HLT54115 Nursing : Examine Existing Documentation Provided

Consider the patient situation

Miss Jane Green is a 30 year old female who was hit by a car that ran a red light whilst she was crossing at a pedestrian crossing.  The impact caused Jane to been thrown into the kerb resulting in an obvious left lower leg fracture.  She has just arrived on your ward from the emergency department.  You introduce yourself to the patient and ask how she is going. She winces visibly but answers that she is worried about her mother  who is in the early stages of dementia and for whom she is the sole carer.  You also notice that she has a bad graze on her left shoulder. The time is 0800.

Collect Cues

Review:

Examine existing documentation provided.

From the review of progress note  for Miss Green, it has been found that the patient is currently in severe pain. However, review of past medical or family history is not available except the facts that patient’s was given morphine for good effect. As part of the nursing assessment and care planning process, the review of patient’s medical chart and patient history is important to collect all patient information and get guidance regarding other cause behind certain symptoms observed in patient.

Gather new information (patient assessment):

Upon undertaking a further assessment of Miss Green you obtain the following new information:

Vital signs

BP: 155/90   

Pulse: 107bpm

RR: 22

Sa02: 97%

Temp: 36.6

Other data

GCS: 15

Pain score: 9/10 on movement. 8/10 on rest

Patient becoming anxious in regards to her mother’s welfare.

Neurovascular assessment

Capillary refill rate of >3 seconds.

Complaining of tingling in the toes of left leg

Increased pain at rest and upon passive movement of affected limb

Left leg appears more pale than right leg

Recall:

Recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring before proceeding with the rest of the cycle (self-directed) 

Process Information

Interpret:

List the data that you consider to be normal/abnormal below (not included in word count)

Normal

Abnormal

<<insert text here>>

RR

SpO2

Temp

Capillary refill rate

<<insert text here>>

BP

Pulse

Pain

Neurovascular parameters

Relate & Infer: 

· Relate the two most significant abnormal findings to the underlying physiology/pathophysiology to justify why it is considered abnormal in this context.

·  Based on your interpretation of all the information/cues presented, form an overall opinion on what may be happening and justify your answer (400 words).

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Miss Jane had suffered lower leg fracture after being hit by a car and a backslab was applied after the admission to the hospital.  After the review of vital sign assessment record and neurovascular assessment record, it can be said that paleness of the left leg and tingling sensations of the left leg are two abnormal findings for patient.

The patient was having tingling sensation on the left leg or suffering from parasthesia due to the effect of trauma related injury. The peripheral sensory nerves are responsible for carrying sensation from different parts of the body to the brain, however problem in the pathway between trigeminal nerve and brain stem result in parasthesia.  Such pathway was affected in case of Miss Jane because of leg injury or pressure on the nerve of the leg. This condition is mostly seen in patient because of infection, inflammation or trauma (Sharif-Alhoseini, Rahimi-Movaghar and Vaccaro 2012). Hence, this condition needs to be managed in patient as it may result in neurological disease or traumatic nerve damage in the future.

Palor or discoloration of the skin of the leg might be seen in patient is seen due to the body response to injury. When patients like Miss Jane fracture any part of the body due to a car accident, they experience physical trauma. Due to the effect of such trauma,  the nerve and muscles of the leg was affected and this resulted in cessation of blood supply to the leg muscle. Because of these physiological changes, symptom of paleness of the left leg was observed in patient. Blood flows to the superficial vessels of legs are responsible for color of skin and paleness is seen due to little blood flow to the affected area of low oxygen level in the blood (Stephen, Sen  and Lees 2016). Both these abnormal signs are indication of neurovascular complication in patient.

After collecting cues and review of overall assessment data for Miss Jane, it can be said that the patient is suffering from the immediate effect of physical trauma caused by injury and lower leg fracture.  Due to the damage to the nerve muscles of the leg and blood flow restriction, tingling sensation and paleness of skin are major concern for patient. Due to the effect of injury, the vital signs of patient like respiratory rate, blood pressure and pulse rate of patient was also affected. This might be happening because of damage to the nerve muscles of the leg which has affected the sensory response system and the blood flow to the leg. This has resulted in discoloration of the leg and tingling sensation in patient (Sharif-Alhoseini, Rahimi-Movaghar and Vaccaro 2012).Hence, for Miss Jane, management of these two conditions are necessary.

Predict:

What may happen to your patient if you take NO action and why? (100 words)

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If no action is taken to treat symptom of parasthesia, then it may increase the risk of permanent neurological damage or traumatic nerve damage in the future. The sensation of pain in patient will be altered too.  Due to peripheral neuropathy, the patient is likely to fall too due to poor balance and coordination (Finnerup et al. 2015).

If to no action is taken to address paleness of skin and pain, then patient may suffer severe complications like born deformity, swelling in the legs, permanent nerve damage and muscle and ligament damage. Hence, management of pain and paleness of skin should be a major nursing priority for recovery of Miss Jane (Frink et al. 2010).

Identify the Problem/s

List in order of priority at least three key nursing problems (not included in word count)

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The three important nursing problem in order of priority are as follows:

1. Management of parasthesia in patient due to peripheral neuropathy

2. Management of chronic pain

3. Management of paleness of left leg of Jane Green

Establish Goals & Take Action

From the above (identify problems), use the top 2 nursing problems identified and for each of these establish one goal and then list related actions you would undertake, including detailing any relevant nursing considerations (350 words)

Evaluate outcomes & Reflect on new learning

Briefly describe how you would evaluate the effectiveness of the care provided (i.e. what do you want to happen?) and reflect on how this encounter has informed your nursing practice if you were to encounter a similar situation in the future (150 words).

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The main purpose of the above nursing action is to provide pain relief to patient and increased the level of discomfort that the patient was facing due to leg fracture.  The effectiveness of the nursing action can be understood when the patient  the patient has no tinglinging sensation and changes in color of the skin. Improvement in symptom will also be understood by low pain score and improvement in mobility of patient. Hence, by implementing pharmacological and non-pharmacological intervention for pain relief and peripheral neuropathy related compliacation, wound healing will be promoted and patient will be able to mobilize very soon. By the experience of preparing care plan for Miss Jane, I have learned that the technique involved for pain relief is also essential to promote quick mobilization of patient. In the future, I aim to learn more about non-pharmacological technique of pain relief so that I can effectively handle emergency case of patient with fracture.