Implement and Monitor Nursing Care for Clients with Acute Health Problems - Case Study Example

Implement and monitor nursing care for with acute health problems Part A Clinical Manifestations Third-degree burns seen in Harold includethe following: Skin on his anterior lower leg and superior of his left foot appears pearly white and leathery Harold does not feel anything at all (no pain, no sensation) on his lower leg and superior of his left foot 2. Second degree burns on left knee and left thigh manifest the following symptoms: Blisters on burnt areas Painful sensation on burnt areas which he grades at 9 out of 10 (on a scale of 1-10, 10 being the most painful) on the Visual Analogue Scale Burnt areas appear tender and are reddish Burnt areas appear moist 3. First degree or superficial burns on his left hip, left buttock, left arm Redness Tenderness Pain rated as 5 out of 10 (on a scale of 1-10, 10 being the most painful) on the Visual Analogue Scale Slight swelling Effects on ADLs I would anticipate that the above clinical manifestations would affect his activities of daily living (ADLs) in the sense that he would be having difficulties in accomplishing them. Since he has burns mostly at the left side of his body, he would have difficulties in moving about, in walking, getting to and from the bathroom, in bathing, in eating, and in grooming himself. Many parts of his body would be tender and may be painful when touched; therefore, it would be very awkward for him to do his daily activities without touching his skin and even possibly injuring himself further in the process. Harold’s injuries would limit his mobility and would confine him for a while to a bed or to a chair (University of Virginia “Physical Medicine & Rehabilitation). He would likely need assistance for all his activities – from his waking to his sleeping hours. I would involve Harold’s family in meeting his self-care needs by placing them on shifts. I can ask his wife to sleep in a separate bed, but still be in the same room as her husband in order to assist Harold in his ADLs. However, since Harold’s wife has initial manifestations of Alzheimer’s disease, she cannot be left with Harold for prolonged periods of time. Members of the family can take shifts in helping care for Harold. His children and grandchildren can be asked to assist Harold in performing his ADLs. They can help groom him, assist him to and from the bathroom, and keep him company. This can help ensure that Harold would not be bored and his morale always kept up. This would also ensure that his burns would not get infected or be subjected to further injury. The grandchildren have to be taught the proper ways of assisting and caring for their grandfather by demonstrating to them the proper ways of grooming and assisting in order not to subject Harold to further injuries. Assessment Data Assessment Rationale 1. Determine the depth of tissue damage (Springhouse & Lippincott, p. 619) To give an idea of the severity of the burn and level of management needed 2. Assess patient for infection at burned areas (Hom, et.al., p. 184) To prevent infection and assess for early signs of infection 3. Assess metabolism. Burn victims are in a hypermetabolic state. (Hom, et.al., p. 184), which increases their risk for prolonged inflammation, cardiac dysfunction, infection, sepsis, and death (Bankhead “News by Specialty) To enable early treatment of the inflammatory response, insulin resistance, catabolism, and cardiac dysfunction (Bankhead “News by Specialty”). 4. Assess nutrition To ensure that patient is adequately nourished with proper electrolyte and nutritional balance, in order to allow for optimal healing and to prevent infection (Hom, et.al., p. 184) 5. Assess for emotional or psychological trauma (post-traumatic stress disorder) (University of Virginia “Physical Medicine & Rehabilitation”) To ensure that the patient is emotionally coping well with his current medical condition and with the traumatic incident which caused his present injuries Preoperative Care The preoperative education that I would give to Harold would include the following: 1. Explaining to Harold the debridement process – how the procedure would be undertaken, the risks of the procedure, and the ultimate goal of the surgery. This would help reduce the patient’s anxiety and stress about the procedure (Steele, et.al., p. 55). 2. Instructing Harold not to eat or drink anything for at least 12 hours before his surgery (Steele, et.al., p. 56). 3. Instructing Harold on what he can expect during the surgery itself. I would explain to Harold why intravenous access will be needed before the surgery; the surgical skin preparations that have to be undertaken before the surgery; and the need for preoperative procedures; the type of anesthesia which would be used on him; what he can expect to feel from said anesthesia before, during, and after its induction; and how the patient can rate and express pain sensations he may experience before and after the induction of anesthesia (Steele, et.al., p. 56). Preoperative checklist The nurse has to ensure that the following preoperative procedures are carried out. This list is based on Timby (p. 623). 1. Documented history and physical examination 2. Name of procedure in the surgical form matches the scheduled surgery in the operating room 3. Surgical consent form is signed by the patient or his proxy. 4. Laboratory results have been retrieved and reported in cases of abnormal levels seen 5. Patient wearing an identification bracelet 6. Allergies and blood type identified and clearly seen in the patient’s chart 7. Patient was NPO for 12 hours before the procedure 8. Skin preparation completed 9. Vital signs assessed and documented in patient’s chart 10. Dentures, nail polish, glasses, contact lenses, hairpins, jewelry, wedding ring has been removed 11. Patient wearing a hospital gown only with hair covered 12. Client has urinated 13. Location of IV, and type of IV solution is identified, with rate of infusion indicated 14. Preoperative medication as ordered is already given. Postoperative nursing interventions Intervention Rationale Evaluation 1. Monitor vital signs every 15 minutes or as ordered To detect hypotension, hyperthermia, and prevent complications such as shock (Aschenbrenner & Venable, p. 209) V/s monitored every 15 minutes as ordered 2. Maintaining respiratory support To ensure adequate metabolic oxygen supply to the body’s cells (Aschenbrenner & Venable, p. 209) Oxygen supply delivered via nasal cannula 3. Keep patient warm To prevent hypothermia and shock Patient wrapped in blankets and warmers placed on bed 4. Monitor for bleeding To prevent blood loss Bandages checked for soaking every 15 minutes 5. Placed patient on right side-lying position To prevent aspiration No aspiration when patient vomited 30 minutes after the operation Part B Responsibilities of an Enrolled Nurse Responsibilities Rationale 1. Medication endorsement a. compliance with the requirements of Poisons and Therapeutic Goods Act (Nursing Midwifery Board, p. 1) b. medication administration only with the supervision of the registered nurse (Nursing Midwifery Board, p. 1) To ensure that medications endorsed are within legal parameters 2. Monitoring and recognizing normal and abnormal vital signs from patient (Funnell, p. 9). To ensure that the patient’s vital signs are within normal ranges and to report possible abnormal manifestations 3. Monitor impact of nursing care and maintain constant communication with the registered nurse (Funnell, p. 9). To ensure that the care being administered to the patient is appropriate and effective. To ensure that the actions being taken by the enrolled nurse are within the parameters of the enrolled nurse’s responsibilities 4. Provide support and comfort to the patient; as well as assist the client in his ADLs (Funnell, p. 9) To keep up the morale of the patient and to ensure that the patient does not cause himself further injury while undertaking his ADLs To “enable clients to achieve their optimal level of independence” (Funnell, p. 9) Urgent assessments that I need to do on Harold after he becomes unresponsive and unconscious, would be to assess his pulse and respiration. I would also assess his airway for possible obstruction. This immediate assessment would help determine his vital signs and if life-saving measures shall have to be performed on him. Basic, and even advanced life saving techniques, work best if they are administered on a patient immediately. I would also assess his level of consciousness including his response to pain sensation. I would immediately report my observations to the registered nurse. If he is manifesting respiratory and/or cardiovascular failure, the proper resuscitative interventions shall then be performed for the patient. However, such interventions have to be reported to the RN for proper action. The Registered Nurse would also decide if the attending physician needs to be notified about the patient’s condition. My role during these procedures would be to assist the RN and the attending physician. Any actions and interventions I would be administering to the patient have to be monitored by the RN. And the actions I can perform for the patient have to be within my competence as an enrolled nurse (Funnell, p. 9). My interventions are limited because I do not have adequate training for the procedures which would be undertaken in behalf of the patient. Overstepping the bounds of my training might injure or even endanger the patient’s life. Nursing Care Plan Intervention Rationale Evaluation 1. Monitoring of his vital signs at baseline and every hour thereafter To assess fluctuations or changes in vital functioning; and to detect early signs of possible infection (Rosdahl & Kowalski, p. 1398) To maintain normal levels in vital signs 2. Monitor for signs of infection To eliminate or minimize infection of wounds or burns (Herndon, p. 478) Wounds or burns not infected with good signs of healing 3. Monitor for signs of bleeding To prevent blood loss (Drain, p. 611) No blood loss and no signs of bleeding or discharges from wounds and burns 4. Clean wounds and change dressing daily and as needed To prevent infection and check wound for bleeding (Herndon, p. 478) Wounds and burns not infected, not bleeding, and healing well 5. Administer pain medications as ordered To minimize or eliminate pain and to improve pain and reduce discomfort of patient (Loeser & Bonica, p. 785) Minimal or no pain felt by patient 6. Assist in ADLs To keep the patient properly groomed, to assist him in regaining independence in his daily activities, to prevent further injuries to patient while performing ADLs (Atchison & Dirette, p. 257) Patient is well-groomed, slowly regaining his independence in his ADLs, and incurs no further injuries while performing his ADLs 7. Intravenous Therapy To allow sufficient fluid perfusion (Brunner & Suddarth, p. 634) Patient adequately hydrated without signs of dehydration or even overhydration (Brunner & Suddarth, p. 634) Discharge Plan Intervention Rationale Evaluation 1. Wound Management by family members or by the caregiver (daily cleaning of wound and daily change of dressing) To prevent infection and allow for immediate wound healing (Herndon, p. 478) No signs of infection and healing wounds and burns within a week after discharge 2. Pain and Itch Relief (analgesics) To promote healing and patient comfort (Loeser & Bonica, p. 785) Minimal or no pain at all 3. Exercises (range of motion exercises) To prevent burn scar contractures (Atchison & Dirette, p. 257) No burn scar contracture 4. Emotional support for patient and his family (counseling for family and for patient) To prevent depression and improve coping skills of the patient and his family (Bryant & Nix, p. 284) Well-adjusted patient and family members 5. Assistance from family in patient’s ADLs To help the patient regain independence in his ADLs and to encourage participation of family members in caring for the patient (Atchison & Dirette, p. 257) Patient is able to regain independence in his ADLs. Works Cited Aschenbrenner, D. & Venable, S. “Drug Therapy in Nursing”. p. 209. 2009. Pennsylvania: Lippincott Williams and Wilkinson Pennsylvania Atchison, B. & Dirette, D. “Conditions in occupational therapy: effect on occupational Performance”. p. 257. 2007. Pennsylvania: Lippincott Williams & Wilkins Bankhead, C. “Burn Size Predicts Hypermetabolic Response that Drives Mortality Risk”. News by Specialty. 23 August 2007. MedPage Today. 19 October 2009. Brunner, L. & Suddarth, D. “The Lippincott manual of nursing practice”. pp. 631-635. 1986. Pennsylvania: Lippincott Williams & Wilkins Bryant, R. & Nix, D. “Acute and chronic wounds: current management concepts”. pp. 284-383. 2007. Missouri: Elsevier “Burns”. Physical Medicine & Rehabilitation. 5 July 2007. University of Virginia. 19 October 2009 Drain, C. “Perianesthesia nursing: a critical care approach”. p. 612. 2003. Missouri: Elsevier Health Science Funnell, R. “Tabbners nursing care: theory and practice”. p. 9. 2005. New South Wales: Elsevier Australia Griffith, H., et.al. “Complete Guide to Symptoms, Illness & Surgery”. p. 197. 2006. New York: Penguin Group. Herndon, D. “Total burn care”. p. 478. 2007. Missouri: Elsevier Health Science Hom, D., et.al. “Essential Tissue Healing of the Face and Neck”. p. 184. 2009. Connecticut: People’s Medical Publishing House Loeser, J. & Bonica, J. “Bonicas management of pain”. p. 785. 2001. Pennsylvania: Lippincott Williams & Wilkins “Medication Endorsement for Enrolled Nurses”. p. 1 . (n.d) Nursing Midwifery Board. 19 October 2009 Rosdahl, C. & Kowalski, M. “Textbook of basic nursing”. p. 1398. 2008. Pennsylvania: Lippincott Williams & Wilkins  Springhouse & Lippincott Williams & Wilkins. “Critical care nursing made incredibly easy”. p. 619. 2004. Pennsylvania: Springhouse, Lippincott Williams & Wilkins Steele, S., et.al. “Ambulatory anesthesia and perioperative analgesia manual”. pp. 55-56. 2005. USA: McGraw-Hill Timby, B. “Fundamental Nursing Skills and Concepts”. p. 623. 2009. Pennsylvania: Lippincott Williams and Wilkins   Read More