An Important Role of a Nurse - Case Study Example

Running head: Post Surgical Elderly (Hemiarthroplasty with secondary complication) Nursing case Nursing Case Study You’re The case presented here, is about a female elderly patient admitted to this hospital for Left Hip Hemiarthroplasty, intra-operatively patient manifested complications that include pulmonary oedema, acute myocardial infarction and hypocalemia. She is recently transferred to an orthopaedic ward for further nursing treatment. Our primary aim in this paper is to establish an effective care plan to be implemented to address identified health issues and promote wellness to this patient. The implementation of this care plan is an important role of a nurse especially in critical situation such as this case at present. The primary aim shall be focused on the critical health issues affecting the ABC’s (airway, breathing and circulation) of life, where wellness shall be promoted, discomfort be alleviated and complications be prevented with in the duration of her stay inside the hospital. As part of a nurse’s care, an effective well comprehended discharge plan shall be discussed both to the patient’s daughter as well as the patient herself for home treatment. One of the most important tasks that a nurse assumes in the medical industry is to make sure that the patient shows optimum if not maximum health conditions prior to discharge. It also her duty to provide health education unto the patient and the patients significant others for a thorough out patient care, one that is understood by both in terms of semantics, relevance and importance so as to be religiously followed. Nursing Care Plan for Patient Tee Focused Assessment: Admitted to my ward 3 days post surgery, 77 years old Patient Tee is currently in 2 litres oxygen therapy with 99% saturation via nasal prong. Chest x-ray indicates that the lower lobe of the lung has collapsed with a sputum microscopy that revealed a few gram positive Vancomycin resistant enterococcus. The patient also suffers from dysphagia characterized by post swallowing cough as well as dysphonia. Physical mobility is likewise restricted possibly due to fatigue and or fear of pain. While patients pre-hospitalization history already reveals poor nutrition, as verified by her daughter’s statement that the patient refuses to eat her meals, this is much heightened with the presence of dysphagia (Medline and Mayo clinic home page. 2006). The patient’s micro culture and sensitivity results tested positive on Enterococcus species, although there is no sign of elevated temperature as of the moment. The initial focused assessment that shall be made by interviewing patient Tee’s of her present condition in order to gather information related to how and what she is feeling, taking into consideration dysphagia, pain (if any), breathing and communication ability, her appetite, urine and bowel movement, and the reasons for inability and her description of the intensity of pain/discomfort, as part of my acquisition of subjective data. As a nurse the observation that will take into account my own objective assessment will include, her breathing pattern, willingness to move about, range of movement, coherence and affect; her response to touch as well as the psychological manifestation of how she feels about her recent conditions and finally verifying this observations with laboratory results Nursing Diagnosis with rationale: Ineffective breathing pattern and impaired gas exchange secondary to collapse of the left lower lobe of the lung as evidenced by the decrease in oxygen saturation in the blood whenever oxygen pattern is removed (Orem, 1980. p.11). Activity intolerance related to shortness of breath as well as fatigue related to impaired oxygen exchange system. Anxiety related to feeling of suffocation and possible fear related to disabling respiratory deficiency. Impaired verbal communication secondary to dependence of prong/masked O2 inhalation and lastly chronic or situational low self esteem related to loss of normal respiratory function (Taylor, 2005 p. 1357- 1414). Gas exchange in the respiratory system refers to the intake of oxygen and the release of carbon dioxide through a process called respiration and perfusion. The exchange takes place via diffusion in which gas moves from an area with higher concentration onto one that has less. The greater pressure of this oxygen inside the alveoli causes the oxygen to move into the capillaries. Similarly, the carbon dioxide in the returning venous blood exerts more pressure than that of the alveoli, which thus causes exhalation. Surface area is among the factors that makes such process possible, thus where alterations or aberrations occur, is consequential to the inability of lung expansion. The expected outcome of the above would be for the patient to manifest signs of improve gas exchange through the cessation the demonstration of a pulse oximetry reading of more than 95% without O2 therapy (nhlb, 2006). Preserve pulmonary function by maintaining optimal ADLs (Activities of Daily Living), one that is identifiable and achievable (according to range of patient’s capabilities). For patient to manifest self care behaviours that provides relief from symptoms (Orem, 1980. p.6), alleviation of stress and other psychological factors that intensify further pulmonary crisis and ultimately for the improvement of psychosocial, physical and spiritual dimension to prepare patient Tee for discharge 2 weeks post surgical treatment (Wotton, 2002). Intervention would include, proper monitoring of oxygen therapy to make sure of an uninterrupted alternative oxygen supply (Curtin. 2003). Comprehensive health teaching to the client and significant other, regarding the importance of pollution free environment for the prevention of future pulmonary complications especially after discharge as well as the promotion of optimal function that fosters stress management, anxiety alleviating and proper breathing (The Chartered Society of Physiotherapy. 2002) techniques. It is also important to emphasize regular return consultation with physician for further prognostic check. Diagnostic map Intra-operative pulmonary oedema ● ● ● Lower left lung collapsed myocardial infarction (due to impaired oxygenation supply to other organs ● Decrease surface area for gas exchange ● ● Fatigue and impaired physical mobility Water retention in the lungs ● Presence of phlegm in the airways irritates membrane that forces immune system to expectorate this through cough thereby irritating the linings, causing inflammation and dysphagia ● Presence of phlegm in the airways alters taste buds affecting appetite ● Inadequate nutrition ● Impaired/deficient resistance of the immune system ● High risk/possible infection (VRE) ● UTI Difficulty in Swallowing Consequential to pulmonary oedema and lower left lung collapse, phlegm is likely to be trapped in the debris of the airways causing it to become constricted thereby forcing the normal body defences to produce cough reflex necessary for expectoration. In the event that phlegm passes through the buccal cavity, altering the normal taste buds. Persistent cough causes the bronchial lining to inflame, making swallowing difficult. This will all the more worsen because of the inability to swallow water which could be effective to soften cough and flushes out whatever bacteria trapped within the body (Porth, 2004 and Taylor et al, 2005). As an intervention, since there has been a prescription of ensure fluids, is a need for such to be continued until nutritional status stabilizes. This fluid drink is vital not only in keeping fluids regularly coming into the body, but the nutritional effects of such is vital to nutrition since there is inadequacy of the solid food intake at this point. There is also a need to continue the antibiotic round the clock to address problems on infection. Urinary Tract Infection As far as my analysis is concern, there is a possibility that the development of UTI can be attributed over the fact that the patient tested positive of Enterococci in the patient’s urine test, therefore it points us to the possibility if VRE otherwise known as Vancomycin Resistant Enterococci. “Enterococci are normal inhabitants of the human gastrointestinal tract”. Other major sites of colonization that may act as reservoirs for enterococci in hospitalized patients or patients with postoperative wounds, and while it they are seldom found in pure culture in wounds, but when they are, there is a possibility that this will spread along the digestive pathways. Since Digestion ends via the process of excretion (i.e., urine or feces) there is this likelihood that these pathogens proliferated secondary to urethral catheterization. While at this point, the patient does not manifest any clear inclination to severe prognosis, much can be said about its predisposition. It is but significant then, to point this out as another health issue that posses Mrs Tee at great risk. As a nurse on duty, one of the intervention to address this issue would be the promotion of increase fluid intake and electrolyte balance as well as promoting and maintaining normal micturition and illumination process (Porth. 2004). Highlighted by encouraging patient to increase oral intake of soft foods including the prescribed ensure drink. Since it has been identified earlier that patient’s mobility is restricted, this can be done in the aid of bed pans (when catheter is removed), in order to flush out the pathologic cause of this problem. Again, it should be emphasized to the patient as well as the significant other, the religious adherence to antibacterial medications along with proper nutrition upon discharge (Taylor et all, 2005 p 1308). Discharge Plan Must include, plotting out nutritional diet plan for patient and alternative food preparations should appetite still prove inefficient upon discharge. Another relevant plan would health education more particularly in the aspect of adherence of medication and the promotion of unpolluted environment. Part of the health education must pay emphasis on regular hygiene to be incorporated in the patient’s activities of daily living. The patient should also be encouraged to move about to foster optimum circulation. Most of this discharge plan is dependent upon the cooperation of the client, which when not present could lead us back to recurring problems in the aspect of infection. With particular consideration to the patient’s age, not to mention her impaired psychosocial disposition, if the nurse is unable to extract patient’s concurrence to the effectiveness and importance to the outcome, health condition of the patient will not improve (Timiras. 2003). Pharmacologic Treatment Medication currently taken by the patient includes the following items stated below, with particular elaboration of its rationale, contraindication, side effects, normal dosage and schedule as below" Pantoprazole = is used to treat damage to the oesophagus associated with gastroesophageal reflux disease by reducing excessive stomach acid production contraindicated for those who are know to have allergic reaction to omeprazole, lansoprazole, pantoprazole, other medicines, foods, dyes, or preservatives as well as liver disorder. Interacts with ampicillin; delavirdine, iron salts, itraconazole, ketoconazole. Expected side effects may include diarrhea; nausea, dry skin, headache and stomach pain or gas. Diltiazem 240mg od oral = for treatment of angina and hypertension contraindicated for patient under beta blocker treatment Isosorbide mononitrate 60mgs oral mane = for treatment of angina pectoris and acts by dilating the blood vessels so as to reduce the blood pressure also increases supply of oxygen to the heart by dilating the arteries which supply the heart itself. To be taken twice daily, with the two doses taken 7 hours apart. Interacts with anti depressants, antipsychotics and benzodiazepines like valium or morphine. Side effects may include headache and at time nausea and vomiting. Atenolol 50mg od op GTN spray sublingual x 1 prn = are Beta blockers that are competitive inhibitors and interfere with the action of stimulating hormones on beta-adrenergic receptors in the nervous system. Works by competing for receptor sites on cardiac muscle and slows down the strength of cardiac contractions reducing its oxygen requirements and the volume of blood it has to pump. Side effects includes, bronchospasm, GI effect, fatigue and blurring of vision Symbicort (Budenoside/efornoterol 100/200) twice daily = inhaled treatment for asthma, combines in a single inhaler two active ingredients:* budesonide (Pulmicort), an anti-inflammatory corticosteroid* formoterol (Oxis), a rapid-acting and long-lasting bronchodilator. Simvastatin 10mg nocte = used to reduce cholesterol with dose range 20 - 80 mg. Reduce cholesterol to < 5mmol/l or by 30%, whichever is the greater. Caution should be exercised when combining simvastatin with any CYP3A4 inhibitor like Erythromycin, Clarithromycin, Telithromycin. Vitamin B12 1000mcg IMI twice weekly = its primary functions are in the formation of red blood cells and the maintenance of a healthy nervous system by an insulating fatty sheath comprised of a complex protein called myelin. B12 has very low toxicity therefore no overdose may cause alarm. This is required to be maintained on adequate levels in the elderly and in patients with a diagnosed deficiency. Salbutamol nebulisers 1:3 prn = are used in the treatment of asthma and the reversible element of airways obstruction commonly found in chronic obstructive airways disease (COAD). The have a similar molecular structure based on the isoprenaline molecule, which produces bronchodilatation, relaxation of the uterus and tremor. In the treatment of mild asthma, the agents are given by inhalation as the aerosol or powder for the relief of symptoms or prior to exercise. Allendronate one tablet weekly = is used to prevent and treat certain types of bone loss (osteoporosis) maintains strong bones by slowing bone loss helps to reduce the risk of fractures in elderly. Taken orally once daily, before taking in any food, beverage or other medications. Side effects include stomach pain, constipation, gas, or nausea. Calcitrate 600mgs once daily oral = are used to ensure an adequate intake of calcium during important periods of bone growth. In adults, calcium is used to prevent osteoporosis. Taken orally with a large glass of water during or after a meal. Side effects in over dosage include nausea, vomiting, loss of appetite, constipation, stomach pain, thirst, dry mouth, increased urination. Interacts with tetracycline, quinolone and antibiotics. Betamethasone Valerate cream to right forearm for rash = for prophylaxis of skin infections where long term uses decreases the production of natural hormone in the adrenal gland. Morphine 10mgs IMI 4/24 prn = for pain relief, to reduce anxiety post-infarction and in pulmonary oedema basically for more rapid onset of action, and less nausea Start with 5mg - 10mg as slow IV bolus, followed if needed by a dose of 2.5mg - 5mg at intervals of 5-10 min until pain is relieved. The dose should be reduced or morphine should be discontinued if toxicity (hypotension, respiratory or CNS depression) is observed.  Once total dose of 20mg/4hrs has been reached contact medical staff for review, lower dose is favoured for frail or elderly patients and in patients with hepatic and renal disease. Tramadol 50-100mgs QID - maximum 400mgs per day oral/IMI/SC = used as an analgesic for treating moderate to severe pain. Contraindicated to patients who are allergic to tramadol or other narcotic pain medications such as meperidine (Demerol), morphine, codeine (or medications that contain codeine such as Tylenol with Codeine), hydrocodone (e.g., Vicodin), hydromorphone (e.g., Dilaudid), oxycodone (e.g., Percocet), propoxyphene (e.g., Darvon, Darvon N), any other medications. Side effects among others include dizziness, nausea, diarrhoea and constipation. Panadol 1Gm QID oral/PR regularly = an analgesic used for the fast, effective temporary relief of pain and discomfort associated with headache, period pain, colds and flu, tension headache, backache, and muscular aches. Suitable for asthmatics who are sensitive to asparin and non-steroidal anti-inflammatory drugs (NSAIDS) References Curtis, R. and Timiras, P. (2003). The Physiological Basis for Aging and Elderly 3rd ed. CA:CRC Press. Curtin, L. (2003). An integrated analysis of nurse staffing and related variables: Effects on patient outcomes. Online Journal of Issues in Nursing. Retrieved December 3, 2004 from http://nursingworld.org/ojin/topic22/Tpc22_5.htm Difficulty Swallowing (27 May 2006) Mayo Foundation for Medical Education webpage. Retrieved 27 May 2006 from http://www.mayoclinic.com/health/difficulty-swallowing/DS00523 Karth, A (2006) Nursing Drug Guide. New York:Lippincott Williams & Wilkins Mengel, M. and Schwiebert, L. (2005). Family Medicine: Ambulatory care and Prevention. UK: McGraw-Hill Publishing Orem, D.E. (1985). Nursing: Concepts of practice (3rd ed.). New York: McGraw Hill Porth, C,M. (2004) Essentials of Pathophysiology: Concepts of Altered Health States. Philadelphia:Lippincott Williams & Wilkins. Powell HDW. (1960).Simultaneous bilateral fractures of the neck of the femur. J Bone Joint Surg (Br).42:236-52. Simon, RR and Koenigsknecht, SJ. (2001) Emergency Orthopedics: The Extremities 4th ed. UK: McGraw-Hill Publishing. Taylor, C., Lillis, C and Lemone, P. (2005) The Fundamentals of Nursing 5th. Ed. PA: Lippincott Williams and Wilkins Taylor LJ, & Grant SC.(1985). Bilateral fractures of the femoral neck during a hypocalcemic convulsion: A case report. J Bone Joint Surg(Br). 42:536-7 The Chartered Society of Physiotherapy (April 2002). Activity And Exercise In Selected Populations. Retrieved on 27 May 2006 from world wide web http://www.csp.org.uk Wotton,K. (2002). Selecting a Nursing Theory for Clinical Practice: Analysis and Critique. In Nursing Theory in Australia: Development and Application. (2nd Ed.). J. Greenwood (ed). Frenchs Forest, NSW.: Pearson Education . Read More