TOPIC: Nursing Process
Case study essay with headings (including ELP assessment) 2000 word count (+/-10%) Learning Outcome: – Develop an appropriate response to the acute nursing needs of a diverse range of clients. – Utilise evidence based practice to identify and problem solve the needs of patients in acute situations. Scenario: Mike Miller 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 Mike to ED. On arrival to ED, Mike complained of pain in his lower left leg, which had an obvious deformity, significant swelling and a 5cm lacerated wound. Mike’s ED admission observations were: T-36.4oC, HR-90bpm, RR-22pm, BP-136/72mmHg, O2-95% RA, and pain score 10/10 on movement. Mike is allergic to latex (causing pruritus and welts), is not on any medications, and has no other medical problems noted. Mike was given opioid analgesia in ED for his pain, and the ED 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 Mike to undergo surgery for open reduction and internal fixation (ORIF) of the fracture. You are a student nurse looking after Mike since he returned to the surgical ward post-operatively at 10:50hrs. The surgeon’s post-op orders are for routine observations, wound dressing to stay intact for 72hrs, bung IVT when current bag completed, neurovascular observations two-hourly for first 48-hours, and may ambulate non-weight bearing with crutches. He is drowsy and responsive to voice; and has a dressing on his lower left leg, with minimal sanguineous ooze evident. Mike’s observations on return to ward are: T-35.9oC, HR-66bpm, RR16pm, BP- 109/71mmHg, O2-97% via HM at 6LPM, and pain score 2/10. Mike was given prophylactic Cefoxitin 2g IV during surgery. The anaesthetist has prescribed Paracetamol 1g IV/PO 6 hourly, Ibuprofen 200-400mg PO TDS, Tramadol SR 100mg PO BD prn, and Cefoxitin 2g IV/ IM 6 hourly for 2 further doses. IV Compound Sodium Lactate 1L is running at a six-hourly rate into Mike’s left arm. Lay out of Essay: Students are required to research and write a case study essay with headings, directly relating to the above scenario. Using the nursing process, outline the nursing management for the patient post- surgery, discussing all care in general, but focussing on the two (2) prioritised nursing diagnosis/ problems. As well as the information in the Unit Plan, please review modules in the Learning Materials content tab on BB; and Assessments content tab on BB for further information about the assessment. Presentation • Format in accordance with School of Nursing & Midwifery guidelines (see BB Assessment tab). • Academic writing style. • Appropriate sentence structure, word use, grammar and spelling (this is an ELP specified unit). • Logical flow. Students should format their essay management section with headings as: Assessments; Nursing Diagnosis Priority 1: (name of nursing diagnosis) – with subheadings for Planning/GOAL, Implementation, Evaluation; and Nursing Diagnosis Priority 2: (name of nursing diagnosis) – with subheadings for Planning, Implementation, Evaluation. The assignment must flow smoothly and read logically for the reader. Introduction (approx 100 words) • An outline of the paper Background (approx 200 words) • This should be given as an iSoBAR handover (with iSoBAR subheadings). • From the information given in the scenario, students should provide an iSoBAR handover as though you are updating the nursing team they are working with, after having completed the first set of post- op observations as is given in the scenario. • For the iSoBAR handover, students may use first person to introduce themselves and their patient, however all other information in the essay and background must be in third person academic writing style. • Any nursing terminology that requires a definition Management (approx 1200 words) • Using the nursing process (Assessment, Nursing Diagnosis, Planning/Goals, Implementation, & Evaluation), outline the nursing management for this patient post-surgery, discussing all care in general, but focussing on two (2) priority nursing diagnosis/ problems and explain why you them as priority. • Ensure that each part of the nursing process is discussed within the essay, showing depth, critical thinking and coverage of each section. • Assessment – Students should demonstrate that they have looked at all of the assessment data • Subjective data using the SAMPLE acronym o Symptoms o Allergies o Medications o Past medical, surgical, and family history o Last meal o Events heading up to the presentation • Objective data: normal and or abnormal (if any findings are abnormal then students should identify this and give a rational) • Body system applicable to the patient • 12 ADL’s (describe the 12 ADL’s But only discuss the ADL s applicable to the patient) • Any appropriate assessment tools applicable (e.g. Fall risk, Braden scale or Pain Assessment) • This section will require references • No information should be assumed (i.e. only use information within the case study) • Nursing diagnosis – • Students should discuss their two (2) prioritised nursing diagnoses in-depth (focus should be on post-operative care). After analysing all of the assessment data and patient’s responses, students should consider the actual and potential nursing problems/ issues, and demonstrate why they have prioritised these diagnoses (eg. use of primary survey, use of first-aid DRSABCD, actual v potential, etc) – this should demonstrate the student’s ability to prioritise, not just choosing two that they wish to discuss. • Planning/Goals- • Students should demonstrate their three (3) GOALS for each nursing diagnosis. • These should all utilise SMART goals (specific, measurable, achievable, realistic, and with timeframe). • Implementations – • Students should demonstrate one nursing intervention for each GOAL. Each intervention should include the rationale why this intervention is required, and be supported with references (reference – see care plan in preparation). • Evaluation – • Students need to describe how they would know whether planned outcomes had been met? • What is the evidence that goals have been met? • What tools were used? • Where this is documented (usually documentation as evidence). Potential complications and post-operative education (approx 200 words) • Outline the potential complications that the nurse and patient should be aware of. • Outline the post-operative education would need to be provided to your patient, in order to promote a successful recovery. • Referencing required for potential complications and post-op education Involvement of the interdisciplinary team (approx 150 words) • Highlight the members of the interdisciplinary team, and which particular members that would be involved in your patient’s management of care, including what service that they will provide. • References required Conclusion (approx 150 words) • Provides an overview of the assignment • No new material introduced Referencing • In-text and end-text referencing per – APA style. • Minimum of 10 current and credible academic references, using a variety of sources (including a minimum of 4 journal articles and minimum of 2 quality websites). • All sources are up to 5 years old. • Recent and quality sources used – Wikipedia and Dictionary.com will not be accepted as a reference source! • Medical dictionary used for medical terminology.
The purpose of this case study is to discuss the nursing management for Mike Miller, a 24-year-old male who suffered an open fracture of the left tibia and fibula after falling off his motorbike. The nursing process will be used to outline the care provided to Mike post-surgery, focusing on two prioritized nursing diagnoses.
I am a student nurse and I have been assigned to care for Mike since he returned to the surgical ward post-operatively at 10:50hrs. On arrival to the ED, Mike had a T-36.4oC, HR-90bpm, RR-22pm, BP-136/72mmHg, O2-95% RA, and a pain score of 10/10 on movement. He had an obvious deformity, significant swelling, and a 5cm lacerated wound on his lower left leg. Mike was given opioid analgesia in ED, and x-ray confirmed the diagnosis of an open fracture of the left tibia and fibula. After review by the orthopedic team, it was arranged for Mike to undergo surgery for open reduction and internal fixation (ORIF) of the fracture. The surgeon’s post-op orders are for routine observations, wound dressing to stay intact for 72hrs, bung IVT when current bag completed, neurovascular observations two-hourly for first 48-hours, and may ambulate non-weight bearing with crutches. Mike’s observations on return to ward were: T-35.9oC, HR-66bpm, RR16pm, BP- 109/71mmHg, O2-97% via HM at 6LPM, and pain score 2/10. Mike was given prophylactic Cefoxitin 2g IV during surgery. The anaesthetist has prescribed Paracetamol 1g IV/PO 6 hourly, Ibuprofen 200-400mg PO TDS, Tramadol SR 100mg PO BD prn, and Cefoxitin 2g IV/IM 6 hourly for 2 further doses. IV Compound Sodium Lactate 1L is running at a six-hourly rate into Mike’s left arm.
Initial assessment of Mike’s vital signs and pain level, as well as the wound on his lower left leg and neurovascular status of the affected limb.
Assess for any signs of adverse reactions to the analgesics and antibiotics prescribed.
Assess for any potential latex allergies.
Nursing Diagnosis Priority 1: Acute pain related to injury and surgery
Goal: To reduce pain to a manageable level
Interventions: Administer analgesics as ordered, monitor pain level and adjust medication as needed, use non-pharmacological methods to manage pain such as positioning and relaxation techniques, provide emotional support and explain pain management plan
Administer medication as ordered and document the effectiveness
Monitor pain level and document any changes
Encourage the use of relaxation techniques and provide emotional support
Re-evaluate the pain management plan and adjust as needed
Assess pain level and document any changes
Assess for any adverse reactions to the medication
Assess patient’s satisfaction with pain management
Nursing Diagnosis Priority 2: Risk for infection related to open wound and surgery
Goal: To prevent infection
Interventions: Assess wound for signs of infection, monitor wound dressing and change as needed, administer prophylactic antibiotics as ordered, educate patient