Nursing Planning and Implementation

Question: Discuss about theNursingfor Planning and Implementation. Answer: Introduction S.R was a 24-year-old female who suffered the injury while skateboarding. The patient had suffered a fall at the time of skatiing, leading to the injury. She had been transported by the ambulance when she was stabilised. Later she was moved to the emergency ward of the hospital. She had suffered her fractured right femur. She was found to have suffered trauma. The present case study analysis details the nursing actions for the patients. The paper outlines the social history and background of the patient, the diagnosis made, an overall examination of the patient, and management of the patient. The nursing management encompasses assessment, planning, implementation and evaluation. The paper ends with a logical conclusion that gives an overall appraisal of what has been learnt from the case study. Diagnosis The patient had been complaining of immense pain in the right leg and was not able to move the leg. She had suffered the fracture as well as severe soft tissue injury in the leg due to the traumatic event. The case was of a high-energy traumatic event as she had fallen while skateboarding and the severity of the injury had made a great impact. According to Crane et al. (2014), the majority of traumatic events caused due to activities like skateboarding are suffered by young adults. Predominantly advanced skateboarders suffer fracture commonly due to direct-impact, high energy falls or collision. These lead to severely comminuted fractures. The patient had no drug allergy. She had suffered a fracture in her right hand when she was six years old. Social History/ Background An overall background assessment was carried out at the time of admission to the unit. The patient had been a regular smoker with 5-6 packets of cigarettes a week. She also had been drinking alcohol on the social basis and was not a regular drinker. She was unmarried and lived with her parents and her younger brother in their three bedroom apartment. She was a graduate and worked at a multinational company in her hometown. Overall Examination Assessment for the social history and the background of the patient was followed by a clinical assessment. A thorough physical examination was carried out for the patient. The weight of the patient was 55 kgs, and the body mass index was 32.6 kg/m2. The fasting capillary glucose was 166 mg/dl. Blood pressure on the right arm was 154/96 mmHg while lying and 140/90 mmHg while sitting. Her pulse was 87 bpm while her respiration rate was 21 per minute. Upon further examination it was noted that her pupils were reactive to light, there was an absence of retinopathy and arteriolovenous nicking. Her thyroid was palpable, and lungs were clear to auscultation. Heart rate and heart rhythm were regular with no gallops or murmurs. The clinical assessment included questions on what led to the injury and the presenting symptoms. The presenting symptoms were evaluated. The patient was examined for ecchymosis and swelling and the point of tenderness. Any secondary complaints were noted. After an X-ray examination, it was indicated that the patient had suffered a femur fracture, particularly a femoral shaft fracture. The Glasgow Coma Scale (GCS) was applied for assessing the level of consciousness for the student. The patient scored a 7 in this scale. The GCS is a neurological scale that provides an objective and reliable way of understanding the level of consciousness of an individual (Barker et al. 2014). The Pain Quality Assessment Scale (PQAS) was utilised for assessing the severity of pain of the patient. The PQAS is a short instrument used for quantifying the intensity and quality of pain. The common areas looked after by this assessment numbness, tenderness, throbbing, radiating, cramping and aching (Stang e t al. 2014). Management of Patient The femur, commonly the femur bone, is the largest tubular bone in the body. It is the most proximal bone present in the leg in tetrapod vertebrates. The head of the femur is in alignment with the acetabulum in the pelvic bone that forms the hip joint. The distal part of the femur is in alignment with the kneecap and the tibia that forms the knee joint. This is the strongest bone present in the human body (Gosling et al. 2016). A femur fracture is a break in the femur bone. The fracture in the femur can be in either of three areas-the main shaft of the bone, the lower end of the bone near the thigh and the head or neck of the bone. Femur injuries occur when a high-force blow takes place on the area. This can be due to a collision with an object or a fall (Gedmintas et al. 2013). A femoral fracture takes place in the femoral diaphysis between 5 cm proximal to the adductor tubercle and 5cm distal to the lesser trochanter. Large muscles circumferentially pad the femoral shaft. The femor al shaft gets its vascular supply from the profunda femoral artery. The nutrient vessels enter the bone along the linea aspera. The periosteal vessels also supply blood. After a femoral shaft fractures there is a disruption of the blood supply. In such case, the peristeal vessels undergo proliferation for acting as the main source of blood supply in order to achieve healing. Healing of the fracture is fast if there is no compromise in the blood supply (Ficco and Nowotarski 2015). Vcsei (2014) explains the mechanism of injury for femoral shaft fracture. The patterns of fracture indicates the type of force that had been exerted for producing the break. Spiral fractures result from falls. In such cases, the foot is often found anchored, and a twisting force transmits to the femur. Oblique and transverse fractures are results of direct violence or angulation. These are more common in road accidents. In case of severe violence, the break may be in more than one place. In the present case, the patient has suffered a spiral fracture. A femur fracture leads to extreme pain in the upper leg. Patients commonly suffer from swelling in the hip area, and are inable to move the leg or stand. A change in the bone area is common. A localised clotting of blood leads to discoloration, and this condition is known as a hematoma. Severe bruising is due to rubbing against the surface on which the patient suffers the fall (Gosselin et al. 2014). The patient in the present case had severe bruising in the area and had blood clotting in three areas. She also suffered muscle spasms in the thigh. Upon assessment, it was found that there was numbness and tingling in the leg. The nursing care needs of the patient were identified. The patient had no significant breathing problems. The nutritional status of the patient was well-balanced, and therefore there was a need of maintaining the nutritional level through proper diet and fluid intake. She had impaired mobility and was at high risk of falls due to impaired mobility. The patient was at risk for a number of complications. According to Nikose et al. (2015), there are a number of complications that arise after a femoral shaft fracture. Nerve injury is less common in femoral shaft fractures. The most common complication after injury is a vascular injury. Such injuries occur due to tethering of the artery of the femor at the adductor hiatus. The patient also suffered risks for infections, blood clots and fat embolis. The nursing care priorities included addressing the patients need and stabilising the patients condition. Neurological checks were carried out very 2 hours. Signs of neurological changes indicated serious complications for the patient. Intravenous fluids D5 1/2 NS were administered at 100 mL/hr. The rationale for administering IV fluid is multi-faceted. Physical trauma often leads to dehydration. It is vital that patients have a balanced level of rehydration through the fluid intake. Management of pain with medications is effective when the patient is not dehydrated. Blood loss is common after surgery and for maintaining proper circulation of blood, it is pivotal to have proper rehydration level (Hoste et al. 2014). The patient was provided with the ice pack and her right upper as well as lower extremity was elevated. This was done to reduce swelling and decrease the chances of compartment syndrome (Giannoudis and Pape 2014). According to Kirkpatrick et al. (2013) compartment syndrom e is a condition occurring in patients when a pressure in muscles reaches extreme levels. The impact of the pressure is significant decrease in the flow of blood, thereby hindering the supply of oxygen and nutrition to the muscle cells and nerves. The patient was administered Morphine sulphate 5 mg intravenously on a regular interval of 4 to 6 hours. Morphine is a sedative that acts to relieve pain in patients. The drug is a first line choice of drug for pain management (Tripathi 2013). Neurovascular checks were carried out every 1 hour for ensuring that the patient was not showing progress towards compartment syndrome (Schaffzin et al. 2013). The patient was also administered Cefazolin 880 mg intravenously at 6-hour intervals for ensuring that the patient did not get infections that lead to further medical complications (Satoskar, Rege and Bhandarkar 2015). Deep breathe, cough and incentive spirometer (IS) assessments were carried out at every 2 hours. Optimal oxygenation was maintained. Following the assessment and basic pain management, the patient underwent surgery. Femur fractures are treated on the basis of fracture pattern. The choice of treatment for femoral shaft is generally intramedullary nailing (Guo et al. 2016). After the surgery and after the patient was transferred to the ward appropriate post-procedural care was taken. On the second day of surgery, the patient was encouraged to move the leg with the help of proper support. Early hip range of motion was encouraged. Recognition of the cognitive and developmental need of the patient was crucial so that her status continued to improve. The discharge planning consisted of follow-up care. The discharge summary and information sheet contained the care providers contact number for cases of emergency. The list of medications was outlined in details, and the routine for medications was explained to the patient as well as the family members. It was advised to appoint a social worker in case of need. All queries that the patient and the family members had were addressed sufficiently (Potter et al. 2016). The patient was referred to a dietician for maintaining the nutrition level. It is important that patients after traumatic injury has an increased calorie intake and maintains the level of hydration. The diet chart recommended had a balanced level of protein, carbohydrate, lipid, vitamin, calcium and macromolecules like zinc and iron. An occupational therapist was appointed to help the patient with her da ily activities of living at home (DiCenso, Guyatt and Ciliska 2014). A physical therapist works with a patient suffering a fracture to increase the mobility and have enhanced quality of life (LeMone et al. 2015). A therapist began teaching particular exercises to the patient while she was in hospital. The therapist was about to visit the patient at her home after her discharge to teach her how to use crutches and a walker. Patient education forms a major element of a discharge plan for all patients so that self-care in fostered. A patient also has the right to be aware of the potential complications arising from her condition and the implications for future care (Butcher et al. 2013). The patient was also educated to reinforce care. Proper reporting of pain was taught, and the patient was taught to carry out self-neurovascular cheks. Any sign of infection had to be reported. Physical retrictions had to be maintained. The evaluation of the nursing intervention demonstrated the success of the interventions. The patient had significant relieve from pain as the patient complained of pain less often. The consciousness level was also increased. The patient had signs of normal appetite and fluid intake. She was satisfied with the interventions provided and was found to be in the positive state of well-being. Conclusion The above case study analysis was a valuable one for getting insight into the adequate management of femoral fracture injury. I learnt that pain after injury is a natural process and that pain management should be the key focus for such cases. Nursing interventions should always put the emphasis on providing the patient with a comfortable environment so that the healing process is faster. I also realised that collaboration with other health care professionals is always beneficial for achieving best health outcomes for patients. My future practice would be guided by the lessons learnt from the present case study. References Barker, M.D., Whyte, J., Pretz, C.R., Sherer, M., Temkin, N., Hammond, F.M., Saad, Z. and Novack, T., 2014. Application and clinical utility of the Glasgow coma scale over time: a study employing the NIDRR traumatic brain injury model systems database.The Journal of head trauma rehabilitation,29(5), pp.400-406. Butcher, H.K., Bulechek, G.M., Dochterman, J.M.M. and Wagner, C., 2013.Nursing interventions classification (NIC). Elsevier Health Sciences. Crane, C., Heron, J., Gunnell, D., Lewis, G., Evans, J. and Williams, J.M.G., 2014. Childhood traumatic events and adolescent overgeneral autobiographical memory: Findings in a UK cohort.Journal of behavior therapy and experimental psychiatry,45(3), pp.330-338. DiCenso, A., Guyatt, G. and Ciliska, D., 2014.Evidence-based nursing: A guide to clinical practice. Elsevier Health Sciences. Ficco, R.P. and Nowotarski, P.J., 2015. Femoral shaft fractures.Encyclopedia of Trauma Care, pp.607-614. Gedmintas, L., Solomon, D.H. and Kim, S.C., 2013. Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systematic review and meta?analysis.Journal of Bone and Mineral Research,28(8), pp.1729-1737. Giannoudis, P.V. and Pape, H.C. eds., 2014.Practical procedures in orthopaedic trauma surgery. Cambridge University Press. Gosling, J.A., Harris, P.F., Humpherson, J.R., Whitmore, I. and Willan, P.L., 2016.Human anatomy, color atlas and textbook. Elsevier Health Sciences. Gosselin, R.A., Quasem, F. and Zirkle, L.G., 2014. Trauma of the Hip and Femoral Shaft. InGlobal Orthopedics(pp. 187-201). Springer New York. Guo, Y.C., Feng, G.M., Xing, G.W., Yin, J.N., Xia, B., Dong, Y.Z., Niu, X.Q., He, Q. and Hu, P., 2016. A meta-analysis of flexible intramedullary nailing versus external fixation for pediatric femoral shaft fractures.Journal of Pediatric Orthopaedics B,25(5), pp.466-470. Hoste, E.A., Maitland, K., Brudney, C.S., Mehta, R., Vincent, J.L., Yates, D., Kellum, J.A., Mythen, M.G. and Shaw, A.D., 2014. Four phases of intravenous fluid therapy: a conceptual model.British journal of anaesthesia,113(5), pp.740-747. Kirkpatrick, A.W., Roberts, D.J., De Waele, J., Jaeschke, R., Malbrain, M.L., De Keulenaer, B., Duchesne, J., Bjorck, M., Leppaniemi, A., Ejike, J.C. and Sugrue, M., 2013. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome.Intensive care medicine,39(7), pp.1190-1206. LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L. and Reid-Searl, K., 2015.Medical-surgical nursing. Pearson Higher Education AU. Nikose, S., Arora, M., Singh, P.K., Shrivastava, S. and Taywade, S., 2015. Treatment of femoral shaft fractures in young children by Enders nail: indications complications. Potter, P.A., Perry, A.G., Stockert, P. and Hall, A., 2016.Fundamentals of nursing. Elsevier Health Sciences. Satoskar, R.S., Rege, N. and Bhandarkar, S.D., 2015.Pharmacology and pharmacotherapeutics. Elsevier Health Sciences. Schaffzin, J.K., Prichard, H., Bisig, J., Gainor, P., Wolfe, K., Solan, L.G., Webster, L. and McCarthy, J.J., 2013. A collaborative system to improve compartment syndrome recognition.Pediatrics,132(6), pp.e1672-e1679. Stang, A.S., Hartling, L., Fera, C., Johnson, D. and Ali, S., 2014. Quality indicators for the assessment and management of pain in the emergency department: a systematic review.Pain Research and Management,19(6), pp.e179-e190. Tripathi, K.D., 2013.Essentials of medical pharmacology. JP Medical Ltd. Vcsei, V., 2014. Femoral Shaft Fractures. InBone and Joint Injuries(pp. 265-296). Springer Berlin Heidelberg.