Assessment Task:

Nursing Assessment Answer

Clinical reasoning scenario

Mr. Richards is a 79-year-old man, undergoing surgical repair of a fractured hip. He has no known living relatives. He was living at home independently when he slipped and fell in the bathroom, fracturing his right neck of femur. He was on the floor for an indeterminate amount of time prior to being found by a neighbour, who came to check in on him. The ambulance was called. Paramedics found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Mr Richards had sustained a small scalp laceration over his right temporal region, which was clotted by the
time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure. The paramedics also noted Mr Richards Webster pack has not been opened this morning.

Upon arrival in the emergency department, the patient is evaluated by orthopaedic, cardiology, and neurology specialists. His history was reviewed and revealed a previous open-heart procedure 8 years ago, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and malodourous, indicating poor personal hygiene. He has a list of medications in his wallet, which identifies the following drugs: Digoxin, Simvastatin, Frusemide, Potassium Chloride, Metoprolol and Timolol eye drops.

Mr Richards greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anaesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anaesthesia. The orthopaedic surgeon performs the fractured hip repair. Mr Richards is transferred back to the ward. His hip is positioned for optimum healing. His vital signs are: blood pressure 182/105 mm Hg, pulse 102 beats per minute, respiratory rate 26 breaths per minute, oxygen saturation 89% on 4 litres nasal prongs, and core temperature 34.5°C. GCS 13/15 (E 3, V4, M6). No urine is noted in the Foley catheter. He has a right peripheral cannula, a belovac drain in situ which has drained 20mls of blood-stained fluid.

 

Task:
You are the registered nurse caring for Mr Richards following his surgery. Apply the clinical reasoning cycle to this case study to establish a plan of care for Mr Richards. Use the headings of the clinical reasoning cycle to guide your thinking. Not all phases of the cycle need to be responded to.

  1.  You do not need to include an introduction or conclusion.
  2.  You must use the headings provided below.
  3.  Your responses must be written in full sentences and adhering to academic convention (no use of personal pronouns).
  4.  Approved nursing abbreviations and acronyms are allowed.
  5.  Your responses need to be supported by a minimum of 10 current (less than 7 years) in total. Peer-reviewed and scholarly sources are to be used.

 

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  • Posted on : November 14th, 2018

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