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Nursing Case Study

Case Study 1

a. The neuro-vascular assessment of the patient after the accident is done using the six P’s that are, pain, pallor, pulselessness, paresthesia, and paralysis (Tang & Ovanez, 2020). To assess the neuro-vascular damage in the patient due to the accident through these signs, the baseline vitals are assessed. The blood pressure is checked through auscultations, pulse rate assessment, and quality. The respiratory rate is also assessed with the observation of pupils. Perfusion is checked through the assessment of the skin (Bose, 2016).

b. The “moments of hand hygiene” have been established by the World Health Organization to prevent cross infections and promote sanitized conditions in the care facilities (Woodard et al., 2019). These include washing and sanitization of hands by the healthcare practitioner at six specific points as mandatory action. These include, before touching the patient, before initiating an aseptic procedure. The hand sanitation must also be ensuring after there is an exposure to body fluid or with the risk of exposure. Sanitation is also ensured after touching the patient, and after touching the patient surroundings (Fulchini et al., 2018). Therefore, to assist Dan, the moments of hand hygiene will be followed at all the instances to promote his personal hygiene and also to limit the chances of cross-infection by adherence to hand hygiene protocol.

The environment of the patient will be sanitized and cleaned properly allowing with assistance for washing and cleaning with due hand hygiene protocol. Hands will be washed before touching the patient and surroundings, and after cleaning the surroundings and touching the patient. The nurse must perform hand hygiene before addressing the needs of Dan. The practitioner should use gloves and masks to ensure patient safety. Dan should be encouraged to follow hand hygiene along with the healthcare practitioner to ensure patient safety after completion of personal hygiene.

c. It is recommended that Dan should be given paracetamol for pain management as even when the pain is ranged 7/10, administration of oxycodone can further trigger respiratory distress in the patient.

d. One tablet of 1000mg should be administered to the patient.

e. The drug should be prescribed with a generic name. The use of a generic name is better than using the trade name as it helps to prevent ambiguity and allows for the provision of suitable medication (Korb-Savoldelli et al., 2018).

f. It will be safe to discharge Dan when he is free from pain and with complete awareness and consciousness with no signs of trauma. When the pain of the patient decreases are and the patient is healthy, he can be discharged from the care setting (Kristensen & Kehlet, 2018). Since the patient has a pregnant wife, it is suggested that patient stays in care setting until complete recovery from fracture to ensure his well-being as his mobility will be impaired and will require assistance with permanent care.

g. The referrals that are required to safely discharge Dan include a referral from the physicians, that is, orthopedician who can assess the bone recovery, X-ray reports to validate the fracture recovery, and orthopedic associates like trauma specialists to ensure his neurovascular health (Gaughen et al., 2017).

Case Study 2

a. The six parameters associated with the patient that have increased her chances of fall in the hospital are her age (78 year old), absence of a walking frame, Rheumatoid arthritis that will cause pain in movement and may result in disbalance, Urinary Tract Infection that will cause urgency, vertigo that will cause dizziness, affecting movement in lack of walking frame, and Glaucoma that can affect her vision and cause difficulty in walking.

b. Nursing interventions would be, assistance in walking to provide support and prevent falls, assistance for bowels to prevent falls due to urgency generated by UTI, pain management for rheumatoid arthritis to support walking and minimize falls (Byun et al., 2020), and management of vertigo by promoting slow movements to prevent falls (Imoukhome et al., 2020).

c. Conscious state assessment of the patient should be done by classical Glasgow Coma Scale (GCS) assessment (Kupas et al., 2016). The GCS assessment should be done starting with visual abilities with eye-opening (E) and is scored out of 4. The spontaneous eye-opening in the patient is observed, eye-opening to sound is observed and is scored 3 where the patient is asked a question and talked to and the eye-opening response is observed. Eye-opening to pain is observed by applying pressure and is marked 2, no response for eye-opening in the patient is marked 1 (Waterhouse, 2017). The verbal response is assessed next where the orientation of the patient is checked with the response obtained.

If an oriented response is obtained, the patient is marked 5, if a response is obtained but it is confusing or doesn’t seem right, the patient is marked 4. If inappropriate or random words are used, the patient is marked 3. When incomprehensible sounds are obtained in place of an answer, the patient is marked 2, and no response is marked 1. The motor skills of the patient are also assessed. If the patient can do the physical activity as directed, the patient is marked 6, response to localized pain is marked 5, withdrawal response to pain is marked 4, abnormal flexion of the patient is marked 3, abnormal extension response is marked 2, and no response is marked 1(Waterhouse, 2017). Since the patient has vertigo, nystagmus assessment should also be done by assessing the gaze direction to ensure consciousness (Zhang et al., 2018).

AVPU assessment can also be done to assess the consciousness of the patient. If the patient is responsive and alert with idea of time, place, and the communication, the patients is marked “A”, that is, awake (Hoffmann et al., 2016). If the patient responds to verbal stimulation and is not entirely alert, patient is marked V. If the patient responds to pain stimulus and not through verbal or alert action, patient is marked P, and, if the patient is unresponsive, he or she is marked “U” (Hoffmann et al., 2016).

d. GCS score for eye response: 3, the verbal response by the patient: 4, Motor response of the patient: 6, the total score of 13 is obtained.

e: ISBAR

Identification: This is regarding patient Ms. Evans in the Emergency Department who was admitted with signs of weight loss, vertigo, and UTI after a fall incident that led to a laceration on her right anterior tibia.

Situation: The patient is currently showing signs of confusion, fever, and vertigo with significant weight loss. The patient has also experienced increased urinary frequency and has to be shifted to the wardroom 1B.

Background: Patient is 78 years old and possesses a history of hypertension, chronic heart failure, anxiety, glaucoma, Tinnitus, UTI, and rheumatoid arthritis. The patient visits regularly for wound dressing for a laceration after a fall last week. This was her third dressing. The patient is on a range of medications that include “Atenolol 50mg, Aspirin 100mg, Frusemide (0.5) 40mg BD and Alprazolam (0.5) 1mg BD”.

Assessment and action: The patient requires immediate aid and needs to be shifted to the wardroom as the health condition requires attention. The dressing for the laceration has been conducted. Further investigation will require shifting the patient to the ward. The GCS scale of the patient at present has fallen to 13. It is suggested that the patient is shifted to the ward so that further assessment can be done to obtain a clear diagnosis. The patient had a fall one week back, the consciousness of the patient requires monitoring due to the present condition of confusion. The cause of fever and weight loss needs to be determined as well.

Response: kindly arrange a physician address at earliest.

f. To take the medication orders accurately through phones it is suggested that the name of the patient and their date of birth are written to avoid confusion, the medication name and their strengths should be written accurately. To avoid confusion the generic name with nature of medication can also be written. The amount to be taken and the route of administration should be recorded. The amount to be provided by the pharmacy and the number of refills must also be noted with a record of physician identifiers (Vogelsmeier et al., 2017).

g. the format is to be filled by the client

h. The dose is ordered in 25mg and the strength available is 50mg. The medication can, therefore, be calculated as 25/50; half tablet.

i. A medication order is said to be valid if it adheres to the quality indicators for the preparation as well as medication administration. The safety in medication administration is ensured by the seven rights of medication administration. The seven rights include The right patient, right drug, right dosage, right time of administration, right route of administration, right reason, and right documentation (Jones & Treiber, 2018).

Case Study 3

a. The pain assessment using COLDSPAA is inclusive of the following elements: Character, onset, location, duration, severity, pattern, and associated factors (Claassens, 2017). The patient will be asked about the severity and intensity of pain. The onset of the pain and the duration is recorded. The onset in the case of Mrs. Edwards can be associated with her fall. To identify the nature of the pain, assessments are done to identify if the pain is radiating or non-radiating. The duration of the pain is recorded and the incidences of recurring are noted. The course or temporal pattern of the pain is noted. The character and quality of pain are determined. The aggravating or provoking factors associated with pain are also determined along with identification of associated symptoms for complete assessment (Dains et al., 2018).

b. Since the pain that is being experienced by Mrs. Edwards is mild, the management can be done by the administration of paracetamol. This is ideal as it is suitable for mild pain and safe with the anti-inflammatory and non-steroidal mode of action (Saragiotto et al., 2019).

c. Medication administration in the patients is protected by the rights that ensure safe administration. These rights include the right patient, right medication, right dosage, right time, right documentation. The right to refuse, right to assessment and right to evaluation are also included (Jones & Treiber, 2018). In the presented case, it should be ensured that the medication is administered is as per records with suitable dosage and time of administration. The documentation should be proper with readings about timings and dose administered to Mrs. Edwards. Pain assessment should be done regularly to identify the efficacy of the medication and suitable management interventions can be applied to assist the recovery and wellbeing of the patient (Miller et al., 2016).

d. The suitable nursing intervention for the patient will be to use relaxation techniques like cold or heat application and use of distractions to help in pain management. In extreme cases, it is suggested that the dose of medication for main management, analgesia, is altered after getting the approval and prescription of the concerned doctor (Sargent, 2020).

e. as per the medication record prepared for the patient, the first medication that requires administration is Hydralazine 50mg, to be administered orally for the treatment of hypertension. The second medication to be administered is Indapamide hemihydrate 2.5mg orally. The medication record is appropriate and identifies the patient as well as the prescriber accurately.

f. Assessment of medication should be done before the administration of the medication (Pratt & Roughead, 2018). The procedure of assessment includes an assessment of pain, respiratory assessment, and cardiac assessments. This allows identifying the degree of pain and the impact of medications so that the dosage can be altered. The cardiac and respiratory assessments are part of vital regulations and help in determining the impact of medication administered (Pratt & Roughead, 2018).

g. 50mg dosage is required for Hydralazine. The available stock strength is 25mg. Therefore, 2 tablets must be administered. 2.5 mg of Indapamide hemihydrate is required. Only one tablet will suffice as the stock strength is concordant with the required strength in prescription.

h. The suitable nursing intervention will be to assess the frequency and consistency of bowel movements of the patient. The medication that functions as a laxative and has enema use should also be noted with type and frequency. The dietary intake and fluid regulation of the patient must be noted. A diet poor in nutrition, limited fluid intake, and a sedentary lifestyle can also cause problems in the bowel movements. The patient may also present with intrinsic hindrances like fear of pain for which the underlying health condition should be accurately determined. The patient must be encouraged to increase her fluid intake and participate in physical activities and minimal exercises (Blekken et al., 2016).

i. The metabolism rate of an individual slows down with age. As Mrs Edwards is elderly and her movement is restricted due to her medical condition, the bowel may be restricted and can result in constipation (Hernández-Olivas et al., 2020).

j. Limited movement and lowered metabolism due to age is the suitable nursing diagnosis for constipation in the patient.

Case study 4

a. The precautions that must be taken include following hand hygiene protocols, using personal protective equipment (PPE), ensure the sanitized environment, following of infection control protocols, handling of patient equipment with care, maintenance of respiratory hygiene, and individual room placement for the patient (Gammon et al., 2019). This is done in special conditions where the medication condition of the patient is contagious with high possibilities of transmission. The body burns, in the case of Mr. Graham would have resulted in increased chances of exposure to the pathogen. Assessment is required for the presence of congenital conditions in the patient as it may result in compromised immunity. The standard PPE ensure that the chances of infection are minimized and sanitized protocol is followed as they are disposable with the use of biohazard protocol. The room must be isolated and sanitized frequently to ensure safety (Gammon et al., 2019). The safety protocols will minimize the chances of cross infections.

b. The patient must lie on back for the location of the apical pulse. The pulse is found at the left side of the chest in the fifth intercostal space at the midclavicular line (Zhao et al., 2020). Once the patient is on back, the sternal notch is located between the clavicles and is notched above the sternum of the patient (Douglas et al., 2016). The angle of Louis is identified using the index finger. The finger then slides to the second intercostal space. This is repeated until the fifth intercostal space is reached where the apical pulse is identified to be palpated through auscultation. A clean stethoscope is used and the diaphragm is placed at the identified pulse. The apical pulse rate is observed for one minute. In adults, it should be more than 60 beats per minute. If the pulse is weak, the patient is asked to lean towards left for better auscultations (Zhao et al., 2020). It is important to note the apical pulse auscultations as it can help in the identification that each beat is getting transmitted effectively (Douglas et al., 2016).

c. The “North American Nursing Diagnosis Association” is a process of nursing assessment that is crucial for the process of nursing diagnosis. The notes collected using this tool indicate that the patient is developing cardiac deterioration.

d. The patient shows clear signs of respiratory depression. Therefore, it is suggested that non-steroidal and non-inflammatory analgesia is provided for pain management other than Oxycodone as it can further worsen the respiratory depression of the patient.

Case study 5

a. The moments of hand hygiene have been established by the World Health Organisation that requires the following of the hand sanitation practice to ensure safety and minimize the chances of infection in the clinical setting (Sasko, Dixon & Smith, 2017). The hands of the healthcare practitioner must be sanitized before the patient is touched. The hands must be sanitized before performing an aseptic procedure so that a clean environment for the procedure is ensured. The hands must also be sanitized if there is an exposure or risk of exposure to the body fluids of the patient during any medical procedure. The hands must also be sanitized after touching the patient and patient touching the patient surroundings. Following the hand hygiene protocols ensures that the rate of cross infections in the medical settings is the limited and clean and safe environment is maintained in the clinical setting (Sax et al., 2017)

b. The documentation needs to be done by the client

The patient belongs to the category of review and rapid action. Since the condition is deteriorating, immediate assistance of a doctor is required.

c. The advantages include, first, recording of temperature from a safe distance. Secondly, it allows for measuring of temperature from the surface. Thirdly, multiple uses with a range of variation. The fourth advantage includes inbuilt memory, this will allow for recording the observations and provide a comparative analysis. Fifth, the device is compact and easy to transport or carry increasing its utility, and sixth, it is easy to use (Tamasaki et al., 2019).

The disadvantages of tympanic thermometers include (Taslaki & Gökgöz, 2018): First, it has marginalized accuracy, second, the degree can be impaired by the use of layer. Third, impurities like dust can hamper the reading of the device. Fourth, costly, fifth, reading can be affected by the external environment like humidity. Sixth, the device is based on sensors and therefore subject to a range of fluctuations.

d. The nursing assessment of the respiratory conditions should be done by thorough inspection and recording of observations. The respiratory rate of the patient is considered to be a vital sign of health (Kroschel & Demirakca, 2020). The healthy respiratory rate should fall between 12-20 breaths per minute. In the present case scenario, the patient has a high respiratory rate than normal indicative of a lack of adequate oxygen levels in the body. The lungs are respiring faster to accumulate more oxygen levels to maintain the saturation levels in the body. A pulse oximeter is used to record the observations of the oxygen saturation levels in the body. Respiratory acidosis is also measured by performing the atrial blood gas analysis (Tagami & Ong, 2018).

e. 27.7mL of Amoxicillin should be administered to the patient.

References

Blekken, L. E., Nakrem, S., Vinsnes, A. G., Norton, C., Mørkved, S., Salvesen, Ø., &Gjeilo, K. H. (2016). Constipation and laxative use among nursing home patients: Pevalence and associations derived from the residents assessment instrument for long-term care facilities (interRAI LTCF). Gastroenterology Research and Practice, 2016.

Bose, D. (2016). Management of open fractures in austere environments. In Orthopaedic Trauma in the Austere Environment (pp. 351-361). USA: Springer, Cham.

Byun, M., Kim, J., & Kim, M. (2020). Physical and psychological factors affecting falls in older patients with arthritis. International Journal of Environmental Research and Public Health, 17(3), 1098.

Claassens, T. (2017). Nursing a patient with acute pain. Kai Tiaki: Nursing New Zealand, 23(7), 15.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. United Kingdom:Elsevier Health Sciences.

Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus on core skills. Journal of Clinical Nursing, 25(13-14), 1890-1900.

Fulchini, R., Kohler, P., Kahlert, C. R., Albrich, W. C., Kuhn, R., Hoffmann, M., & Schlegel, M. (2018). Hand hygiene adherence in relation to influenza season during 6 consecutive years. American Journal of Infection Control, 46(11), 1311-1314.

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Gaughan, J., Gravelle, H., Santos, R., & Siciliani, L. (2017). Long-term care provision, hospital bed blocking, and discharge destination for hip fracture and stroke patients. International Journal of Health Economics and Management, 17(3), 311-331.

Hernández-Olivas, E., Muñoz-Pina, S., Sánchez-García, J., Andrés, A., & Heredia, A. (2020). Understanding the role of food matrix on the digestibility of dairy products under elderly gastrointestinal conditions. Food Research International, 109454.

Imoukhome, E., Weeks, L. E., & Abidi, S. (2020). Fall prevention and management app prototype for the elderly and their caregivers: Design, implementation, and evaluation. International Journal of Extreme Automation and Connectivity in Healthcare (IJEACH), 2(1), 48-67.

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Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal of Medical Informatics, 111, 112-122.

Kristensen, M. T., & Kehlet, H. (2018). The basic mobility status upon acute hospital discharge is an independent risk factor for mortality up to 5 years after hip fracture surgery: Survival rates of 444 pre-fracture ambulatory patients evaluated with the Cumulated Ambulation Score. Acta Orthopaedica, 89(1), 47-52.

Kroschel, K., & Demirakca, S. (2020). Parameters of Respiration. In Laser Doppler Vibrometry for Non-Contact Diagnostics (pp. 57-85). United Kingdom: Springer, Cham.

Kupas, D. F., Melnychuk, E. M., & Young, A. J. (2016). Glasgow coma scale motor component (“patient does not follow commands”) performs similarly to total glasgow coma scale

in predicting severe injury in trauma patients. Annals of Emergency Medicine, 68(6), 744-750.

Miller, K., Haddad, L., & Phillips, K. D. (2016). Educational strategies for reducing medication errors committed by student nurses: a literature review. International Journal of Health Sciences Education, 3(1), 2.

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Sax, H., Allegranzi, B., Pittet, D., & Boyce, J. M. (2017). My five moments for hand hygiene. Hand Hygiene: A Handbook for Medical Professionals, 134-143.

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Tagami, T., & Ong, M. E. H. (2018). Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when?. Current Opinion in critical Care, 24(3), 209.

Tamasaki, Y., Ueshima, H., Yoshiyama, S., Higuchi, S., & Otake, H. (2019). New tympanic membrane temperature shows good correlation with the esophageal temperature—accuracy of a noncontact continuous tympanic thermometer. Open Journal of Anesthesiology, 9(04), 51.

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Tasli, H., & Gökgöz, M. C. (2018). Does central tympanic membrane perforation affect infrared tympanic thermometer measurements in adults?. Journal of Otology, 13(4), 128-130.

Vogelsmeier, A., Anderson, R. A., Anbari, A., Ganong, L., Farag, A., & Niemeyer, M. (2017). A qualitative study describing nursing home nurses sensemaking to detect medication order discrepancies. BMC Health Services Research, 17(1), 531.

Waterhouse, C. (2017). Practical aspects of performing Glasgow Coma Scale observations. Nursing Standard, 31(35).

Woodard, J. A., Leekha, S., Jackson, S. S., & Thom, K. A. (2019). Beyond entry and exit: hand hygiene at the bedside. American Journal of Infection Control, 47(5), 487-491.

Zhang, P., Hou, X., Zhou, L., Zhu, X., Qian, L., Yuan, X., & Wang, J. (2018). Visual Eye movement-vestibular ocular balance assessment in the diagnosis of central and peripheral vertigo. Clinical Medicine of China, 34(6), 502-506.

Zhao, J., Jiang, W., & Zeng, R. (2020). Physical Examination of Chest. In Handbook of Clinical Diagnostics (pp. 169-203). USA: Springer, Singapore.

Hoffmann, F., Schmalhofer, M., Lehner, M., Zimatschek, S., Grote, V., & Reiter, K. (2016). Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting. Prehospital Emergency Care, 20(4), 493-498.

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