Nursing assesment and its role in care planning - Essay Example

?Nursing Assessment and Its Role in Care Planning Introduction A fracture is defined as the morphologic to the bone continuity or part of the bone such as the epiphyseal plate or cartilage (Chang, Daly & Elliot 2006, p. 303). A bone that is fractured increases the risk for trauma and infection as musculoskeletal system is highly vascular. Fractures frequently occur in female and elderly population, an example of which is the fractured neck of femur. According to Jester, Santy & Rogers (2011, p. 426), the term ‘fractured neck of the femur’ applies to the fracture of the proximal femur or hip fracture, which includes the trochanteric region and the femoral neck. Fractured neck of the femur is more common among older people and women who often presents to the emergency department following a fall or collapse (Jones, Endacott & Crouch 2003, p. 81). The 1990 incidence of hip fractures worldwide was 1.26 million and an estimated 2.6 million in 2025 and 4.5 million by 2050 are expected to populate the incidence of hip fractures among elderly (Carr, Layzell & Christensen 2010, p. 11). Affected individuals are likely to experience significant distress, physical pain, complications, and possible incapacitation. This paper will seek to discuss the typical presentation of a fractured neck of femur by facilitating prompt admission to trauma and orthopedic care and by conducting a rapid and comprehensive assessment of elderly people with fractured neck of the femur. In addition, multidisciplinary and ongoing community rehabilitation, as well as a supportive discharge will be addressed to promote safety and independence among elderly patients suffering from fractured neck of the femur. Nursing Assessment Patient X has been admitted to a trauma and orthopedic ward following a fall. Patient X is a 70-year old woman who was previously independent. The fall resulted in a fractured neck of femur (hip fracture). Patient X is assessed using the ‘FALLS’ assessment guidelines of the older person who has fallen. FALLS stands for falls history, assessment, locomotor problems, loss, and social circumstances and has been developed by Jones, Endacott, and Crouch in 2003. Falls history include time, location, mechanism, consciousness/recollection, method of raising alarm/rescue, and frequency/pattern of falls; assessment include emergency care fundamentals such as airway, breathing, circulation, disability, and exposure; locomotor problems include physiological effects of aging; loss refers to reduced or loss of vision; and social circumstances include history of social circumstances, support network people, and type of housing or social contact (Jones, Endacott & Crouch 2003, p. 82). Applying the assessment tool, the nurse has gathered the following assessment data: Patient X fell on the ground at 5:00 pm. She has been lying still on the ground for 3 hours in her house until help is sought by a concerned neighbor. Assessment of fall history revealed a misplaced placemat on the floor as a hazard for the occurrence of fall. The patient only regained consciousness when she’s in the hospital and clearly recollects incident of fall and other previous experiences. Patient X has no method of raising alarm/rescue and there were no other frequency/pattern of falls except for the current incident. Nursing assessment revealed a patent airway and a regular breathing pattern (20 breaths /minute). Circulatory perfusion is assessed using the neurovascular examination and found a 3 seconds toe capillary time which indicate that the circulation in the lower extremity are starting to be compromised (Brunner et al. 2009, p. 2100). Neurological assessment described Patient X as lethargic upon admission and GCS scores totaled to 12 because of lapses in verbal responses due to confusion and disorientation and withdrawal of motor responses when pain is experienced. A full physical assessment were done presenting fall impact on the lateral aspect of the hip, pain the groin with radiation to the knee, pain exacerbated by movement, and inability to bear weight. Core body temperature is 36.9 °C and there were neither history nor presence of postural hypertension. Medical records showed that Patient X was previously admitted to the hospital due to mild hypertension and diabetes mellitus but the client verbalized that it was not the reason of her fall because she kept track of her medication always. Using the Hendrich II Fall Risk Model illustrated by Boltz (2007 p. 2), risk factors for falls were assessed and identified and Patient X garnered a score of 6. A score of 5 or greater in the Hendrich II Fall Risk Model indicates that the patient is at high risk for falls (Boltz 2007, p. 2). In addition, Rubenstein (2006, p. ii38) also identified causes of causes of falls in elderly, among of which are: accident/environment-related, gait/balance disorders or weakness, dizziness/vertigo, drop attack, confusion, postural hypotension, visual disorder, and syncope. In Patient X’s case, accident/environment-related cause accounts for the fall of Patient X. To identify need for admission and further investigation, nurse providers used the Ottawa knee rules to assess need for further imaging. In Ottawa knee rules, patients need to have X-ray if she is more than 55 years old, has tenderness at head of fibula and patella, and unable to flex and bear weight (Hughes & Cruickshank 2011, p. 43). Patient X is positive from all Ottawa rules and therefore, warrants X-ray for further investigation. Based upon observation and results of laboratory tests, Patient X does not suffer from any nutritional imbalances or deficit. Drug history revealed taking Cardizem for hypertension and Metformin for diabetes. A collaborative approach is applied in the assessment of Patient X as referrals for full assessment were also asked from occupational therapist and social services. Potential effects of the fractured neck of femur to the patient were explored as there were no caretakers at home that would assist or help Patient X in recovery. The third nursing assessment is assessment for locomotor problems. Due to the physiologic effects of aging, joint movement of upper and lower limbs are unstable and movements such as walking, and sitting to walking were difficult for Patient X. In addition, posture, stance, and gait were poor due to the physiologic effects of aging. As stated earlier, visual disorders are known risk factors for falls. Patient X’s visual acuity is 20/70. No other visual disorders were noted upon assessment. Patient X verbalized that there was adequate lighting prior to the fall incident. Patient X also expressed her worries of how she would take care of herself when she got home as there were no relatives that would take care of her. Referrals to social services or voluntary services were discussed by the nurse and practical advices were given to prevent falls in the future. The last assessment focused on social circumstances. History revealed that Patient X has been living alone for the past 10 years. She is also an independent woman with no support from network relatives but only informal social circumstances with friends and neighbors. Patient X lives in an apartment with 1 bedroom and 1 comfort room, with adequate lighting and water needs, but housing arrangements are disorganized such as misplaced placemats, loose carpets, baths without handles, and wet floors. Aside from the FALLS assessment guidelines, pain, laboratory investigations, need for pressure relief areas, and referral were assessed by the medical and nurse practitioners. On the scale of 10 (0 = no pain and 10 severe pain), pain experienced of Patient X scored 6. Aside from X-ray of hip and pelvis, further investigations were conducted in terms of blood-urea and electrolytes, full blood count (FBC), and 12-lead ECG to rule out cardiac alterations as cause of fall. The condition of the mattress at home in the care setting were also assess to determine degree of comfort and further assessments in terms of referral were made in order to integrate care pathways or fast track pathways. Assessment Summary and Priority Nursing Care Comprehensive assessment revealed that the patient’s fall was caused by a misplaced placemat on the floor which had caused the accidental slips and fall of the client. History revealed previous admissions due to hypertension and diabetes mellitus, taking Cardizem and Metformin, and 10 years of living alone. Alterations in peripheral circulation were noted as evidenced by 3 seconds to capillary refill. In addition, physiologic effects of aging in locomotion and visual acuity were observed. Fears and worries were also expressed by the patient since there were no support groups to depend on. Priorities for nursing care include those of peripheral circulation, safe discharge, and independent rehabilitation. Independent rehabilitation presents that highest need of the patient both in short-term and long-term durations. Since the client is living alone for the past 10 years, it is essential that ambulation is optimized with little assistance as possible. An intensive and multidisciplinary rehabilitation effort can restore patient’s pre-fracture functional status and independent living (Magee, Zachazewski & Quillen 2009, p. 522). Even if the patient sustained a fracture that warrants surgery, it has been shown that effective rehabilitation predicts achievement of basic functioning, improvement of physical function and quality of life, and reduced disability (Magee, Zachazewski & Quillen 2009, p. 522). Interventions Before discussing in detail interventions needed for independent rehabilitation, health care needs in terms of circulation and safe discharge must be addressed first. Because Patient X’s circulation in distal areas was altered as evidenced by toe capillary refill 3 seconds, nursing interventions are geared towards restoration of normal vascular circulation. Thus, Basavanthappa (2003, p. 511) developed nursing interventions to improve tissue perfusion in peripheral areas, among of which are: perform patient assessment and monitoring which includes ABCs, C-spine and hemorrhage control to aid the nurse in discovering overt/covert changes in patient’s status at frequent intervals; perform neurological exam such as Glasgow Coma Scale and note vital signs at frequent intervals to early recognize changes and to provide timely and appropriate care; and perform capillary refill checks and assessment of neurovascular function of the immobilized extremity to determine status of tissue perfusion. After alterations in circulation have been resolved, the creation of a safe discharge plan is essential prior to independent rehabilitation. Davies & Wallace (2009, p. 67) identified the Department of Health’s key principles for an effective discharge which includes: used of whole systems thinking to ensure that assessment and care management considers both discharge planning and admission avoidance; active and equal partnerships between patients and carers in planning and delivering effective discharge to provide meeting of individual needs and opportunities for choice; involvement of acute hospitals, primary, and local authorities at earliest opportunity in discharge planning; coordination from all appropriate staff and significant others regarding pre and post admission; effective use of intermediate care and other facilities available within the localities to meet the patient’s individual needs and ensure that individual outcomes are maximized; and assessment and referral should be delivered as described within the national framework. The nurse has an important role in discharge planning thus, the nurse should possess good communication skills, knowledge of the services within the locality, and understanding of other healthcare professionals’ roles within the process. The core and key priority nursing interventions for Patient X is the need to address independent rehabilitation. Patient X feared that after suffering from fractured neck of femur, achieving independence would be difficult. Thus, a rehabilitation plan must be developed in order to return the patient to the pre-fracture status and achieve a quality life. Bracewell, Gray & Rai (2005, p. 37) identified WHO’s definition of rehabilitation as an active process by which people who are disabled by injury or disease achieve a full recovery or realize their optimal physical, mental and social potential, and integrate rehabilitation to the most appropriate environment. Rehabilitation of Patient X will cover not only restoration of physical functioning but the self-confidence of living independently as well. Rehabilitation is a complex process and the nurse is at the right position to deliver rehabilitative care while exercising effective leadership. Rehabilitation is especially important among elderly like Patient X as acute illness or injury such as fracture in older people has functional consequences especially in self-care and activities of daily living and the prevalence of disability increases as one ages. A nurse must ensure that rehabilitation of Patient X must be holistic, individualized, functional abilities-focused, not time limited, and has active, planned responses (Bracewell, Gray & Rai 2005, p. 38). Rehabilitation after a fractured neck of femur must be started as early as possible after surgery to promote independent mobility and function and collaboration between orthopedic surgeons, geriatricians, and other members of the multidisciplinary team. Early rehabilitation after a fractured neck of femur also focused on the prevention complications such as deep vein thrombosis, pressure sores, pneumonia and atelectasis, and constipation (Bracewell, Gray & Rai 2005, p. 44). In addition, Patient X can return to pre-fracture status and normal physiologic functioning at the earliest time possible and thus, fears regarding not being able to live independently will be alleviated. Rehabilitation after fractured neck of femur will need the collaboration of physiotherapist, occupational therapists, dieticians, and local support groups. Physiotherapists assess hip movement the day after surgery and isometric exercises of the unaffected leg and gluteals and quadriceps of the affected leg are begun. Bed transfer and mobility and assisted standing are begun in day 2 while walking exercises are started from day 3. Weight bearing is also taught at this point and depends on the type of fixation, bone quality, fracture location, and patient’s functional and cognitive ability. By week 2, patient may progress to wheeled walker and improved gait pattern may eventually be observed. Satisfactory outcomes will progress the patient to use of stick held at opposite hand. During this time, the nurse has a critical role in educating the client about avoidance of posterior dislocation. The nurse should instruct Patient X to avoid hip flexion over 90°, leg adduction past the midline, and combined movements of flexion and internal rotation. The nurse must also emphasize that exercise programs should be undertaken in longer term to improve balance and coordination and reduce the risk of further falls. On the other hand, occupational therapists assess and improve functional activities to facilitate independent living while dieticians provide the needed nutritional advice as most of the elderly patients suffering from fractured neck of femur are malnourished. Poorly nourished elderly patients may negative affect healing of fracture and outcome of rehabilitation (Bracewell, Gray & Rai 2005, p. 45). Conclusion Fractured neck of the femur or hip fracture applies to the fracture of the proximal femur which includes the trochanteric region and the femoral neck. Fractured neck of the femur is more common among older people and women and affected individuals are likely to experience significant distress, physical pain, complications, and possible incapacitation. The acronym FALLS served as assessment guidelines for older people who have fallen. FALLS stands for falls history, assessment, locomotor problems, loss, and social circumstances. The Hendrich II Fall Risk Model is used in assessing the degree of risk of falls among elderly population whereas the In Ottawa knee rules identifies the need for further investigation, imaging, or X-ray. The case scenario of Patient X identified nursing care needs in peripheral circulation, safe discharge, and independent rehabilitation. To improve tissue perfusion in peripheral areas, nurses need to: perform patient assessment and monitoring which includes ABCs, C-spine and hemorrhage control to aid the nurse in discovering overt/covert changes in patient’s status at frequent intervals; perform neurological exam such as Glasgow Coma Scale and note vital signs at frequent intervals to early recognize changes and to provide timely and appropriate care; and perform capillary refill checks and assessment of neurovascular function of the immobilized extremity to determine status of tissue perfusion. Discharge plans follow as tissue perfusion is resolved. An effective discharge plan follows the Department of Health’s key principles in discharge planning and is holistic, promote active and equal partnership, well-coordinated, and maximized to the full potential. Independent rehabilitation is the core and key priority nursing interventions for patients like Patient X with fractured neck of femur. Rehabilitation among elderly who lives alone is difficult as there were no support system to assist them after sustaining fractured neck of femur thus, a nurse must ensure that rehabilitation must be holistic, individualized, functional abilities-focused, not time limited, and has active, planned responses. In addition, the restoration of the pre-fracture state including the physical, mental, emotional, and social state is the overall goal of rehabilitation. Reference List Basavanthappa, B.T. 2003. Orthopedic Nursing. Medical Surgical Nursing, 1st ed. New Delhi: Jaypee Brothers Medical Publishers Ltd., pp. 460-516. Boltz, M. 2007. Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model. Hartford Institute for Geriatric Nursing, 8, pp. 1-2. Bracewell, C., Gray, R. & Rai, G.S. 2005. Principles of Rehabilitation. Essential Facts in Geriatric Medicine, Reprint ed. Oxon: Radcliffe Publishing Ltd., pp. 37-45. Brunner, L.S., Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. 2009. Management of Patients with Musculoskeletal Trauma. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, pp. 2091-2113. Carr, E., Layzell, M. & Christensen, M. 2010. Nurse-led femoral nerve block service for patients with fractured neck of femur. Advancing Nursing Practice in Pain Management. West Sussex: Blackwell Publishing Ltd., pp. 11-26. Chang, E., Daly, J. & Elliot, D. 2006. Musculoskeletal Health Breakdown. Pathophysiology Applied to Nursing Practice, Reprint ed. New South Wales: Elsevier Australia, pp. 295-324. Hughes, T. & Cruickshank, J. 2011. Back, pain, hip, and knee injuries. Adult Emergency Medicine at a Glance. New Jersey: Blackwell Publishing, pp. 42-43. Jester, R., Santy, J. & Rogers, J. 2011. Regional Musculoskeletal Injuries. Oxford Handbook of Orthopedic and Trauma Nursing. New York: University Press, pp. 385-442. Jones, G., Endacott, R. & Crouch, R. 2003. Emergency Care of the Older Person. Emergency Nursing Care: Principles and Practice. California: Greenwich Medical Media Limited, pp. 75-90. Magee, D.J., Zachazewski, J.E. & Quillen, W.S. 2009. Hip Pathologies: Diagnosis and Intervention. Pathology and Intervention in Musculoskeletal Rehabilitation. Missouri: Saunders Elsevier, pp. 497-527. Rubenstein, L.Z. 2006. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing, 35-S2, pp. ii37- ii41. Wallace, C. & Davies, M. 2009. Applying Theory to Practice. Sharing Assessment in Health and Social Care: A Practical Handbook for Interprofessional Working. City Road: SAGE Publications Ltd., pp. 49-90. Read More