Mrs Deborah Scott Case Study Sample

Rib Fracture Management With Comorbidities

Introduction to Rib Fracture

Rib fracture is a serious problem in old age population as it can significantly increase mortality and morbidity in this age group (Schmoekel et al., 2019). This case study discusses the effect of rib fracture on a patient who has much comorbidity. Pneumonia and mortality is a significant risk in the elderly patient with cardiopulmonary comorbidities (Van Vledder et al., 2019). For a nurse, it becomes difficult to set priorities in dealing with such a complex situation. Levett Jones clinical reasoning cycle provides a framework which logically considers several steps to effectively manage a patient’s situation in an optimum way (Europian Heart Association, 2018). This paper analyses the case study by using this framework to set priorities and manage the situation.

Analysis Using Clinical Reasoning Cycle

Patient’s Situation

This case study is about Mrs Deborah Scott, a 65-year-old woman who lives with her husband. She fell and broke her ribs and injured her chest wall as suggested by the chest x-ray. She is admitted in the hospital forthe third time for fall in the last 6 months. Her medical history says she has insulin-dependent type II diabetes; osteoarthritis; hypertension and Chronic obstructive pulmonary disease (COPD). She is prescribed atenolol, telmisartan,spironolactone, Novolin 70/30, Metformin, Ventolin, Symbicort, Vitamin D, and Panadol Osteo.

Collect Cues and Information

The patient fell and broke her ribs, this suggests she is osteoporotic, her history and old age also suggests that she is osteoporotic as indicated by fragile bones. Osteoporosis takes place due to loss of bone mass and skeletal structure deterioration (Pouresmaeili et al., 2018). They further state that bone mass decreases with increasing age after 40s, but women are particularly susceptible because due to deficiency of estrogen after menopause they lose bone mass rapidly. Besides, diabetes mellitus and history of falls are other risk factors for osteoporosis (Pouresmaeili, Kamalidehghan, Kamarehei, & Goh, 2018). Due to diabetes mellitus risk of fracture increases and it interferes with bone formation and impairs fracture healing (Jiao, Xiao, & Graves, 2015).She is also suffering from COPD, hypertension, insulin-dependent type II diabetes and osteoarthritis and prescribed medications for these diseases. Atenolol, telmisartan, spironolactone are prescribed for hypertension; Novolin 70/30 is man-made insulin and metformin is prescribed for controlling blood sugar levels in diabetes. Ventolin and Symbicort are prescribed for COPD; Panadol Osteo is pain medication for osteoarthritis and vitamin d supplement for bone health. Rib fracture along with other comorbidities present in such an old aged patient considerably increases the risk of complications

Process Information

It is necessary to process the information and collected cues to accurately diagnose the problem areas in this case. There are some acute and some chronic conditions which are to be managed. Her fall has given rise to some immediate concerns which need to be addressed first. Pain is the most common problem of rib fracture whose acuity depends on the severity of the fracture, pain may increase when deep breathing and coughing (He et al., 2019). Rib fracture in old age is a major risk and can be life-threatening if left untreated, also for older patients more than 65 years of age risk of pneumonia rises by 27 per cent and risk of death by 20 per cent(Baiu& Spain, 2019). Also, COPD and its pharmacotherapy is a risk factor for pneumonia (Restrepo, Sibila, & Anzueto, 2018). Rib fractures causes three main problems which increase the morbidity and mortality in patients: due to pain patientshypo-ventilate, there may be impaired gas exchange if the lung is damaged due to fracture, and breathing mechanics are changed (Park, Hyun, Kim, & Jang, 2017).

The characteristic feature of COPD is airflow limitation which is caused by narrowing or obstruction of the airway (WHO, 2017).Hypoventilation results in an ineffective cough where the airway is not cleared and sputum retention occurs (Jeffery, Everson, & Carty, 2019).Thus COPD and rib fracture exacerbate her pain and respiratory conditions. Besides, there are other chronic conditions which are to be regularly monitored and effectively managed so that these conditions do not add to complications. Hypertension is a chronic condition which can significantly increase the risks of heart, brain, kidney and other diseases (WHO, 2019). Type 2 insulin dependent diabetes mellitus is another chronic condition characterised by hyperglycemia, i.e., high levels of glucose in blood. It is to be managed by lifestyle modification and insulin therapy like in the case of Deborah (Harvard Health, 2018). Deborah faces another chronic condition osteoarthritis which also adds to her discomfort and pain.

Identify Problems

There are short term and long-term priorities which are to be addressed in Deborah’s case. The immediate priorities have arisen due to rib fracture which gives rise to pain, and due to coughing and deep breath, this may increase. Her chest injury can result in infection which can be serious due to her age and comorbidities.COPD increases the complications as it causes impaired gas exchange and increases the risk of infection and pneumonia (Ko et al., 2016). Monitoring and management of hypertension and diabetes is required as an ongoing basis for long term priorities. Based on these priorities we can now list the problems as NANDA diagnosis: Risk for Impaired Gas Exchange due to injury and underlying disease condition; Acute pain related to chest injury; Risk for infection due to injury and underlying disease condition; Risk for unstable blood glucose, Risk of lack of compliance in hypertensive management due to knowledge deficit or inability, Risk of lack of adherence to diabetes management, Risk of insulin deficiency or excess of insulin.

Establish Goals

Patient will be relieved of acute pain. Her airway will be cleared and she will be able to breathe effectively which will be evidenced by normal breathing patterns and normal oxygen saturation on measuring PaO2. Her infection risks will be lowered as evidenced by normal breathing, decreased retention of secretions. Her hypertension and diabetic condition will be under control.

Implement an Action Plan

To manage ventilation in rib fracture, supplemental oxygen therapy is given (May, Hillermann & Patil, 2015). As per May et al. (2015) bronchodilators which are prescribed for her COPD can be included as nebulizers along with oxygen therapy. To relieve pain in rib fracture, as per acuity of pain, analgesics ranging from simple ones like paracetamol or NSAIDs(Non-steroidal anti-inflammatory drugs) to opioids can be given as medication management. Deborah is already prescribed Panadol Osteo for her arthritis, this could be effective for rib pain also. Advice and support fracture site with a soft pillow when coughing or during physical therapy to reduce pressure on the injury site. Patient is taught active cycle breathing technique which involves deep breathing, relaxed breathing and forced expiration. Physical therapy is gradually started and also postural drainage, assisted coughing can be included with it(Witt & Bulger, 2017). Compliance to her COPD, hypertension and diabetic medications is ensured.

Evaluate Outcomes

Patient is relieved of pain. She shows normal breathing pattern and her oxygen saturation levels are normal. Her risk of infection is lowered, as she does not have secretion retention and she can expel her secretion freely. Her blood pressure and blood glucose levels are in the normal range. Her situation improves as evidenced by increased mobility.

Reflection on The Process of Learning

I was able to analyse the case study in a better-organised manner using Levett Jones reasoning cyle. It provided me with a new perspective in dealing with a complicated case. Earlier I tend to become overwhelmed with the amount of information in a complex case. I used to give up easily and not able to set my priorities right. This framework enabled me to think every case in a new light and I feel more confident that I will be able to deal with every type of case by using this reasoning. I can plan a more patient-centred approach to care by using this framework. I understood that older people present with comorbidities and are at increased risk for complications, their treatment should be planned according to short term and long term priorities. Levett Jones clinical reasoning cycle will be my primary framework to evaluate priorities to provide optimum care to my patients. I will also recommend to my colleagues that they also use this framework. I will ask my supervisors to discuss case study according to this framework.

Conclusion on Rib Fracture Management With Comorbidities

Levett Jones reasoning cycle provides an effective framework to make clinical decisions. This paper analysed the case of Mrs Deborah Scott by this framework. She is an old woman who was admitted in the hospital emergency due to chest injury and was present with several comorbidities. By using Levett Jones reasoning cycle the priorities of managing her conditions are established and effective strategies are planned. Falls and fractures make older people at an increased risk for morbidity and mortality and their needs are to be effectively identified for their proper care.

References for Rib Fracture Management With Comorbidities

Baiu, I., & Spain, D. (2019). Rib Fractures. JAMA, 321(18), 1836–1836. https://doi.org/10.1001/jama.2019.2313

Europian Heart Association. (2018). The Clinical Reasoning Cycle: The 8 Phases and their Significance | European Heart Association. Retrieved June 6, 2020, from https://www.heartassociation.eu/the-clinical-reasoning-cycle-the-8-phases-and-their-significance/

Harvard Health, H. H. (2018). Type 2 Diabetes Mellitus. Retrieved June 6, 2020, from Type 2 Diabetes mellitus website: https://www.health.harvard.edu/a_to_z/type-2-diabetes-mellitus-a-to-z

He, Z., Zhang, D., Xiao, H., Zhu, Q., Xuan, Y., Su, K., … Xu, E. (2019). The ideal methods for the management of rib fractures. Journal of Thoracic Disease, 11(Suppl 8), S1078–S1089. https://doi.org/10.21037/jtd.2019.04.109

Jeffery, Z., Everson, M., & Carty, S. (2019). Management of rib fractures. British Journal of Hospital Medicine, 80(10), C146–C149. https://doi.org/10.12968/hmed.2019.80.10.C146

Jiao, H., Xiao, E., & Graves, D. T. (2015). Diabetes and Its Effect on Bone and Fracture Healing. Current Osteoporosis Reports, 13(5), 327–335. https://doi.org/10.1007/s11914-015-0286-8

Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A. (2016). Acute exacerbation of COPD. Respirology, 21(7), 1152–1165. https://doi.org/10.1111/resp.12780

May, L., Hillermann, C., & Patil, S. (2015). Rib fracture management. BJA Education, 16(1), 26–32. https://doi.org/10.1093/bjaceaccp/mkv011

Park, H. B., Hyun, S. Y., Kim, J. J., & Jang, Y. S. (2017). Prognosis of Pulmonary Function in Patients with Multiple Rib Fractures. J Trauma Inj, 30(4), 179–185. https://doi.org/10.20408/jti.2017.30.4.179

Pouresmaeili, F., Kamalidehghan, B., Kamarehei, M., & Goh, Y. M. (2018). A comprehensive overview on osteoporosis and its risk factors. Therapeutics and Clinical Risk Management, 14, 2029–2049. https://doi.org/10.2147/TCRM.S138000

Restrepo, M. I., Sibila, O., &Anzueto, A. (2018). Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Tuberculosis and Respiratory Diseases, 81(3), 187–197. https://doi.org/10.4046/trd.2018.0030

Schmoekel, N., Berguson, J., Stassinopoulos, J., Karamanos, E., Patton, J., & Johnson, J. L. (2019). Rib fractures in the elderly: Physiology trumps anatomy. Trauma Surgery & Acute Care Open, 4(1), e000257. https://doi.org/10.1136/tsaco-2018-000257

Van Vledder, M. G., Kwakernaak, V., Hagenaars, T., Van Lieshout, E. M. M., Verhofstad, M. H. J., Boonstra, O., … On behalf of the South West Netherlands Trauma Region Study Group. (2019). Patterns of injury and outcomes in the elderly patient with rib fractures: A multicenter observational study. European Journal of Trauma and Emergency Surgery, 45(4), 575–583. https://doi.org/10.1007/s00068-018-0969-9

WHO. (2017). WHO | COPD. Retrieved June 6, 2020, from WHO website: https://www.who.int/respiratory/copd/definition/en/

WHO. (2019, September 13). Hypertension [World Health Organization]. Retrieved June 6, 2020, from Hypertension Fact Sheet website: https://www.who.int/news-room/fact-sheets/detail/hypertension

Witt, C. E., & Bulger, E. M. (2017). Comprehensive approach to the management of the patient with multiple rib fractures: A review and introduction of a bundled rib fracture management protocol. Trauma Surgery & Acute Care Open, 2(1). https://doi.org/10.1136/tsaco-2016-000064

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