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NRSG258 Health Issues in Given Case Study and Nursing SMART Goal Assessment Answer

    NRSG258 Semester 1 2020 Supplemental Assessment

    Marita Müller is a fit, healthy 22-year-old German woman, with no past medical history and nil known allergies. Marita is currently working on a cattle farm in outback central Australia. Two days ago, she was thrown from her horse and fell into a barbed wire fence. At the time of the fall Marita was wearing only shorts, a tee-shirt, sturdy work boots, riding gloves, and a helmet. Marita sustained the following injuries in the fall:

    • Two deep lacerations to her right leg
    • Grazes to the right side of her face, shoulder, arm, leg, and torso 
    • Severe injury to her right wrist and upper right arm
    • She had no altered conscious at the time of the accident. Marita denied any neck pain and denied any altered sensation in her limbs. 

    Marita was taken to Alice Springs hospital via air ambulance. Where she had multiple Xrays that showed:

    • Fractured Right humerus, 
    • Fractured Right radius
    • Fractured Right 3rd & 4th ribs.
    • There were no other injuries
    • Head CT showed no signs of bleeding or trauma to her brain.

    Surgery

    Marita required surgery under general anaesthesia to clean and suture her multiple wound lacerations and reduce her fractures.  A plaster cast was applied to her right arm.  She has sutures in her right thigh wound and a Jackson Pratt drain to her thigh, and sutures to her calf laceration. 

    The operation was mostly uneventful apart from approximately 300ml of blood loss from her lacerations. She was given 1 unit of packed red cells, and 1 litre of Hartmann’s solution intra-op. 

    Marita was transferred to the orthopaedic ward from theatre last night at 10:30pm. It is now the following morning and you are assigned to care for Marita. You assess Marita at 08:00 hours and your assessment findings are:

    • Marita is awake and alert. She is orientated to time, place & person.
    • Her right eye is bruised and almost shut due to an extensive haematoma.  She is quite teary & asks if she is going to be ugly due to the facial grazes and her other scars.  She’s extremely worried she’ll never get full use of her right arm back.  She is also very concerned that she won’t be able pay for this as she’s not covered by Medicare.
    • There is blood staining the dressings on her leg. The right leg drain has about 70ml of frank blood in it. Her right arm is swollen and bruised. The fingers on her right hand are also swollen.  She has good movement and normal sensation in the fingers of her right hand. The skin is the same colour as her left hand apart from some bruising. The fingers to her right hand are cool to touch, and the capillary refill time is 3 seconds. Marita is complaining that the cast feels tight. 
    • Her vital signs are: Temperature: 37.6C, Pulse: 115 & regular, Blood Pressure 92/58 mmHg, Respirations: 20 & shallow, Oxygen Saturation: 95% on 3LNP. She says it hurts to breath. 
    • Marita is complaining of a dry mouth and being thirsty. There is no record of her passing urine since her return from surgery. Marita can’t remember when she last used the toilet.   
    • She did not eat much of her breakfast but drank some of the orange juice and half a cup of coffee. She said it hurt her face to eat and the coffee was cold and not real coffee. 
    • She has a PCA in place and says her pain is bearable at the moment if she doesn’t move too much or try to breathe deeply or cough.  Her PCA and IVT are connected to the cannula in her left arm. She has a litre of Normal Saline running at 40mls/hr.  

    Complete the 3 tables below to address the following questions:

    1. Using the case study information above, identify and justify three (3) important health issues that you need to address for Marita during your shift.  Identify and explain the significance of the clinical cues you have used to prioritise your selection.
    2. Provide an explanation of the action you will take to manage each health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  

    [hint: There are 3 tables/care plans because you need to identify 3 health issues.]

    [hint: your care plans may end up more than 1 page each.]

    Question 1: Using the case study information above, identify and justify your first important health issues that you need to address for Marita during your shift 
    Health Issue Evidence - Clinical Cues and literature to support
    1.
    Provide a Nursing SMART Goal for this issue

    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  

    Question 1: Using the case study information above, identify and justify your Second important health issues that you need to address for Marita during your shift
    Health Issue Evidence - Clinical Cues and literature to support
    2.

    Provide a Nursing SMART Goal for this issue

    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  

    Question 1: Using the case study information above, identify and justify your third important health issues that you need to address for Marita during your shift
    Health Issue Evidence - Clinical Cues and literature to support
    3.

    Provide a Nursing SMART Goal for this issue

    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  


    Answer

    Question 1: Using the case study information above, identify and justify your first important health issues that you need to address for Marita during your shift 
    Health Issue Evidence - Clinical Cues and literature to support
    Blood loss which may cause hypovolemia or haemorrhagic shock











    		 The patient has already lost 300ml of blood during surgery, her bandages are still soaked in blood subsequently Her vital signs are indicating low blood volume, her Pulse: 115 & regular which could be the result of compensatory vasoconstriction, her blood pressure is low Blood that is  92/58 mmHg, with Respirations are low and shallow, and suppressed urine output. History of deep lacerating wounds on thigh is indicative of acute blood loss. The vital signs too may indicate first-degree blood loss (Standl et al., 2018).
     Intrathoracic injuries sometimes also result in the blood loss into the thorax which might get unnoticed without any external evidence. Lower extremities deep lacerating wounds may lead to lacerations of vessels causing excessive bleeding.
    Hypovolemic shock is the condition that results from the decreased blood volume due to blood loss causing reduced cardiac output and restricted tissue perfusion. Hypovolemic shock may cause dehydration, hypotension, insufficient urine production, faster heart rate and pulse rate, mental confusion. Hypovolemic shock results in the organs failure and Later it may cause coma and cardiac failure (Kislitsina et al., 2019)

    Provide a Nursing SMART Goal for this issue

    1. The main goal is to immediate prevention of the bleeding and to restore circulating blood volume where the desired outcome should be to maintain the Heart rate at sixty to hundred beats per minute, with systolic Blood pressure to ninety mm Hg, and maintaining urinary output greater than 30ml/hr, and normal skin turgor which is indicative of normal blood volume.
    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.

     NURSING INTERVENTIONS
    In the case of hypovolemic  or haemorrhagic shock, the Interventions should be focused on the bleeding and further consequential changes in hemodynamic parameters from loss of the volume , these may be indicated through central venous pressure, blood pressure, cardiac output, pulmonary artery pressure and heart rate,

    • Monitor the blood pressure in both the standing and supine position. A common presentation of fluid loss/ blood loss is postural hypotension. A loss of 100 mmHg is indicative of blood volume by 20 per cent whereas greater than 20-30 mmHg drop indicated a 40 per cent decrease in blood volume.
    • Control the external source of bleeding, apply a thick dry bandage over the wound to exert direct pressure for stopping bleeding.
    • Assess the level of consciousness haemodynamic like mean arterial pressure, central venous pressure, cardiac output (Cecconi et al, 2014).
    • Asses for the secondary changes in her symptoms, changes in her level of consciousness, source of bleeding, skin and mucous membrane for turgor as the sign of dehydration. Decrease skin turgor may be a sign of loss of interstitial fluid.
    • Monitor her coagulation studies and haematocrit, haematocrit should be monitored after every thirty minutes to four hours depending on the progress of the condition. Lower haematocrits indicated continuous blood loss (Lawton et al, 2014).
    • Prepare for procedure Arterial line or central line, take consents and prepare fluids and tubing.
    • Intubation: identify the need for respiratory therapist and charge nurse for support, ensure availability of monitoring equipment. The arterial line is placed for hemodynamic monitoring, when used with FloTrac machine can measure CO, SV and SVR.
    • Administer bolus 1-2 L of IV fluid as ordered, use crystalloid solutions providing required electrolyte and fluid balance. Fluid therapy may be given in this time cautious to avoid precipitation of pulmonary oedema.
    • Provide Transfusion to the client with blood packed red blood cells.


    Question 1: Using the case study information above, identify and justify the Second important health issues that you need to address for Marita during your shift
    Health Issue Evidence - Clinical Cues and literature to support
    2.Fractured Right humerus, 
    Fractured Right radius









    		If care not taken properly complications may develop post-fracture of her humerus and radius or improper bandaging. Her right arm is swollen and bruised. The fingers on her right hand are also swollen however she has good movement and normal sensation in the fingers of her right hand. The fingers to her right hand are cool to touch which might indicate some obstruction to the blood flow, and the capillary refill time is also delayed from normal of 2 seconds to 3 seconds. She also feels her cast to be tight.
    There are several stages of fracture healing which should be closely monitored for avoiding any complications. There are several complications which can occur as the result of fracture which may include compartment syndrome and fat embolism (Mathews et al, 2019). It may also cause arterial damage if not managed properly. Humerus shaft is surrounded by large muscles, blood vessels and nerves (Martin et al, 2018).  The structure surrounding may include Brachial artery and vein, Biceps Brachii, brachialis, coracobrachialis and median and ulnar nerves. Fracture of the humerus may cause damage to any of the structure. In posterior compartment injury, it may affect Radial nerve and triceps (Laulan et al, 2019).
    Provide a Nursing SMART Goal for this issue

    1. Avoid complication, promote pain-free mobility of forearm
    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  

    NURSING INTERVENTION 
    The nursing care plan, management and treatment of bone fractures should focus on avoiding complications, physical rehabilitation of patients and better pain management for the patient as the treatment can add significantly to the expenses because of the cost of surgery, possible chances of complication development or rehospitalisation (Singaram et al., 2019). 
    • Provide care during client transfer. Immobilize the extremity with the splint in the position of the injured part or joint involved (Handoll et al., 2015).
    • Assess and record the level of pain intensity through Wong-Baker Faces pain rating scale,
    • Maintain the immobilisation of affected part through best, cast, splint and traction.
    • Elevate and support the injured area example forearm.
    • Administer prescribed medicine which may include pain-killer, opioids, nonopioids analgesics and prophylactic antibiotic. Or maintain the adequate administration of analgesic through IV using a peripheral epidural.
    • Observe for any symptom of a fat embolism which may cause dyspnoea, crackles, white sputum, petechia over buccal mucosa and chest. If presented assist with respiratory support.
    • Observe for any symptom of compartment syndrome, which has signs symptoms including deep pain, oedematous muscle and decreases tissue perfusion. These complications may reduce the capillary filling time with swollen hand and finger but solely cannot diagnose for compartment syndrome.
    • Monitor closely for any other sign and symptom of complication if the present report to the senior nurse.
    • Observe for any sign of cast syndrome and discuss for the possible treatment. Also, teach the client regarding the cast care depending on the type of the cast.
    • Encourage the client to increase things which may facilitate the healthy healing of the fracture.
    • Perform and supervise the active and passive exercise, these exercise helps in maintaining the strength and mobility of muscles and facilitates resolution of the injured tissue (Gulanick & Myers, 2016).
    • Provide alternative comfort measure like massage, backrub and position change. This helps in the establishment of the nurse-patient relationship and also helps in local muscle fatigue. 
    • Explain the prescribed restriction to her also motivate her for long term modification as she is fearful for not being able to use the arm in the long run
    • Provide emotional support to encourage the appropriate involvement in the stress management techniques like relaxation, deep breathing.


    Question 1: Using the case study information above, identify and justify the third important health issues that you need to address for Marita during your shift
    Health Issue Evidence - Clinical Cues and literature to support
    1. Anxiety 











    In the case of Marita, the anxiety could be due to both psychological as well as physical origin. As she is uncomfortable with her injuries and is under constant pressure this may have caused anxiety in her. Also, the sense of uneasiness and discomfort can be created due to autonomic response secondary to lower blood volume (Finnerup et al., 2016). She is quite teary and extremely worried about her conditions and future limitation of movement. As she’s not covered by Medicare it is adding to her anxiety.
    Anxiety may be also related to fear of her acute emergency condition and unfamiliar environmental setting (Sadat et al., 2015). 
    Anxiety is defined as the generalised uneasiness feeling of discomfort or dread which is accompanied by the autonomic nervous system response. This could be as the result of the feeling of anger, fear and anticipation about issues. Anxiety may be characterised by following sign and symptoms which may include: the feeling of being inadequate, marked apprehensions, expressed concern about what next, restlessness. Physiological symptoms may include dryness of mouth, increased pulse and blood pressure, dry mouth and fatigue.
    Provide a Nursing SMART Goal for this issue
    3.Identifying the coping strategy for the patient to reduce the anxiety
    Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.  

    • Assess the level of anxiety, shock both physical and mental in an acute threatening condition may result in a high level of anxiety.
    • Acknowledge the presence and awareness of the client’s anxiety. The process validates the feeling and communicated the acceptance of the situation (Bandelow et al., 2014). As the cause of the anxiety cannot be directly established patient may feel it as a counterfeit.
    • Validate observation by asking “Are you feeling anxious”. Being supportive and approachable helps in communication and relationship establishment.
    • Help patient familiarizes with the situation, awareness with surroundings help in reducing anxiety as well as panic, it may increase to further level if the patient feels threaten through stimulus.
    • Accepts the defence of the patient as far as they are not threatening.
    • Assess the psychological and physiological comfort of the patient. Reduce external stimuli which cause aggravation of anxiety.
    • Encourage patient to verbalize about her anxiety and coping mechanism (Bandelow et al., 2017)
    • Help the patient develop a coping mechanism and to help the patient move out of the possible anxiety. Although in acute emergency settings it may not be possible but try getting information about the past coping mechanism if once patient is stable.
    • Explain all the procedure client going through simple, clear instruction as information helps to reduce the client’s anxiety (Antai-Otong, 2016).
    • Maintain an assured and confident nurse-patient relationship as anxiety of nurse can be perceived by the client. The feeling calm down in the non-threatening atmosphere.
    • Instruct patient regarding the use of the anti-anxiety drug if anxiety cannot be controlled through psychological measures.


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