Patient Assessment and Condition
Question:
Discuss about the Complex Nursing Care Study Of Ben Casey.
Mr.Ben Casey, with 38 years and male, was rushed into the UTS Emergency Department today morning by an ambulance reporting injuries as a result of MVA. Bens major complaint was pain and his admission vital observation were as follows; heart rate of 120 beats/min, BP of 130/78, respiration rate of 24 breaths/min, and an oxygen saturation of 96% on room air. The X-raysat the ED presented an oblique fracture of the left femur and an open displaced tibia affecting flow of blood to the limbthe wound had a lot of dirt and gravel from the accident scene. He has a fractured rib and a small hemo-pneumothorax. Estimated blood loss at the scene was 750-1000mls. An ICC was inserted. He was immediately scheduled for an urgent surgery for reduction and internal fixation of the femur and the tibia. The procedure lasted for three hours and was noneventful with a blood loss of 750mls. Ben has been given 25mg of morphine and reports pain to be at 4/10. He has a drain in the right thigh that is active. Has a dressing on the thigh and shin that are intact with a small ooze. The pedal pulses are strong and palpaple. He is on oxygen via nasal cannula at 2L. He is resting and rates pain at 6/10. He is alert with a GCS of 15/15.
Assessment of the patient was performed by the A-G approach. Subjective data was patient verbalization of pain of level 6/10 on his left leg. The objective data was the patient appeared disturbed, anxious and presence of facial grimaces and guarding of the left thigh. The vital observations were: pulse-120beats/min, respirations of 24 breaths/minute, BP of 130/78, and an oxygen saturation of 96% on room air. The patient reported injuries on his left limb which was a possible risk of infection. The objective data was that the patient had an open wound on the left shin of the tibial bone and the wound was filled with gravel together with sand from the scene where he incurred the accident, there was compromised blood flow and the sugical procedure increased the risk for infection.
Actual problem is; acute pain related to the bone fracture, soft tissue damage, movement of bone fragments, devices applied for immobility, muscle spasms due to the injury.
Pain is what the patient says it is. It is subjective, and it’s an emotional, physical and sensory feeling of ailment of injury to the bone and tissues. The cluster of cues for the finding was Patient verbalizing the unpleasant feeling rating it at 9 in a scale of 1 to 10, Patient has facial grimaces demonstrating perception of pain, Patient is restless and anxious with an increased heart rate of 120 beats/min and Patient guards the place of injury (Kua et al., 2016).The data was both subjective and objective in nature. The assessment data was arrived at by collaboration and teamwork from a team of nurses and other physicians. The expected outcome was that patient verbalizes relief of pain and demonstrates calmness, rests and sleeps. Patient will demonstrate normal heart rate ranging 60-100 beats per minute (Chaudhuri et al., 2015).
Acute Pain and its Management
Injured limbs were immobilized using a cast, skeletal tractions and patient was advised to rest so as to alleviate pain and ensure stability of the fracture for alignment hence promoting fast and prompt healing. The broken areas were carefully raised to facilitate return of blood to the heart hence reduce accumulation of fluid at the extremity and ensure the integrity of the nerves and foot in general. Frequent assessment and recording of pin was done in reference to the pain scale (Lavin, Harper and Barr, 2015). Documentation ensures ease and prompt monitoring as it provides the shift in presentations. Objective data for pain; patient mood, facial grimace and vital observations majorly the heart rate were observed. This was to perform the evaluation aspect of all the interventions applied by the health care workers. Direct actions were applied to ensure gaining of physiological function and ensure client centered care.
Nurses established trust by reassuring him of client confidentiality. They educated ben on reporting any signs of changes to the wound, such as increased pain or feeling of itchiness. (Banaszkiewicz, 2014). Before performing any procedure, the process was explained and its importance to alley anxiety and prepare him. Consent as also obtained before each procedure. They explained on how he should participate positively towards quality care promoting collaborative care (Gordon, 2014).
Close monitoring was done to check the fluctuation of pain with the analgesics. Monitoring was by assessing the wound and taking vital signs against the normal ranges. Patient was given emotional care by being educated on use of ways of managing anxiety such as gaseous exchange exercises and was reassured on the prognosis of his condition. Pain was assessed often in reference to the scale of 1-10 to ensure relief from pain and comfort (Lamego et al., 2017). Left limb was assessed for presence of sensation to monitor the function of the nerve and limb. The doctor was consulted to reassess him for severity of pain and give a medical prescription to the patient. Patient was encouraged and supervised on exercises on active and passive Range of motion to promote strength and activity of the joint and muscle to promote relief of swelling and in damaged soft tissues to ensure normal physiology.
Patient was assessed for pain using a scale of 0-10 to assess comfort and healing. To check the prognosis of the interventions of the nurse and other clinicians implemented, repeat assessment was done. Patient confirmed relief of unpleasant feeling and demonstrated calmness and rest. Ben was at ease of resting and sleeping without the unpleasant feeling. The patient outcomes were concluded based on the patient’s report of decreased perception of pain and the face appeared brighter.
Potential Problem: Risk of Infection related to impaired defense mechanism due to broken skin, damaged tissues, open and dirty wound, surgical procedure and insertion of foreign materials.
Ben has a risk for infection due to impaired defense mechanism in relation to presence of broken skin, destroyed tissues that have weakened the body’s immunity, he suffered an open wound that is dirty and full of gravel from the scene (Mohania et al., 2017). The dirt is a source of infection from the environment. Ben underwent a surgical procedure, reduction and internal reduction. In the surgery, he was fixed with interlocking nails and screws which are foreign objects and make him susceptible to infection. The procedure itself places him at a risk for infection.
Prevention of Infection
The main objective in this case is to ensure Ben remains infection free and the wound heals well and he regains normal physiological function. The interventions also centered at educating Ben on the proper ways of keeping his wound clean and out of reach of microorganisms. He was also warned about contacting the wound. Aseptic technique use awareness was created on change of dressings and cubital intravenous line care. This breaks microorganism’s chain of transmission and renders Ben infection free through the period of hospital stay.
The interventions included assessing the wound for presence of increased pain and edema. Use of aseptic technique during dressing and cleaning of the wound (Kamoun, Kenawy, and Chen, 2017). The wound should be assessed for changes in color and any smell. This will identify early signs of infection that will call for prompt management. Vital observations should be observed for fluctuation, especially temperature monitoring to pick out infection.
All clinicians were enlightened on the advantages of proper hand washing before any procedure to Ben (Siddiqui et al., 2017). Use of clean running water and rubbing hands eliminated some of the pathogens from one patient to another. Clinicians maintained the hand washing protocol.
Mr. Ben, his family and friends were educated on the importance of hand washing before entering the ward and after visiting the patient.
Conclusion
Ben’s case was handled with professional care and collaboratively from the clinicians. Careful assessment was done to arrive at priority nursing diagnoses; acute pain, impaired skin integrity, risk for infection, risk for trauma and falls, diminished physical immobility and risk for impaired neuromuscular function. Appropriate nursing interventions were implemented towards management. Patient education was given appropriately and the patient participated positively towards management.
References
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Gordon, M., 2014. Manual of nursing diagnosis. Jones & Bartlett Publishers.
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Siddiqui, N., Friedman, Z., Macgeer, A., Yousefzadeh, A., Carvalho, J. and Davies, S. (2017). Optimal hand washing technique to minimize bacterial contamination before neuraxial anesthesia: a randomized control trial. International journal of obstetric anesthesia, 29, pp.39-44.
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