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Adult Health : Case Study

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Nursing

Assessment Instructions (Case study essay)

Mark Antony is a 24 year old male who fell off his motorbike whilst riding in the bush. A riding mate witnessed the fall and called an ambulance to transport Mark to hospital. On arrival he complained of pain rated 9/10 in his lower left leg, which had an obvious deformity, significant swelling and a 5cm lacerated wound. Mark had no other medical problems.

An x-ray confirmed the diagnosis of an open fracture of the left tibia and fibula. After review by the orthopaedic team, it was arranged for Mark to undergo surgery for open reduction and internal fixation (ORIF) of the fracture. The repair of the fracture would involve the insertion of a metal rod and screws (GK nail).

You are looking after Mark on the ward pre-operatively. His left leg is in a split cast; and his current vital signs are: T-36.4oC, HR-80bpm, RR-18pm, BP-136/72mmHg, O2-95% RA, and pain score 10/10 on movement. Assume nothing, if data is not stated, you should state that it is not known or information has not been provided, and advise what actions you would take.

You are required to research and write an essay directly relating to the above scenario.

Presentation

 Format in accordance with School of Nursing & Midwifery guidelines

 Appropriate sentence structure, grammar and spelling

 Logical flow

Introduction (100-200 words)

 A general overview of the topic and define terms

 An outline of the paper

Body of essay

Background of condition (200 words)

Management (1000-1200 words)

 Outline the nursing management of Mark pre-surgery. You may wish to include a table to show your use of the nursing process. Make sure you have identified at least 3 priority areas.

 Outline the pre-operative education you would provide Mark to promote a successful recovery.

 Discuss the other members of the interdisciplinary team that would be involved in the management of Mark.

2 Assessment 2 Information From Unit Plan

Potential complication/s (200 words)

Conclusion (100-200 words)

 Provides an overview of the assignment

 No new material introduced

Referencing

 Minimum of 10 current and credible academic references using a variety of sources (including a minimum of 4 journal articles and maximum of 3 quality websites)

 All sources are up to 5 years old (electronic) or 8 years old (texts).

 Recent, quality sources used – Wikipedia will not be accepted as a reference source!

 In-text and end-text referencing per current ECU referencing guidelines – APA style

Introduction :

(This case study is about a patient with broken leg (with lacerated wound), open fracture, the skin is pierced by the broken bone, chance of infection increased).

Nursing Process :

Explain 5 steps :

  1. Assessment (Subjective and Objective Data)

Subjective Data (Allergies, Medications, Last Meal)

Objective Data (Vital Signs)

Establish Therapeutic Relationship, as a whole, ADLs, assessment tools.

Allied team Physio, to be contacted to educate about rehabilitation and liaise with anesthetist

  1. Nursing Diagnosis (May include the following)

Risks for peripheral neurovascular dysfunction related to fracture, mechanical compression (Split Cast) and immobilization.

Potential Risk : Eliminating, Mobilizing, Blood Loss, Breathing or airway, Sleeping

Three most important risks are

  1. Pain (why priority, doesn’t heal etc) (given PRN medication as per doctor’s orders
  2. NVO (Neuro Vascular) (open wound, infection control, blood loss)
  3. Mobility (need assistance, frame, sticks, nurse present, call bell in reach)

 

  1. Planning (Prioritized risks (a, b and c) needs to be detailed and planned)

Planning stage that client centered S.M.A.R.T (specific, measurable, achievable, realistic and timely) goals and outcome

  1. Implementations (Prioritized risks (a, b and c) needs to be detailed and planned)

To determine care that will be best support for health state

Example for NVO to avoid compartment syndrome, should always be elevated and iced to minimize potential risks for swelling

  1. Evaluation (involves effectiveness of nursing interventions) (the risk tools provided such as pain management scale, neurovascular chart, wound assessment chart and risk fall chart)

Conclusion

Verbal handover to hold by nurse (when patient is going to theatre with all those documented and all necessary paperwork) like ID, allergy check, baseline observations/data, Nil by mouth 6 to 8 hours prior to surgery, no jewelry and most important the patient consent as a nurse you make sure that patient understood procedure. To provide psychological support, patient’s issues and concerns are addressed

 

After references please make three charts for Pain, NVO (cardiovascular) and Mobility as under :-

No Assessment/ Clinical manifestations Diagnosis/ Identified problem Plan/goal Implementation/ Intervention Rationale Evaluation
             
             
             

 

Please make sure that

  1. rationale must be with references.
  2. Implementation should have 4 to 6 essential activities

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