Case one: unfolding
a vertical six-node ladder of the clinical judgment steps running beside the case column, with leader lines from the 0615 data block to the first two nodes.
THE CASE
0600. Mrs. R, 78 years old, is postoperative day 1 from a right total hip arthroplasty performed for a fractured femoral neck. She lives alone and was independent before the fall. There is no history of dementia. Overnight she received hydromorphone by patient-controlled analgesia. The night nurse charted "slept well."
0615 · assessment. Temperature 100.9°F (38.3°C) oral. Heart rate 112 and regular. Blood pressure 98/56, down from 128/74 on admission. Respirations 24 and shallow. Oxygen saturation 88% on room air. She is pulling at her intravenous line and does not know the year. She was oriented to person, place, and time at 2200. Pain reported as 3 out of 10. The indwelling urinary catheter was removed at 2200 and she has not voided since. Lungs diminished at both bases. Lower abdomen firm and full on palpation. Surgical dressing dry and intact. Bladder scan 620 mL.
0700 and 0800 data are released on page 63, after you commit to steps 4, 5, and 6.
STEP 1 · RECOGNIZE CUES
Six of the eight findings below are abnormal for this client on postoperative day 1. Select the six.
- Temperature 100.9°F
- Heart rate 112
- Respirations 24 and shallow
- Oxygen saturation 88% on room air
- Does not know the year, having been oriented at 2200
- Bladder scan 620 mL with no void since 2200
- Surgical dressing dry and intact
- Pain reported as 3 out of 10
STEP 2 · ANALYZE CUES
2a. For each finding, select the one explanation it best supports.
Columns: HYPOXEMIA FROM ATELECTASIS AND SPLINTING · OPIOID-RELATED RESPIRATORY DEPRESSION · ACUTE URINARY RETENTION
| Finding | Column |
|---|---|
| Oxygen saturation 88% with diminished breath sounds at both bases | ☐ ☐ ☐ |
| Respirations 24 and shallow | ☐ ☐ ☐ |
| Bladder scan 620 mL with no void since the catheter was removed | ☐ ☐ ☐ |
| Hydromorphone delivered by patient-controlled analgesia through the night | ☐ ☐ ☐ |
| Pain reported as 3 out of 10 the morning after hip arthroplasty | ☐ ☐ ☐ |
| Lower abdomen firm and full on palpation | ☐ ☐ ☐ |
2b. Which single finding argues most strongly that low circulating volume is not the whole story?
- Heart rate of 112
- Oxygen saturation of 88% with diminished breath sounds at both bases
- Temperature of 100.9°F
- Bladder scan volume of 620 mL
STEP 3 · PRIORITIZE HYPOTHESES
3a. Rank the three explanations in the order they must be addressed. Write 1, 2, 3.
___ Acute urinary retention ___ Hypoxemia from atelectasis and splinting ___ Opioid-related respiratory depression
3b. Which statement names the rule that produced your ranking?
- Hypotheses are ranked by which one is most likely.
- Hypotheses are ranked by which one will harm the client soonest.
- Hypotheses are ranked by which one is easiest to treat.
- Hypotheses are ranked by which one has the most supporting cues.
STEP 4 · GENERATE SOLUTIONS
Choose four of the eight interventions below.
- Apply oxygen by nasal cannula and reassess the oxygen saturation.
- Raise the head of the bed and coach incentive spirometry with incisional splinting.
- Perform intermittent catheterization per protocol.
- Hold the next patient-controlled analgesia dose pending a sedation and respiratory assessment.
- Apply soft wrist restraints to keep her from removing the intravenous line.
- Request a prescription for a sedative to settle the confusion.
- Obtain a urine specimen for culture and begin monitoring for infection.
- Schedule a physical therapy session for ambulation this morning.
STEP 5 · TAKE ACTIONS
5a. Place your four chosen interventions in the order you will perform them. Write 1 through 4 beside each.
5b. Which action must be completed before the nurse notifies the provider?
- Perform intermittent catheterization per protocol.
- Apply oxygen by nasal cannula and reassess the oxygen saturation.
- Hold the next patient-controlled analgesia dose.
- Coach incentive spirometry.
STEP 6 · EVALUATE OUTCOMES
0800 data. Temperature 101.3°F. Heart rate 96. Respirations 20. Oxygen saturation 94% on 2 liters per minute by nasal cannula. She knows her name and that she is in the hospital, still does not know the year, and remains intermittently restless. Intermittent catheterization drained 700 mL; repeat bladder scan 40 mL. Blood pressure 108/62.
6a. Classify each finding as improved, unchanged, or worsened.
| Finding | Improved | Unchanged | Worsened |
|---|---|---|---|
| Oxygen saturation | ☐ | ☐ | ☐ |
| Respiratory rate | ☐ | ☐ | ☐ |
| Orientation | ☐ | ☐ | ☐ |
| Temperature | ☐ | ☐ | ☐ |
| Retained bladder volume | ☐ | ☐ | ☐ |
6b. Which single reassessment determines whether this plan continues unchanged?
- Level of consciousness and orientation
- Surgical dressing integrity
- Pain score
- Repeat bladder scan volume
Margin note: "new confusion in an older adult is a vital sign."
> Watch out: an acute change in mental status is never attributed to age. > → BOOK 09 · P3 and → BOOK 15 · P7
Takeaway. In an older postoperative adult, sudden confusion is a presenting sign of a physiological problem until oxygenation, perfusion, and elimination have each been checked.