The paper is critically analysing and reasoning the case study of Mrs Deborah Scott. This paper is using the research skills to present the effective nursing care for the patient. The evidence-based information is being implemented with the support of the contemporary Australian nursing practice. The paper is presenting two care priorities of the patient and presenting them with comprehensive discussion and justification for presented nursing interventions. This is being achieved using the Levitt-Jones’ Clinical Reasoning Cycle.
Patient situation & health information
Mrs Deborah Scott is a 65-year old woman who has been admitted into the Public hospital’s emergency department (ED) post her falls. She was found by her husband lied on the bedroom floor. She has been admitted for the third time due to fall in past six months. The couple lives with a pet dog. According to the chest x-ray, Mrs Scott has broken ribs and injuries to her chest wall. Her medical history includes type II diabetes mellitus – insulin dependent; osteoarthritis; hypertension; and chronic obstructive pulmonary disease (COPD). She is on multiple medication regime.
Processing gathered information
Fall is a complex form of multifactorial phenomenon. For normal gait, fine neural networks like basal ganglia–brainstem system, cortical–basal ganglia loop, proper sensory information processing and exquisite musculoskeletal structures plus regulated muscle tone are necessary (Pasquetti, Apicella & Mangone, 2014). These components need to be effectively coordinated with adequate concentration and cognition to prevent falls. With age, several of these functions decline that raise fall risk. With ageing, likelihood of more accumulation of medical problems and linked medications increases, and this increases fall risk. Ageing reduces gait velocity and step length, reduces lower limb strength and makes wider base (Vitor et al. 2015). Such changes become most pronounced while waking over irregular surface. Thus, the fall occurs due to the interactions between short-term and long-term predisposing factors and the varied short-term precipitating factors (like adverse drug reaction, acute illness and trip) in the environment (Pasquetti et al., 2014).
Falls are the key cause of disability and morbidity in the elderly people. Vitor et al. (2015) suggests that more than 1/3rd of people of age 65years and above fall annually and in 50% of these cases falls are recurrent as evident in the case. This risk doubles or triples when person has chronic illnesses or cognitive impairment (Vetrano et al., 2016). Osteoarthritis damage hips, knees and sore and stiff the joints. This interfere mobility and balance and raise fall risk as evident in Mrs Scott’s case. There is decreased function due to stiffness and every step makes patient bear 80% of the body weight on a single limb (Saelee & Suttanon, 2018). For compensation, patient shortens stride or widens step impairing balance. Painkillers and antidepressants raise the fall risk by 22% and Mrs Scott takes these medications. These medicines cause drowsiness, dizziness and confusion (Saelee & Suttanon, 2018).
Identify the problem
The first identified problem is the risk of trauma certainly another falls as she has increased susceptibility that can harm her physically. It is because of loss of skeletal integrity due to fractures, weakness in body, lack of bone fragment movement, and if she tries to get up without help. The second identified problem is acute pain as most potential. This unpleasant emotional and sensory experience can occur from tissue damage and sudden or slow onset of the intensity of mild to severe pain with predictable or anticipated end. Due to fracture and injuries to chest wall, she might have muscle spasms, edema, injury to soft tissues, and stress and anxiety due to injury.
The first goal is to assure that Mrs Scott is able to maintain stabilization and alignment of fracture and demonstrate body mechanics that promote stability at fracture site within 48 hours to assure better recovery and no trauma. The second goal is that Mrs Scott verbalizes relief of pain or no pain and display relaxed manner.
For risk of trauma, the most efficient intervention is to maintain bed rest and limb rest with the support for joints above and below the fracture site when turning and moving specifically (Price, Gandhi & Duane, 2018). This will provide her stability, decrease the plausibility of disturbing alignment and muscle spasms to improve healing. Secondly, her fracture site should be supported with folded blankets or pillows with the maintenance of neutral position of impacted part with splints, footboard or sandbags (Reuben et al., 2017). This avoids unnecessary movement and alignment disruption. Accurate placement of pillows can avoid pressure deformities within drying cast. Third, Mrs Scott should be positioned to assure appropriate pull maintenance over the long axis of the bone (Price et al., 2018). This promotes bone alignment and decreases risk of complications. Forth, she should be observed and evaluated for splinted extremity for resolution of edema. It is because coapation splint or Jones-Sugar tong may be utilized for providing immobilization of fracture if excessive tissue swelling is present (Huber, 2017). With subsiding edema, readjustment of splint or plaster application may be needed for consistent alignment of the fracture. Fifth, it is also necessary to assess the integrity of Mrs Scott’s external fixation device. The Hoffman traction gives stabilization and the rigid support in terms of fractured bone with no use of pulleys, ropes, or weights. This permits greater patient mobility, facilitate wound care and comfort patient (Jones, Hamilton & Murry, 2015).
For risk of pain, first, Mrs Scott’s level of pain must be assessed and recorded with the use of pain intensity rating scale inclusive of Wong Baker FACES pain rating scale, FLACC (face, legs, activity, crying, consolability) scale, and visual analog scale (Bérubé et al., 2017). The aggravating and relieving factors with nonverbal pain cues like alterations in vital signs, behaviours and emotions must be noted closely. This influences the intervention effectiveness. Several factors like level of anxiety can impact pain perception. Anxiety is very much probable as Mrs Scott is aged, has several chronic problems and is undergoing huge physical stress (Dries, 2018). Second, Mrs Scott should be encouraged to discuss issues associated with the injury. It assists in alleviating anxiety and she may also feel the need for relieving accident experience. This will keep her anxiety low and this will help in keeping pain aside (Dries, 2018). Third, Mrs Scott needs emotional support and she must be encouraged for using the stress management techniques of progressive relaxation, guided imagery, deep-breathing exercises, or visualization with supervision or should be provided with therapeutic touch (Bérubé et al., 2017). This will help in refocusing her attention and promoting a sense of control and will also be able to improve her coping capabilities in managing stress of traumatic pain and injury that is possibly to persist for the extended period (Dries, 2018). Forth, if Mrs Scott is put on IV patient-controlled analgesia (PCA) with the use of peripheral, intrathecal or epidural routes of administration, then it needs to be maintained and monitored effectively with effective and safe infusions and equipments (Huber, 2017). The routine administration or PCA maintains the adequate level of blood analgesia, the prevention of any fluctuation in pain relief that is linked with muscle tension and spasms (Potter et al., 2016).
Her serial X-rays need to be done to assure better evaluation of recovery in fractured area and injured part. This gives visual evidence of accurate alignment or the start-up of callus formation as well as healing process for the determination of the accurate level of activity and the requirement for alterations in or the extra therapy (Jones et al., 2015). Moreover, her daily feedback about her caring procedures, nursing support and physical capability needs to be evaluated twice to acknowledge if there is any possibility of falls or imbalance if she gets up without support or even with support (Potter et al., 2016). Her mini mental status examination should also be done everyday for a fortnight time and every third day till she recovers fully to acknowledge that her mental status is stable and to define if there is any possibility of mental trauma causing higher risk of falls (Bérubé et al., 2017). For evaluating the interventions for pain management, her pain needs to be assessed subjectively and with closer observation of her body language to define if her pain is relieved well or not. Effective communication plays the critical role to get updates about patient health openly and honestly (Jones et al., 2015).
This experience has presented a new learning that anxiety and stress of the patient directly and greatly impacts the health outcomes and promotes the pain perception. Effective decision making is possible only when patient is consistently observed and interventions are constantly evaluated with equal patient involvement (Huber, 2017). It is necessary to maintain immobilization strictly of the affected areas as it relieves pain and avoids tissue injury extension and bone displacement. When patient starts recovering, it is essential to put patient in mobilization slowly and steadily (Bérubé et al., 2017).
Mrs Scott has been shifted to medical ward under Dr Peter Thai and the registered nurse has the utmost and most imperative role in managing Mrs Scott certainly with the implementation of geriatric nursing skills. The nurse has to understand patient’s health from varied possible domains and then identify the key issues and prepare the plan effectively for better results.
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