide consent? (200 words) • Identify two (2) medications used in this case study and provide:
o the mechanism of action
o side effects o correct dosage o contraindications
For both medications – discuss why they were prescribed for Maisie. (600 words) • Describe the biopsychosocial factors that will impact Maisie and her family as a result of this accident. (May include spiritual or cultural elements). (500 words) Learning outcomes assessed: L01, L03, L04, L05, LO6
How to submit: Students will submit their written assessment task via the Turnitin link in the NRSG258 LEO site national assessment file.
Return of assignment:
Assessment criteria:
Feedback and marks will be returned via Turnitin 3 weeks after submission. If this is not possible, students will be notified via email or LEO
This assessment task will be graded against a standardised criterion referenced rubric. Please follow the criteria closely during the planning and development of your assessment task. (Appendix 1).
Page 9 of 16…. Extended Unit Outline — NRSG258_FINAL MODERATED_202330 © Australian Catholic University 2023

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Biodata
Name: Maisie Wilson
Age: 74 years
Sex: Female
Marital status: Married
C/C
Fell 8hrs ago
The work submitted contained:
Maisie’s pre-surgical risks, their investigations, and how they are linked to her surgical risks- All of Maisie’s pre-surgical risks are identified and discussed. Investigations to be done in assessing these risks are also included.
Legal consent- Requirements for legal consent are discussed and Maisie’s case of consenting is also discussed.
Medications involved in the study- The two medications used in this case study are adequately discussed from the mechanism of action, side effects, and the correct dosage to their contraindications. Reasons for their use in the patient are also addressed.
Biopsychosocial factors that will impact Maisie and her family are also discussed adequately, covering the various perspectives that will affect her and her family.
Appropriate referencing was also done, and the grammar used in the literature was also of good standards.

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Surgical Case Study Assessment
Hello, been checking the assignment and cannot really point out any issue with the paper as far as revision is concerned. The paper is well past 8 pages and trying to understand some specifics you wanted looked at in the assignment. Kindly share your particular concern on it. thanks
Introduction
Doctors, especially the junior in the profession, are tasked with the pre-operative management of patients prior to undergoing any major surgical procedure. This serves to optimize the outcome of the patient. The task is classified under core functions of medical doctors in the medical and surgical wards. The management plan for pre-operative patients most often warrants patient-specific management although a conventional management plan exists and it involves reassuring of the patient as most of them are faced with anxiety prior to undergoing surgery, advising the patients on the importance of fasting before going into the theatre, controlling and moderating the prescription drugs, preparing for the adverse outcome by considering booking for high dependency unit or intensive care unit bed and by conducting appropriate investigations relevant to the specific patient being managed (Shi et al., 2020; Wouters & Lapage, 2017). The health provider should ensure that the patient is fully informed and has good understanding on the plan of care being served to them (Sardar et al., 2018). The paper will put into focus and discuss the current health status of Maisie Wilson as she is being prepared to undergo open reduction and internal fixation, a surgical procedure, following a fall down a staircase. The compromised health status of the patient will be discussed with focus being on the preoperative management with a goal of achieving the optimum outcome of the patient.
Maisie Wilson was brought to the Emergency Department by ambulance following a fall at home and had been on the floor for eight hours. She is a known hypertensive, has history of osteoporosis and osteoarthritis and she also underwent hysterectomy in the year 2009. The patient normally takes her routine medication, that is, atenolol, Panadol osteo and alendronate which she reports to not have taken on the day of admission. The vital signs on admission were blood pressure (BP) 148/96mmHg, pulse rate (PR) 100 bpm, respiratory rate (RR) 19bpm, SpO2 96% on room air (RA), temperature 36.4. Her Glasgow Coma Scale (GCS) was 14/15. The high blood pressure, low temperature and GCS score warrant for further investigations (Shi et al., 2020). Her preoperative examination entailed capillary refill of <3 second, dry blood to face and cut still oozing blood, bruising on left face, cool to touch, grazes to arm and lacerations to left forehead.
Question 1: Pre-surgical risks to Maisie Wilson and investigations needed prior to the surgery
Hypertensive Patient Who Missed Atenolol Dose.
Maisie has had hypertension since 2009. She has been taking atenolol but failed to take her medication on the day she was scheduled to undergo the procedure. This poses significant perioperative risk of hypertension in two ways. First of all, the major worry is the damage hypertension might have done to other body systems that might negatively impact the outcomes of the surgical procedure (Wouters & Lapage, 2017). Hypertensive heart disease, nephropathy, and encephalopathy are among the big worries. Second of all, uncontrolled hypertension especially due to missing the atenolol dose on the day of surgery may cause intraoperative elevation of blood pressure to levels above 180/110mmHg which is catastrophic (Shi et al., 2020). ECG, and echocardiography should be done for the purpose of ruling out hypertensive heart disease. Urea, electrolytes, and creatinine to check the function of the kidneys due to the risk of hypertensive nephropathy.
Preop Nausea and Vomiting
Preoperative nausea is a strong predictor of intraoperative and postoperative nausea and vomiting (Raytis et al., 2018). Incase Maisie vomits intraoperatively, it may cause aspiration which may lead to aspiration pneumonitis. This will pose a big concern to the anesthetists in case intubation becomes impossible. Vomiting will worsen the hydration status and cause electrolyte abnormalities that will in turn worsen the side effects of anesthetic agents. Urea, electrolytes and creatinine levels should be investigated since dehydration is a risk for acute kidney injury.
History of Osteoporosis
Osteoporosis is found in a majority of elderly patients who present with pelvic fractures. Most of these fractures are pathological due to a decline in bone density. The bone is not able to remineralize adequately increasing the tendency for fractures. This is a big concern to the surgeon on call as the fracture will take more time to heal (Kim et al., 2017). More so, she may sustain new fractures during the surgical procedure. Vitamin D and Phosphate levels should be done to check extent of osteoporosis.
Medical History of Osteoarthritis
Osteoarthritis is more dominant in the elderly population. It causes bone weakening hence increasing the tendency of pathological fractures. Consequently, fractures involving joints are highly linked to secondary osteoarthritis of the joint. Therefore, it is predicted that Maisie will develop secondary osteoarthritis of the left hip joint due to the neck of femur fracture (Rollmann et al., 2018). This is a negative predictor as it may lead to subsequent fractures in the region. Radiograph of previous osteoarthritic joints should be done to check the extent of osteoarthritis.
Past History of Hysterectomy
Hysterectomy could cause undesired effects on the body’s bony structures by interfering with blood supply to the ovaries, this predisposes to premature ovarian failure and serum bioavailability of testosterone levels rather than bioavailable estradiol levels are diminished amongst women who have undergone hysterectomy and ovarian conservation. More specifically, a hysterectomy may have been the direct cause of Maisie’s increased risk of fractures. Serum estrogen and testosterone levels to ascertain the effects of hysterectomy to the patient.
Old Age
Older patients have an increased risk of falling due to loss of balance and sight. This is also partly related to age-related brain atrophy. With increasing age, there is a loss of bone mineral density hence the increased tendency to sustain a fracture.
Question 2: Requirement for legal consent and assessment of Maisie Wilson’s ability to make one
Informed Consent
Refers to a conscious, independent choice made by a competent, self-reliant individual to accept a goal or course of action instead of reject it, based on an awareness and knowledge of the circumstances, along with the consequences of undertaking an action even if refusal may cause harm.
Requirements
The involvement should be a process rather than a form. Also, it needs to be a dynamic process with active engagement from all participants and be free from compulsion (voluntarism). The process in general, should follow effective communication techniques and touch on fulfilling relationships. Additional disclosure must be based on some reasonable expectations that are documented and should give sufficient and meaningful information.
Taking an Informed Consent
If not verbally expressed, informed consent must be in writing or be supported by documentation that is witnessed. If possible, the patient should sign it. Nonetheless, it can be approved by a surrogate, a proxy, or a doctor for the betterment of the patient.
Who Can Consent
The patient is one of the people who can give their agreement to the treatment procedure (if adult and competent). But, if there is any impairment brought on by an injury, a court order can be obtained for a surrogate decision maker to consent to administer the EtOH, pharmaceuticals, or narcotics.
When a Proxy is to Sign
A proxy will be needed to sign where the patient is below legal age, is mentally retarded, unconscious or under medication (Xiao & Zhou, 2020). However, refusal of treatment does not mean an incompetent patient since they have a right to refuse.
Why Informed Consent?
Informed consent is a necessity of the law (mandatory by law). Further, it is a statute and regulatory requirement, and should also adhere to the hospital’s policy.
Contents of the Form
The content of the forum includes the patient, a physician, and the procedure, a reason for the procedure, and other alternatives proposed for the process, as well as the benefits and risks associated with the chosen intervention. Therefore, Maisie cannot provide consent because she is not oriented to time and place. This means his mind is altered.
Question 3: Medications involved in Maisie Wilson’s preoperative management
Morphine
Mechanism of action.
Supraspinal actions: should be accomplished in a way that is compatible with its action a MOR, inhibits pain conduction following distribution into confined areas of the brain. The PAG matter, that is, mesencephalic periaqueductal gray is the best characterized of these regions. Nociceptive responses will be blocked by morphine microinjections into this area (Antle et al., 2019). MOR agonists prevent the active systems of PAG that control actions that project to medulla preventing release inhibitory transmitter Gamma Aminobutyric Acid (GABA). At the dorsal horn of the spinal cord, medullary projections from PAG trigger release of serotonin and norepinephrine. The discharge lessens the excitability of dorsal horn of the spinal cord. Locus coeruleus together with dorsal raphe can be made more excitable by this PAG architecture.
Spinal opiate action: Discharge by spinal cord neurons from the action of the afferent fibres in the dorsal horn of the spinal cord is selectively depressed by local action of the opiates in the dorsal horn. Distinct receptor proteins as well as opiate binders are found mainly in the substantia gelatinosa where small nerve afferents with high threshold terminate principally (Ali et al., 2020). A significant proportion of these opiate receptors are associated with small peptidergic primary afferent C fibers and the remainder are on local dorsal horn neurons.
Peripherally its action is by: eliciting anesthetic-like effect when applied directly to a peripheral nerve.
Side effects
Tolerance: tends to mostly develop in cases where large doses are administered over short intervals. Minimization of tolerance can be achieved through administration of small amounts over longer intervals.
Physical dependence: occurs as a result of repeated ingestion of u-type opioid.
Psychological dependence:the sedating effect as well as euphoria tends to spear compulsive use.
Other include respiratory depression and GIT (gastrointestinal) upset.
The Correct Dosage
Pain of acute onset
Immediate-release tablet: 15-30 mg PO q4hr PRN
Oral preparation: 10-20 mg PO q4hr PRN

Suppository tablet
• 10-20 mg PR q4hr
Parenteral solution
• Intravenous or intramuscular: 5-10 mg q4hr PRN; dose range, 5-20 mg
• Intravenous: 2.5-5 mg q3-4hr PRN, infused over 4-5 minutes; range of dose, 4-10 mg
• Epidural injection
o Single dose: 5-10 mg OD in lumbar area
o Continuous infusion over twenty-four hours: 2-4 mg IV
• Intrathecal dose, that is single: 0.1-0.3 mg single dose
o Continuous infusion: 0 .2-1 mg on the lumbar region over 24 hours.
Continuous intravenous infusion for the opioid tolerant individuals: 1-10 mg over 24 hr

Contraindication
Contraindication of opioid use includes bronchial asthma, in cases of depressed respiratory system, gastrointestinal obstruction whether suspected or known or concurrent monoamine oxidase inhibitors use or usage within the past fourteen days.
Indication in the Patient
Provide analgesia
Ondansetron
Mechanisms of action
It’s a selective antagonist of the serotonin receptor subtype 5-HT3 of serotonin. The CTZ of the area postrema, found in fourth ventricle, releases serotonin centrally due to pain by activating the vagal afferents. By stimulating the 5-HT3 receptors on the vagal afferents, it is likely to trigger the vomiting reflex. Ondansetron’s antiemetic properties are most likely a result of the 5-HT3 receptors’ selective inhibition of neurons in the peripheral, central, or both nervous systems.
Side effects
• Diarrhea or constipation;
• Headache;
• Drowsiness; or tired feeling.
• Prolongation of the QT interval
The correct dosage
IV slow infusion:
• 1month- 12years 0.1mg/kg in <40kg, and 4mg in >40kg.
• 12- 18 years 12mg before anesthesia or after procedure IV/IM OR 16mg 1 hour before anesthesia orally.

Contraindication
Known drug hypersensitivity and concurrent usage of apomorphine result in severe hypotension and unconsciousness.
Indication in the patient
Prevention of pre-op (before surgery) and post-op (after operation) nausea and vomiting (Raytis et al., 2018).
Question 4: Biopsychosocial factors that will impact Maisie Wilson and her family post-accident
The accident will have an effect on Maisie and her family in terms of biopsychosocial variables. George Engel proposal in 1977 about Biopsychosocial model, argued that other than biological elements, psychological as well as social factors ought to be put to consideration when attempting to comprehend a person’s medical state.
Bio- physiological pathology entails behaviours like fear, attribution and psychological distress, emotions, current coping methods and psycho- thoughts (Xiao & Zhou, 2020). Social- cultural factors like family circumstances, economics and work issues, socio-environmental, benefits and also socioeconomic.
Often the model is used in cases of chronic pain with perception that pain is some sort of psychophysiological pattern of behavior which cannot be classified into social, biological or psychological factors alone. Maisie will undergo hip surgery that will involve the implantation of metals. This may cause chronic pain and despite all the attempts, she may end up being unable to ambulate again unassisted.
Towards improving her quality of life, Maisie will need a physiotherapist who understands the interaction between biopsychosocial which aids in explaining continuation of condition and allows for a basis of planning for interventions (Alexiou et al., 2018). Physiotherapeutic way of management especially of chronic pain requires biophysical assessment that is clinical and which is needed in order to have an understanding of the mechanism of pain and also psychosocial factors which might be modifiable or non-modifiable for Maisie to have her condition improve.
Substance P-type of pain.
Primary source of pain is clinically recognized and distinguished into nociceptive, neuropathic, and non-neuropathic pain of central sensitization.
S-Somatic and medical factors
The therapist will employ both physical and general examination as a crucial component in their line of work to elevate their awareness of the findings of different clinical examination findings,for instance coordination and neurodynamics. These could at times change with the aim of accommodating of individuals with non-neuropathic discomfort of neurogenic have altered movement patterns and are more sensitive to mechanical stimulation. The other major objectives of the somatic stage are to assess the quality of patient movement, determine whether a certain movement pattern causes discomfort to persist, and determine whether kinesiophobia exists (Alexiou et al., 2018). Further, a physician will examine the patient’s current and past health issues, movement, strength and muscle tone, along with the effects of the medicine on their CNS. Overall, the listed strategy is beneficial for gathering data.
C-cognition or perception
By turning on the neuromatrix pain system, cognition or perception will have an effect on the brain’s biological hypersensitivity. The two will also have an effect on the elements that affect emotions and behavior. Therefore, the therapist will inquire about client’s perceptions, including expectations for the intervention, as well as for the pain’s prognosis. Further examination will also include comprehension of the patient’s condition and the available coping mechanisms, along with considering what the pain emotionally means for the patent (Ali et al., 2020). The short survey on Sickness Perception (Brief IPQ) Scale of Catastrophizing Pain (PCS) can be utilized for the case.
E-emotional factors
Determining whether a patient experiences fear of particular movements, avoidance habits, psychologically devastating pain, or issues with their family, finances, or society is vital (Xiao & Zhou, 2020). The usage of scales such as Assessing State-Trait Anxiety (STAI), Fear Avoidance Belief Questionare and Tampa-Scale of Kinesiophobia (TSK), Patient Health Questionnaire-9 (PHQ-9) (CES-D), the Patient Health Questionnaire-2 (PHQ-2), the Center of Epidemiologic Studies Depression Scale, and Survey on the Experience of Injustice (IEQ) is advisable.
B-behavioral factors
Behavior may cause one to avoid moving or engaging in action out of fear, which manifests as a lack of physical activity or even disuse, ultimately, as impairment. It therefore becomes crucial to assess the patient’s behavior as well as pain-related adjustments.
S-social factors
It encompasses social as well as environmental components that exerts influence a patient’s health and may be supportive, harmful, and even worriesome for the betterment of the patient’s health. The main categories utilized to segment data collection include hosing or living circumstances, social environment, partner relationship, and employment. Therefore, Maisie’s tragedy has had a significant impact on her children’s lives, forcing them to take impromptu trips. Her husband also feels guilty about not being present when the incident occurred.
M-motivation
The patient’s motivation and openness to change should be assessed in to improve his perceptions of the connections between pain-kinesiophobia, pain-disability, acceptance, and catastrophism. The ideal applicable scale for the case would be the pain Inflexibility Scale in Psychology (PIPS) that is used in assessing psychological inflexibility’s of component parts-avoidance and fusion.

References
Alexiou, K., Roushias, A., Varitimidis, S., & Malizos, K. (2018). Quality of life and psychological consequences in elderly patients after a hip fracture: A Review. Clinical Interventions in Aging, Volume 13, 143–150. https://doi.org/10.2147/cia.s150067
Ali, I., Vattigunta, S., Jang, J. M., Hannan, C. V., Ahmed, M. S., Linton, B., Kantsiper, M. E., Bansal, A., & Srikumaran, U. (2020). Racial disparities are present in the timing of radiographic assessment and surgical treatment of hip fractures. Clinical Orthopaedics & Related Research, 478(3), 455–461. https://doi.org/10.1097/corr.0000000000001091
Antle, O., Kenny, A., Meyer, J., & Macedo, L. G. (2019). Antiemetics for postoperative nausea and vomiting in patients undergoing elective arthroplasty: Scheduled or as needed? The Canadian Journal of Hospital Pharmacy, 72(2). https://doi.org/10.4212/cjhp.v72i2.2884
Kim, J. Y., Yoo, J. H., Kim, E., Kwon, K. B., Han, B.-R., Cho, Y., & Park, J. H. (2017). Risk factors and clinical outcomes of delirium in osteoporotic hip fractures. Journal of Orthopaedic Surgery, 25(3), 230949901773948. https://doi.org/10.1177/2309499017739485
Raytis, J. L., Behrendt, C. E., Obenchain, R., Loscalzo, M., & Lew, M. W. (2018). Preoperative concern about nausea and vomiting and postoperative use of antiemetics among patients undergoing breast cancer-related surgery. Open Journal of Anesthesiology, 08(06), 198–203. https://doi.org/10.4236/ojanes.2018.86020
Rollmann, M. F., Holstein, J. H., Pohlemann, T., Herath, S. C., Histing, T., Braun, B. J., Schmal, H., Putzeys, G., Marintschev, I., & Aghayev, E. (2018). Predictors for secondary hip osteoarthritis after acetabular fractures—a pelvic registry study. International Orthopaedics, 43(9), 2167–2173. https://doi.org/10.1007/s00264-018-4169-3
Sardar, P., Kundu, A., Poppas, A., & Abbott, J. D. (2018). Representation of women in American College of Cardiology/American Heart Association Guideline Writing Committees. Journal of the American College of Cardiology, 72(4), 464–466. https://doi.org/10.1016/j.jacc.2018.06.011
Shi, B. Y., Hannan, C. V., Jang, J. M., Ali, I., & Srikumaran, U. (2020). Association between delays in Radiography and surgery with hip fracture outcomes in elderly patients. Orthopedics, 43(6). https://doi.org/10.3928/01477447-20200812-06
Wouters, P. F., & Lapage, K. (2017). The patient with advanced chronic heart failure. Anesthesia in High-Risk Patients, 19–38. https://doi.org/10.1007/978-3-319-60804-4_2
Xiao, P., & Zhou, Y. (2020). Factors associated with the burden of family caregivers of elderly patients with femoral neck fracture: A cross-sectional study. https://doi.org/10.21203/rs.3.rs-18001/v2

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