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Nursing Care Assignment

Introduction

This paper will discuss the nursing care related to the clinical case of mrs audrey smith, 75 years old, widower, of 440 Collins St, Melbourne, Victoria 3000. She was brought and diagnosed in the hospital with a fractured left neck of femur. The recent anamnesis reports she had a fall this morning tripping over her dog, neighbours found her on floor and called ambulance. At the arrival patient was vigil and oriented with CGS score of 13. At the nursing assessment the patient shows a slight right-sided weakness post CVA and chronic constipation, urinary incontinence and anorexia have been highlighted. Intravenous therapy (IVT) and indwelling catheter (IDC) already placed in the ED as she is due for arthroplasty surgery of the left hip at 17:00 this evening. This paper aims to identify all the necessary Nursing Management required for her care commencing from pre-operative preparation down to her immediate and long term post-operative care including preparations for transfer to a fast track rehabilitation facility.It is associated with the analysis of pre-operative and preoperative needs of Audrey and the linked intervention process associated with it. The evaluation has been done on the basis of past medical history of Audrey.

Nursing Care interventions.

1.Safety:

As opined by Richards et al. (2017), continuous observation of the mental status of Audrey is essential. It is mandatory to provide private room closure to Nurses station due to GCS score of 14/15. It is necessary for the nurses to perform the analysis of the chest pain to understand the formation of the deep vain thrombosis. The assessment of the Homan’s sign is essential to minimize the aggravating condition occurrence for Audrey. If the patient does not have problems in the upper shoulder, he will help by taking hold of the trapeze and will be incorporated so that the nurse can bathe in the back. Help perform ........

over her dog, neighbours found her on floor and called ambulance. At the arrival patient was vigil and oriented with CGS score of 13. At the nursing assessment the patient shows a slight right-sided weakness post CVA and chronic constipation, urinary incontinence and anorexia have been highlighted. Intravenous therapy (IVT) and indwelling catheter (IDC) already placed in the ED as she is due for arthroplasty surgery of the left hip at 17:00 this evening. This paper aims to identify all the necessary Nursing Management required for her care commencing from pre-operative preparation down to her immediate and long term post-operative care including preparations for transfer to a fast track rehabilitation facility.It is associated with the analysis of pre-operative and preoperative needs of Audrey and the linked intervention process associated with it. The evaluation has been done on the basis of past medical history of Audrey.

Nursing Care interventions.

1.Safety:

As opined by Richards et al. (2017), continuous observation of the mental status of Audrey is essential. It is mandatory to provide private room closure to Nurses station due to GCS score of 14/15. It is necessary for the nurses to perform the analysis of the chest pain to understand the formation of the deep vain thrombosis. The assessment of the Homan’s sign is essential to minimize the aggravating condition occurrence for Audrey. If the patient does not have problems in the upper shoulder, he will help by taking hold of the trapeze and will be incorporated so that the nurse can bathe in the back. Help perform the hygiene of the body with the patient lying in the supine position and lateral deceits position. In the words of Machiels et al. (2017), auring the process of washing the patient, the change of the dirty-clean sheet will be made parallel to the patient and avoiding wrinkles. Initial immobilization to splint is necessary to help her with movement. The nursing care should be given without causing any sorts of unnecessary harms to the Mrs Audrey. She might be treated with multiple medications but the importance of sufficient care must be there for considering the vulnerability of using multiple medications, so that the occurrences might not produce any adverse effects. The nurses will remain careful enough so that she might not be affected by any (Weiss &Tappen, 2014) clinical risks like hypovolemic shocks, haemorrhages or virus infection as these might cause compromising the safety of her treatment and healthcare initially. All the essential procedures regarding the treatment of Mrs Audrey should be free of any sorts of malpractices and these steps must be undertaken with sufficient care and right ways. The nursing treatment of Mrs Audrey will be facilitating with combined strategies and planning regarding direct care of Mrs Audrey.

2.Comfort:

The patient. Audrey is partially dependent of the nurses thus generation of comfort can be initiated with separation of the feet, one beside the object and one behind;(Ang, Chang & Tay, 2014).From the crouched position (seated position), keeping the back straight (which is not always vertical) will ensure comfort for the patient. Approach the object, arms and elbows next to the body. If the arms are extended, they lose much of their strength. As opined by Nonnenmacher et al. (2017), the weight of the body is concentrated on the feet. Begin the lift with a push of the back foot.

 

3.Hygiene:

As the physical condition of the patient is not in good health the maintenance of the hygiene is not possible for her. Thus, nursing assistance is required for Audrey to manage her hygiene. Preserve the privacy of the patient by isolating him from his environment (by means of a screen or curtain) and keeping him naked for as little time as possible. Now we will place the patient in lateral decubitus to wash the back of the neck, shoulders, back and buttocks. Rinse and dry. This is a blow by blow description of a bed bath. You have not said why you are doing this. It has no relevance to the question. At the time of delivering health care treatments to Mrs Audrey, there might be a risk of her being exposed to varieties of exogenous microorganisms from any other patients, visitors or health care personnel. The equipment and medications of her must be under close hygienic care so that the environmental surfaces or clinical objects for care taking of Mrs Audrey do not get contaminated.  Extensive care must be taken regarding maintenance of the medical devices and equipment that are subjected to take care of her (Zaccagnini& White, 2015). The responsible nurses should be enough careful regarding avoidance of host susceptibility in case of developing infection in her injured body parts being exposed to the pathogenic organisms. In addition to this there are some extrinsic risk factors which include surgical invasive procedures, therapy and diagnostic intervention due to invasion of foreign bodies or personnel exposure. The responsible nurses, taking care of Mrs Audrey, are essentially required to take care of all these important aspects of her medical nursing care.

4.Nutrition:

As opined by Rashvand et al. (2016), assessment of the nutritional requirement is essential for Audrey to cope with het anorexic state and her constipation problem.  Proper application of the nutritional elements can help in the process to heal the wound. It is necessary to check that the diet nurses are going to administer corresponds to the prescribed one, as well as the temperature of it. If there are allergies or intolerances to any food, check its absence in the diet. In the opinion of de Olivera&Toledo (2017),extreme precautions should be taken with patients in a semi-conscious state when administering fluids (risk of aspiration). In this case it would be advisable to use another route of administration, if it were not possible and you have to administer the fluids through your mouth, do it very slowly and with great caution;The providence of essential nutritional values and ingredients to Mrs Audrey will now be essential for the nurses for under this condition, it is also important to maintain fitness of her body. An unfit body which is affected by severe injure, must be tried to remain strong otherwise her weakness will welcome various infectious roots or viruses that might jeopardise her life.

 

5.Psychological:

Audrey needs psychological guidance about techniques that can be applied to their patient to cushion situational negative emotions: respiratory techniques, skin-to-skin contact, and attention diversion techniques.Teach the conscious and oriented patient, techniques of physiological deactivation applicable during tension situations for the elementary control of emotions (visualization, relaxation, breathing techniques, short-circuit techniques) (Urden et al. 2016).While being under the extensive care of the nurses in the hospital, Mrs Audrey might be subjected of being utilised by invasive devices which might expose her to exogenous microorganisms. Therefore for maintenance of the aspects of hygiene subsequent monitoring of the effective treatment procedures along with daily care taking will be highly helpful for Mrs Audrey. She must be placed in such a place under the unit of the hospital where there will be no difficulties due to transmission of airborne diseases, respiratory droplets or vector borne transmission because of mosquitoes or any other vermin (Varcarolis, 2016). An important role might be played by the nurses in case of maintaining hand hygiene which is very significant for the purpose of delivering hazard free health care services and best possible means of treatment for Mrs Audrey. 

Orient the companion and other relatives about the information that should be given to the patient, to transmit security and cushion the emotional reactions that are derived from the situation that lives. Specify the role that plays as a companion to the contingency. It is essential to deal with her anxiety concern in effective manner that helps to deal with the depression.

Activity Levels:

  • We will stand next to the patient's bed, at the level of his chest;
  • We will place an arm below the patient's shoulders
  • The other arm should be placed under the patient's armpit, holding behind it, at the height of the shoulder blade
  • Daily coordination with patient and ensuring the nursing care check list.

 

 

Past medical history:

1.Atrialfibrillation (AF): is an abnormal heart rhythm in which the electrical signals from the atria are fast and irregular and some of them do not reach the ventricles that pump inappropriately and need to explain Audrey why he is having an irregular pulse and check for the causative factors such as electrolyte imbalance for this rhythm that needs to be treated as to revert Audrey’s back to normal sinus.

 

2. Cerebrovascular Accident (CVA): is a neurological disease that causes sudden death of some cerebral cells due to lack of oxygen when the blood flow to the brain is impaired by rupture of an artery, or results in paralysis, coordination problems or memory loss (Delgado, 2017). In addition to this there are some extrinsic risk factors which include surgical invasive procedures, therapy and diagnostic intervention due to invasion of foreign bodies or personnel exposure. The responsible nurses, taking care of Mrs Audrey, are essentially required to take care of all these important aspects of her medical nursing care (Kaplow, 2015).Risk factors include hypertension, atrial fibrillation, ischemic heart disease, smoking and diabetes mellitus (Hinkle& Cheever, 2015). It is important to maintain and monitor her vital signs as to prevent from any CVA episode.

 

3.Type 2 Diabetes Mellitus (T2DM):According to Mckenzie& Porter (2015)it is the medical condition characterised by the body resistance to insulin subsequently leads to decrease absorption of glucose in cells. Audrey’s blood glucose level needs to check and maintain and nurses should check of surgically induced wound for any signs of infection which can be delay the healing.

 

4. Hypertension: As per the study of Xiao et al. (2016), it is defined as a systolic blood pressure which is 140/mm Hg or greater and a diastolic which is 90/mmHg or greater. Persistently at its initial stage it is asymptomatic or could be linked with headache and dizziness, but it further leads to cardiovascular and neurologic complications. It is very important to treat HTN at its early stage and nurse should educate Audrey that how she can keep pressure under control. (Cabrera and Schub, 2014). It is necessary to monitor the blood pressure in frequent intervals to cope with the requirement of the body. The case of hypertension must be taken care of in the initial case and for successfully gaining control over blood pressure Andrew is required to control her pressure at the initial stage. The nurse of Audrey is needed to essentially be careful regarding monitoring the blood pressure at regular interval for attaining the purpose of keeping her well.

 

4.Total hysterectomy: With this condition uterus and cervix are surgically removed (McKenzie & Porter, 2015) mostly 50 precents of all the women are prone to this disease and develop urinary incontinence. Post –operative care is necessary and also bladder training program and pelvic floor exercises are require strengthening Audrey’s muscles.

 

5. Depression: The major impact of the past history of patient is on her psychological imbalance. For patients like her it is the first time they face an important health problem, so it is also the first time that they establish an intense and prolonged relationship with the health system, with all that this entails in these cases, waiting for the performing diagnostic tests, knowing their results, or receiving treatment; more aggressive treatments than usual (chemotherapy, radiotherapy, surgery). With this, it is common that Audrey has been stressed, suffer anxiety and be disoriented.  The appearance of pain aggravates the psychological situation of the patient and, in turn, the psychological problems can be an impediment to their good control. That could affect regular nursing care especially while handling her. Moreover, the patient history shows frequent emotional imbalance.Thus, proper emotional support with medication concern is essential.Any sorts of anxiety might be dangerous for her at this stage and thus it is very important to make her anxiety free and this will keep her with well heath and mind (Urden et al.,2015). Naturally at this stage she might suffer from frequent mental misbalancing, which her nurse is needed to take care of with urgent importance.

 

6. Osteoporosis: It is a systemic skeletal disorder characterized by low bone mass and weakening of bony microvasculature resulting in bone fragility. It arises mostly in women due to menopause that leads to reduction of estrogen. Due to this Audrey’s surgery and her rehabilitation affected(Cabrera and Schub, 2014)

 

7. Gastro- Oesophageal Reflux Disease(GORD): In this condition the pathophysiology is associated with the improper closure of the sphincter of oesophagus that allow reflux of the contents in gastric (Schub&Barove, 2014). In Audrey’s condition as per care plan, GORD will not be impacted directly in the interventions, but requires monitoring and controlling the symptoms to recover her health.It is necessary for Audrey to comply with proton pump that can inhibit the condition by stopping the aggravation.

 

 

 

Medical History:

Digoxin 62.5 mg:

These tablets belong to a group of medicines called cardiac glycosides. These are beneficial for the patients with congestive heart failure as these slow down the heart rate but increase the force with which the heart contract leading to the efficient working of heart (Uribe, 2014).

 

Nursing Implications

  • Before administering digoxin ensure that nutrients, minerals and electrolytes in blood are steady.
  • Keep a regular check for changes in blood pressure and heart rate.
  • Monitoring of weight fluctuations on daily basis

 

As Audrey is suffering from hypertension digoxin should be provided with great care as digoxin can lead to discomfort and unusual tiredness and weakness which is not good for patient psychological state.Monitor HR & withhold <60

 

Warfarin 2mg:

 

This drug serves as an anticoagulant and reduces the formation of blood clots in veins or arteries which minimize the risk of heart attack, stroke and other serious conditions

 

Nursing Implications

 

  • The drug takes about three days in order to produce its full effect so it should be given on regular basis.
  • The anticoagulant effect of the drug should be measured regularly by INR blood test and dose should be adjusted accordingly to make INR fall into acceptable range.

 

As Audrey past medical history indicates that she has been subjected to Osteoporosis, so Warfarin should not be given to him for long term as long-term warfarin therapy could possibly lead to bone mineral loss of Audrey.

 

Effexor 150mg

 

Effexor is an antidepressant of the serotonin-norepinephrine reuptake inhibitor class. The drug is used for immediate recovery from depression by blocking the neurotransmitters when provided at a dose of 75mg/day. Also it is used for social anxiety, panic disorder and generalized anxiety.

 

Nursing Implications

 

  • Monitor for aggravation of depression or emergence of the idealization to commit suicide.
  • Monitor weight periodically and notify in case of excess weight loss.
  • Take measures necessary to ensure safety, as dizziness and sedation are common.

 

Effexor is effective for the treatment of panic disorder and may possibly work when other antidepressants fail to work because it affects two chemicals in brain that affect individual’s mood.

 

Mylanta

 

This drug is used for treatment of upset stomach and heartburn. It belongs to group of drugs named antacids that neutralize stomach acids.

 

Nursing Implications

 

  • Note consistency and number of stools.
  • Check for dose regularly as constipation is common and related to dose.
  • Take lab tests to monitor periodic serum phosphorous and calcium levels.

 

Mylanta has adverse effects in the form of constipation, intestinal obstruction and faecal impaction. As Audrey is suffering from chronic constipation the drug usage should be reduced.

 

Caltrate

 

(Brenner & Stevens, 2013) Caltrate is a calcium supplement that is necessary for the various normal functions of the body that include bone formation and maintenance. Effective for treatment and prevention of hypocalcaemia and osteoporosis

 

Nursing Implications

 

  • Administer the level of calcium carbonate 1 hour after meal and at bedtime.
  • Dissolve tablets in glass of water. Follow oral doses with full glass of water.

 

As Caltrate is a calcium supplement so it proves to be effective for the treatment of Audrey osteoporosis.

Vitamin-D

Calciferol refers to a group of fat –soluble compounds necessary for absorption and maintenance of serum calcium. It is assisting to reinforce Audrey’s bones and help to slow down the osteoporosis.

 

Nursing Implications

 

  • Identify signs and symptoms of Vitamin-D toxicity.
  • Ensure patient to take vitamin rich sources diet.

 

Conversyl

 

(Perindopril) is an antihypertensive ACE inhibitor used to treat hypertension.

 

Nursing Implications

  • Check vital signs regularly.
  • Ensure she is having antihypertensive in case of high B.P.

 

Metformin

 

It is anti diabetic and decrease hepatic gluconeogenesis and increase tissue sensitivity to insulin(Strayer and Buckey, 2015)

 

 Nursing Implications

  • Monitor patient BSL before meals and sign and symptoms for hypoglycemia.
  • Patient should be stabilized on a diabetic regimen and administer insulin withholding with metformin. 

 

Esomeprazole

It is a gastric antisecretory agent given to Audrey’s as to relief her symptoms related to GORD (Uribe &Schub, 2015)

 

Nursing Implications

 

  • Administer this medication 30 minutes before breakfast.
  • Ensure that not to crush this medicine and chew it and avoid acidity secreting food.

 

Venlafaxine

 

It is antidepressant medicine use to treat depression in Audrey.

 

 

Nursing Implications

 

  • Administer this medication with food.
  • Monitor the behaviour of the patient.

Main immediate preoperative nursing interventions

 

As Audrey is suffering from depression, nurse should carefully observe if there is any sign of anxiety in patient due to surgery. These signs may be physical i.e. nausea, sweating or psychological such as behaviour change, aggression or wanting constant attention. In such a case nurse should help the patient release anxiety by having a relative or friend sit with patient to release anxiety (Kaplow, 2015). . For the generation of the preoperative management it is essential to perform the diagnostic laboratory tests and gain the consent form the patient. It is essential from the end of the nurses to prepare the individual ready based on the physical and mental concern. The nurses needs to prepare the patient emotionally with the help of health teachings related to deep breathing, coughing, and use of tri-flow (Weiss & Tappen, 2014).

 In the words of Vasilevskis et al (2016), for preparing patient for theatre nurse should recommend clear fluids up to two hours and food up to six hours before surgery. It is due to the analysis necessity for the contraption process in the body considering the age of the individual.

Before patient leaves for theatre a preoperative checklist should be completed. As it is necessary for the generation of the successful operation for Audrey with the minimization of the complexity in the ward.Further nurse should ensure that the patient understands the operation and gives his consent unless consent is not possible due to age or mental health. It is necessary to perform the electrocardiogram record and monitor it in proper manner so that the complexity at age 75 can be understood (Zaccagnini & White, 2015).

 

 

Main immediate postoperative nursing interventions

 

Audrey physiological state should be continuously and carefully supervised from the time she leaves care of anaesthetist until she wakes up in the ward. It is essential to perform the Neurovascular assessment in immediate manner along the pain assessment to perform the essential pain management process.

Further assessment of following should also be carried out:

 

  • Ensuring the dressing is intact and there are no signs of overt bleeding
  • Rate of intravenous fluids.
  • Extended and supportive maintenance of legs are essential in this case
  • Maintenance of negative pressure with the Jackson Pratt drainage is essential
  • Wound dressing is essential to avoid the infection
  • Reference towards Physical Therapist is necessary

Pain status and respiratory status should be monitored every one to two-hour for initial eight hours. Body temperature should also be checked as patients are often hypothermic after surgery and need blanket. Patient should be monitored for 24 hours.

 

Interventions in preparation for the discharge

 

As opined by Bragadóttir et al. (2017), involve the patient family in discharge process and discuss with patient the discharge plan and verbally explain and make him understand patient detailed prescription so that after leaving the hospital patient can take medicines as prescribed. Further ensure that the patient is able to:

  • Provision of the information is essential for the patient to gather the inquiry data in verbal manner from Audrey to develop the right treatment
  • During the medication administration process, it is essential to follow the health instruction and communicate with the nurses
  • Reassessment of the daily activities and positive reinforcement is essential in this process
  • Assurance is essential towards her during the handover of the assessment to another Nurse

Verify patient medication list in order to identify which medicine have been added, discontinued or changed relative to pre-admission medication list. Further nurse should arrange to teach back activity with Audrey. Teach back is an activity by which nurse ask the patient to repeat the recently taught techniques in his own words. The main motive of this is to make patient memorize what he has to do after discharge.

 

Conclusion:

Based on the above findings it can be postulated that the application of the Nursing Care Management delivery is an important concern for the fast recovery of the individual, Audrey. This context has addressed the dependence and interdependent function of the nursing concern. The holistic care which is essential for the nurses are applied with the maintenance of the framework related to planning based on the assessment, implementation, and evaluation of the needs of Audrey. Immediate care can be improved with the prioritization of the activities in the medical care unit for Audrey.