Commentary

Margaret’s attention and conversation have changed suddenly from how she was before admission. The fracture, operation and pain may contribute, but the team still needs to assess other possible causes. She is eating and drinking little, her kidney function is reduced and she is receiving opioids. Urinary retention then adds discomfort that can be treated. Several factors may contribute; the case does not identify one tablet as the cause.

The team changes her pain medicines while continuing pain relief. Stopping all pain treatment would leave her pain untreated. A catheter relieves the retention, but staff need to keep checking whether it is still needed. Margaret becomes more comfortable before her attention improves. Rehabilitation starts while she still has delirium.

Hawley and colleagues studied a selected group of people with hip fractures. Abnormal postoperative 4AT results were associated with later differences in where people lived and how well they could move [P44]. The study does not predict Margaret’s outcome or show that changing her medicines will restore her thinking. Her return home at six weeks is an outcome chosen for this teaching example. She still needs help.

A healed wound and controlled pain do not establish that Margaret can manage daily life. Assess what she can do, how this varies through the day and how much prompting she needs. Record these observations and continue clinical assessment as her surgical recovery progresses [G01, P43].