Importance Of Critical Thinking In Nursing – A Plan Of Care For Patient With Multiple Injuries

Safety

Importance of Critical thinking in Nursing.

 of competent reasoning as a moniCritical thinking in nursing is an essential technique in providing an appropriate care to patients. Thinking critically is a controlled and knowledgeable process that involves applicationtor to belief or action (Zuriguel Pérez et al., 2014).

For this particular task, the criteria for critical thinking will revolve around good communication and explanations of all points, correct data interpretation, deductive and inductive reasoning, explanations on the method of care, and using contemporary resources and clinical guides. These aspects will then be related back to Audrey to enhance a sound plan for care. Audrey is diagnosed with broken femur hip, soft tissue injury, bruised shoulder and a solid swelling of clotted blood on her forehead. She is set for an operation. This case study will show a sound plan of care pre and post operation by applying the most proficient critical thinking skills that will help Audrey live a quality life.

A close look at her is important considering that she suffers weakness. That will ensure that she does not get more injuries considering that now she suffers a fractured femoral hip. Examination of her respiratory processes is important and necessary. Breathing help should be provided if need be. Bed mobility is also needed for toilet needs. Education on safety practices (what to do and what to avoid) will enhance personal care for Audrey (Birbara et al., 2018).

For comfort, it is important to understand Audrey’s interests and worries. That will solve the issue of anxiety (Bidyamshin, Ryabykh, Chibirov & Popkov, 2016). Audrey’s needs should be considered and provided when necessary. To ensure hygiene, it is also important to assist her when she want to use the toilet. Spending time with her will get her relaxed and consequently comfortable in her new environment.

Proper dieting leads to better healing of both wound and fracture. Therefore, Audrey should not fast for so long as that may lead to decreased health status. Considering the effect of poor dietary status to the weakening of the bulk of muscles for the elderly plus the threat of problems and decreased functioning, proper nutrition is of significant impact on Mrs. Smith (Malafarina et al., 2018).

Pharmacological interventions needed to eliminate pain include systemic analgesia and medications like acetaminophen, NSAIDs and opioid analgesics like morphine and codeine. Others pharmacological interventions include nerve blocks and neuraxial anesthesia like bupivacaine (Gélinas, Arbour, Michaud, Robar & Côté, 2013). Non-pharmacological interventions include transcutaneous electrical neurostimulation (TENS), traction (to stabilize the fracture) or acupressure (Johnson, Mulvey & Bagnall, 2015). Pain medications are known causes of constipation. Therefore, it is appropriate to prescribe anti-constipation drugs against the pharmacological interventions

Hygiene and Comfort

Engaging Audrey in breathing and coughing exercises to ease tension and anxiety is necessary. (Fernandes, 2018). Isometrics and ankle pumps will help prepare Mrs. Smith for active exercise. Bedside sitting is also important as it will help Audrey to begin transfer and progressive gait training processes. Bed mobility cannot be left out as it will train her to move from bed to toilet so as to establish independence with all transfers (Nachamie & Finch, 2015).

It is crucial to deliberate on the extent of anxiety and drive of Mrs. Smith before offering her specialized psychological care (Brooker, Nicol, Alexander & Danielson, 2013). Therefore, through the post-surgical period or rehabilitation process, Audrey should be subjected to activities of social and family environment in the same way as before the accident. That way she will develop a relaxed state of mind and anxiety will go away.

Atrial fibrillation (AF)

AF is a trembling or fast uneven heart rate that is common among old people (Kirchhof et al., 2016). AF leads to other problems like blood clots, CVC, and heart failure (Kim et al., 2016). AF results in increased morbidity and mortality and weaken recuperation efforts for patients of fractured femoral hip (Chia, Gualano, Seevanayagam & Weinberg, 2013). Audrey, since she suffers the disease is predisposed to not recovering steadily and she could even suffer death at the end now that she has multiple injuries in her body.

Hypertension

Hypertension is a name for high blood pressure (Stephens, 2018). The disorder causes severe impediments and increase possibility of stroke, heart failure and death. Studies show that the degree of survival for a patient with hypertension who is set for a surgery from a fractured femur is very low. Mrs. Smith, therefore, can die because of this disease.

L CVC- Cerebrovascular Accident (Stroke)

CVC is unexpected death of some brain cells normally caused by deficiency of oxygen. So L CVC is left side stroke. CVC is a key risk influence for femoral neck fracture and also on the poor post fracture outcome and reduced survival of these patients (Fisher, Srikusalanukul, Davis & Smith, 2013). This is because a patient of stroke will often fall and might keep on getting fractures or inhibiting the healing of a previous fracture. That means, Audrey might have complications when recovering from the fracture if the L CVC persists. She could suffer more fractures or have a poor recovery from this current fracture.

Nutrition Care

T2DM

T2DM is a serious condition that affects the way the body breaks down sugar (glucose), which is the body’s significant source of fuel. Blood glucose levels go high (Marin, Luyten, Van der Schueren, Kerckhofs & Vandamme, 2018). T2DM leads to adverse effect on the skeletal system. Evidence shows that bone healing process after fracture is very difficult with patients of this disease. To Mrs. Smith, therefore, the disorder would affect how her fractured bone heal.

GORD

Gastro-esophageal reflux disease is a disorder where stomach acids go up the esophagus (gullet) causing a burning effect. Patients with the disorder stay longer in hospital because of indigestion (poor nutrition) and therefore Audrey might suffer the same fate.

Osteoporosis 

Osteoporosis is a disorder of weak bones with an increased risk to breakage and is common with women after menopause (Meeta, 2013). Fracture healing of fixed firmly femoral diaphyseal takes more time in grownup osteoporotic patients like Mrs. Smith. Audrey’s fracture therefore could take longer.

Total Hysterectomy

Hysterectomy involves removal of the uterus and the cervix in an operation, and sometimes ovaries, fallopian tubes and other neighboring structures (“NCI Dictionary of Cancer Terms”, 2018). Hysterectomy leads to replicating fracture risk over a 2-year period in premenopausal women and therefore Mrs. Smith is not exceptional.

Depression

Depression affects feelings, thinking, and handling of daily activities like sleeping, eating, or working. According to He et al. (2014), depression affects occurrence of exercise, seriousness of fractures, and quality of life after operation and increased length of hospital stay in hospitals. This makes Audrey a victim.

Digoxin

Indications for use is Atrial Fibrillation (AF) or Atrial Flutter (to reduce ventricular rate) and on nursing implications, the physician should be well conversant of the baseline data like blood pressure and clinical symptoms to inform assessment. Nursing implication on the patient and family include strict adherence to the suggested dosage and avoiding OTC medication like those on coughs without instructions from the doctor. The drug can affect Audrey by causing a regular and stronger heart rhythm by increasing contractility of the heart muscles thus preventing heart failure. Digoxin is important in ensuring an increased and quality life for Audrey by reducing chances of death from heart failure (Ziff et al., 2015).

Warfarin 

Indication for use to Audrey is Atrial Fibrillation because it prevents extension of thrombi and formation of new clots (Acton, 2013). The Nursing implications relevant to Audrey include monitoring older adults because they often don’t comply with the drug and obtaining a careful medication history of the patient before the beginning of therapy because there are many drugs that are incompatible with anticoagulant drugs like Warfarin. The drug is important for Audrey as it reduces chances of heart failure from AF just like Digoxin, to enhance a longer and quality life (Holland, 2018).

Elimination

Coversyl

The indication for use is hypertension because the drug lowers the blood pressure by inhibiting Angiotensin-converting enzyme (ACE) (Kaur, Gan, Phillips, Wong & Saini, 2015). Nursing implication includes monitoring the blood pressure during the first stage of dose alteration and occasionally during rehabilitation, supine positioning of the patient if excess hypertension is detected (Holland, 2018). The drug is useful to Audrey in ensuring that the blood pressure is regulated not to go above the normal levels thus containing the hypertension.

Vitamin D

The indication for use is treating osteoporosis because the drug strengthens weak bones (Compston et al., 2013). Nursing implications include taking the correct amount, taking calcium supplements and a strict diet. Magnesium supplements are discouraged (Holland, 2018).Vitamin D is of importance to Audrey as it ensures that she has strong bones and that can reduce future bone fractures. Again the healing of the current fracture will be facilitated.

Metformin

The drug is used to treat the 2 type’s Diabetes mellitus as it increases tissue sensitivity to insulin and leads to increased glucose transport into skeletal muscles and fat (Rojas & Gomes, 2013). Nursing implications on assessment and drug effects include laboratory assessments like testing for renal or hepatic insufficiency. The drug is of importance as it will ensure that Mrs. Smith recovers from type 2 diabetes mellitus without dieting.

Esomeprazole

 The drug is injected to control Gastroesophageal reflux disease by decreasing acid secretion and inhibition of the acid pump. Nursing implication include monitoring phenytoin levels with concurrent use and reporting pain and discomfort when urinating (Holland, 2018). The drug is important for Audrey in relieving her the acidity thus reducing discomfort and anxiety.

Effexor

The indication for use is depression because of its antidepressant effect. Nursing implication for the drug include checking for worsening of depression, monitoring the neurological status of the patient and reporting when excessive anxiety, nervousness or insomnia is noted. To the patient and family, they should be advised to avoid using any herbal medicine (Holland, 2018). Effexor is among the best ways to help Audrey recover from anxiety and low mood.

Caltrate

The indication for use is GORD and osteoporosis because Caltrate is an anti-acid with a very efficient neutralizing capacity and has calcium as a component. Nursing implications include checking for constipation and conducting laboratory test on the urine of the patient to determine calcium levels. To the patient, she should avoid taking cereals as they have high oxalates and that could lead to formation of insoluble compounds within the body (Holland, 2018). The drug is important because it will help Audrey effectively recover from symptoms of acid indigestion and useful as a calcium supplement.

Activity levels

Mylanta

The drug is also prescribed against GORD because it is a nonsytemic antacid and it has neutralizing effect.  Assessment as a nursing implication include monitoring the presence of constipation. For the patient, she should look for medical intervention if indigestion comes with shortness of breath, sweating, or chest pain (Holland, 2018). Mylanta continued dose for Audrey is important to calm the irritating effects of the acidic liquids and will therefore cause anxiety relief

Audrey is scheduled for an athroplasty surgery in 3 hours (at 5 pm). There are a number of things that can be done to prepare for the surgery as will be discussed below.

A very significant thing to do is explaining the risks and complications that may arise from the operation then asking her to sign an informed consent form as it is required before any anesthesia pre-surgery. This should be prioritized as the operation cannot go on unless the form is signed (Walton et al., 2014, (Healthcommunities.com, 2018)).

Performing blood tests before operation is important in that it establishes the Complete Blood Count and blood clotting is important. White blood count is important in checking whether Audrey has been using drugs that affect white blood counts. Other important tests include chest X—rays to check the lungs and electrocardiogram to check Audrey’s heart. These checks are important safety measure to ensure the operation takes place without hitches.

Audrey should then be instructed to remove personal items like jewelry, eyeglasses, or contact lenses (if she has them) before surgery. This is an important step in ensuring the patient’s safety and preventing losses and damages (Healthcommunities.com, 2018). The clerk, nurse and the anesthesiologist should repeatedly ask Audrey questions. The questions may be more similar but they are important towards verification against errors. By so doing the safety of the patient is put at heart to ensure that the operation does not lead to any complications (Healthcommunities.com, 2018).

Immediately before the operation, the doctor in charge of administration of anesthesia should obtain Audrey’s information regarding medication used regularly, allergies to drugs and any prior unfavorable reaction to anesthesia. That will be important to the anesthesiologist in that it will help him choose the most appropriate analgesic agents and prescriptions to prevent hitches. Audrey should then be moved to a preoperative holding area where an intravenous line (IV) is made. The IV is then used as a channel for injection of sedatives to induce relaxation effects. Otherwise, sedatives could still be given orally (Healthcommunities.com, 2018).

Psychosocial Needs

When the patient arrive at the ward at 8 pm, the first thing should be reading the specification from the notes of the surgeon/doctor for specific post-operative instructions (NHS, 2018). This is very important because the surgeon always give the best way to cope with matters arising from the surgery like pain, bleeding, and has the knowledge of the best medication as at that point.

The next action should be pain management (NHS, 2018). Pain management is one step in enhancing quality life. Because of the flesh cuts during the operation the patient comes from the theatre feeling aggressive pain which can even lead to falling unconscious. Aggressive pain control with higher doses of opiates.

Reduction of patient’s anxiety like in the pre-operative section above is also applicable in this phase. It is good also to check the effects of the operation on the state of the patient. Some operations come with complications such as anemia, which is very important to manage. That should then be followed by respiratory checks and care as appropriate. This will ensure that Mrs. Smith does not breath with difficulties and also to reduce anxiety. If breathing is with difficulties then it is good to help the patent in deep breathing and coughing exercises (NHS, 2018).

The first step is teaching her to walk with crutches. Walking in crutches is not automatic and requires training especially when it is a 75-year old lady like Audrey. Showing the lady how to support herself with the clutches and how to move with the, and how to use them to get off bed.

The first step is mobilizing her with double supports by day 5 but check with MDM (Ma & Zieve, 2018). This is because by day five she will not have adapted to her new state and will not be able to walk comfortably deriving support from the other leg. She can hardly get off bed on her own.

The crutches should then be reduced to one stick by 5^th day. At this day, the patient is comfortable to walk confidently by support of one leg. Again pain will be reduced and healing will have started.

The 10^th day is the discharge day so she will be in a position of getting off bed and standing without support from a nurse and walking on the staircases.

Conclusion

There are a number of things that need to be considered to ensure an effective recovery for Audrey. This piece starts by looking at importance interventions of safety, hygiene, comfort, elimination, activity levels and psychological needs. The health history of Mrs. Smith is also important and should be considered while developing care. That together with the medications prescribes enhances that the care developed is wholesome and does not contradict the ongoing medication. Critical thinking skills have been well applied in the segment of pre-operation and after surgery. The best practices that support a successful operation have all been critically discussed. These include, coping with fear and anxiety, performing blood tests, explaining the operational risks among others. After the operation, the appropriate nursing interventions have been formulated for Audrey specific case. This precedes a systematic discharge process that takes 10 days. A combination of these critically thought practices are important in ensuring that Audrey lives a quality life post discharge even as she nears end of life

Medical Diagnoses

References

Acton, Q. (2013). Atrial Fibrillation: New Insights for the Healthcare Professional: 2013 Edition (p. 300). Atrial Fibrillation: New Insights for the Healthcare Professional: 2013 Edition.

Bidyamshin, R., Ryabykh, S., Chibirov, G., & Popkov, D. (2016). Outcomes of palliative orthopedic surgery for hip dislocation in patients with cerebral palsy. Traumatology And Orthopedics Of Russia, 22(4), 45-59. doi: 10.21823/2311-2905-2016-22-4-45-59

Biotechnology, 31(10), 1543-1554. doi: 10.1007/s11274-015-1903-5

Birbara, C., Dabezies, E., Burr, A., Fountaine, R., Smith, M., & Brown, M., …Verburg, K. (2018). Safety and efficacy of subcutaneous tanezumab in patients with knee or hip osteoarthritis. Journal Of Pain Research, Volume 11, 151-164. doi: 10.2147/jpr.s135257

Brooker, C., Nicol, M., Alexander, M., & Danielson, E. (2013). Alexander’s nursing practice. Edinburgh [etc.]: Churchill Livingstone/Elsevier.

Chia, P., Gualano, L., Seevanayagam, S., & Weinberg, L. (2013). Outcomes following fractured neck of femur in an Australian metropolitan teaching hospital. Bone & Joint Research, 2(8), 162-168. doi: 10.1302/2046-3758.28.2000177

Compston, J., Bowring, C., Cooper, A., Cooper, C., Davies, C., & Francis, R., … Selby, P., (2013). Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013. Maturitas, 75(4), 392-396. doi: 10.1016/j.maturitas.2013.05.013

Femur Fracture Follow-up: Further Inpatient Care, Transfer, Complications. (2018). Retrieved from https://emedicine.medscape.com/article/824856-followup

Fernandes, A. (2018). Inpatient rehabilitation of a patient following total hip arthroplasty subsequent to fall and hip fracture. Retrieved from https://hdl.handle.net/10211.3/190157

Fisher, A., Srikusalanukul, W., Davis, M., & Smith, P. (2013). Poststroke Hip Fracture: Prevalence, Clinical Characteristics, Mineral-Bone Metabolism, Outcomes, and Gaps in Prevention. Stroke Research And Treatment, 2013, 1-17. doi: 10.1155/2013/641943

Gélinas, C., Arbour, C., Michaud, C., Robar, L., & Côté, J. (2013). Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management. Nursing In Critical Care, 18(6), 307-318. doi: 10.1111/j.1478-5153.2012.00531.x

He, D., Xue, Y., Li, Z., Tang, Y., Ding, H., & Yang, Z., … Zong Y. (2014). Effect of Depression on Femoral Head Avascular Necrosis From Femoral Neck Fracture in Patients Younger Than 60 Years. Orthopedics, 37(3), e244-e251. doi: 10.3928/01477447-20140225-56

Healthcommunities.com. (2018). Preoperative Procedures – Before and After Surgery – HealthCommunities.com. Retrieved from https://www.healthcommunities.com/before-after-surgery/preoperative-procedures-surgery.shtml

Holland, R. (2018). RobHolland.com. Retrieved from https://www.robholland.com/

Johnson, M., Mulvey, M., & Bagnall, A. (2015). Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd007264.pub3

Kaur, G., Gan, Y., Phillips, C., Wong, K., & Saini, B. (2015). Chronotherapy in practice: the perspective of the community pharmacist. International Journal Of Clinical Pharmacy, 38(1), 171-182. doi: 10.1007/s11096-015-0228-7

Kim, S., Kim, D., Mogun, H., Eddings, W., Polinski, J., Franklin, J., & Solomon, D. (2016). Impact of the U.S. Food and Drug Administration’s Safety-Related Announcements on the Use of Bisphosphonates After Hip Fracture. Journal Of Bone And Mineral Research, 31(8), 1536-1540. doi: 10.1002/jbmr.2832

Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., & Casadei, B., …Zeppenfeld, K. (2016). 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal, 37(38), 2893-2962. doi: 10.1093/eurheartj/ehw210

Malafarina, V., Reginster, J., Cabrerizo, S., Bruyère, O., Kanis, J., Martinez, J., & Zulet, M. (2018). Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture. Nutrients, 10(5), 555. doi: 10.3390/nu10050555

Marin, C., Luyten, F., Van der Schueren, B., Kerckhofs, G., & Vandamme, K. (2018). The Impact of Type 2 Diabetes on Bone Fracture Healing. Frontiers In Endocrinology, 9. doi: 10.3389/fendo.2018.00006

Meeta. (2013). Postmenopausal osteoporosis (p. 13). JP Medical Ltd.

Murthy, R., & Gupta, A. (2018). Clinical aspects of acute post-operative pain management & its assessment. RetrievFeted from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255434/

Nachamie, H., & Finch, M. (2015). Hip Fractures: A Practical Guide to Management (p. 287). New York, NY: Springer New York.

NCI Dictionary of Cancer Terms. (2018). Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/total-hysterectomy

NHS. (2018). After surgery. Retrieved from https://www.nhs.uk/conditions/having-surgery/afterwards/

Paganoni, S., Karam, C., Joyce, N., Bedlack, R., & Carter, G. (2015). Comprehensive rehabilitative care across the spectrum of amyotrophic lateral sclerosis. Neurorehabilitation, 37(1), 53-68. doi: 10.3233/nre-151240

Rojas, L., & Gomes, M. (2013). Metformin: an old but still the best treatment for type 2 diabetes. Diabetology & Metabolic Syndrome, 5(1), 6. doi: 10.1186/1758-5996-5-6

Stephens, C. (2018). Hypertension: Causes, symptoms, and treatments. Retrieved from https://www.medicalnewstoday.com/articles/150109.php

Walton, A., Muenzer, J., Rasche, D., Boomer, J., Sato, B., & Brownstein, B., …Hotchkiss, R., (2014). Reactivation of Multiple Viruses in Patients with Sepsis. Plos ONE, 9(6), e98819. doi: 10.1371/journal.pone.0098819

Ziff, O., Lane, D., Samra, M., Griffith, M., Kirchhof, P., & Lip, G., …Kotecha, D., (2015). Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ, h4451. doi: 10.1136/bmj.h4451

Zuriguel Pérez, E., Lluch Canut, M., Falcó Pegueroles, A., Puig Llobet, M., Moreno Arroyo, C., & Roldán Merino, J. (2014). Critical thinking in nursing: Scoping review of the literature. International Journal Of Nursing Practice, 21(6), 820-830. doi: 10.1111/ijn.12347