Case scenario
A nurse’s role is often simply defined as a helper, caregiver attending to patients’ needs in the hospital. Nursing, however, is more complicated in the responsibility of caring for patients while being a conduit and connection route for health professionals in different departments. For nurses to provide holistic and comprehensive care, the nursing process is applied. This approach ensures management if patient-oriented by utilizing the principles of nursing intuition and critical thinking to provide quality care with compassion. The nursing process involves assessment, diagnosis, planning, implementation, and evaluation.
Patient Introduction
The patient, Mr. JO (pseudonym), is a 68-year-old male presented in the emergency room of royal Melbourne hospital five weeks ago with a fractured left leg and accompanying pain. He also has a history of transient ischemic attacks (TIA), high blood pressure, type 2 diabetes mellitus (T2DM) managed by diet, hypercholesterolemia, and allergy to strawberries and Kiwi fruit. He lived with his wife in the period preceding his admission. He currently takes the following medications to manage his pre-existing conditions; simvastatin (40 mg), Aspirin (100mg), and Telmisartan (80mg). The patient lacked the previous history of surgery and was admitted to the rehabilitation ward following his total hip replacement (THR) surgery.
Patient assessment
The head to toe outline was applied during patient assessment. Consent was obtained from the patient. Personal protective equipment was appropriately used together with the hand hygiene protocol. The patient was of good nutritional state and could communicate with the staff needing no translator or interpreter.
Central nervous system
Upon admission, a neurological exam was performed. Mr. JO was oriented in person, place, and time. The patient scored a 0 in the 4AT test for cognitive impairment. He scored a 15 in the Glasgow coma scale indicative of a good state of health of higher centers of the brain. Both pupils reacted equally to light stimulus. Vision and hearing were normal, with no need for aids. Upper limbs showed normal strength and range of movement.
The left lower limb exhibited impaired movement and some degree of immobility owing to the pain at the fracture site. The patient rated the pain of 7/10 according to the numerical pain rating scale.
Cardiovascular system
Patient’s heart rate was elevated as demonstrated by the weak and thread radial and apical pulses. The patient is under medication for high blood pressure. Both S1 and S2 heart sounds were present on auscultation. The extremities were well perfused, with no signs of pallor observed. In addition, no fluid retention and peripheral edema were observed. Peripheral lines at the right and left cubital fossa were inserted on admission with no associated disease seen at these sites.
Venous thromboembolism risk assessment was also performed. The patient was at a high risk of formation of thrombosis due to the major THR surgery, his age, and due to the immobility following the fracture.
Respiratory system
Patient’s respiratory system was normal, indicated by the average respiratory rate of 16 breaths per minute. There was no evidence of the use of accessory muscles during breathing, showing no extra breathing work. The oxygen saturation was normal above 96%. On auscultation, breathing sounds were normal, and the patient had no cough present. No tenderness was elicited upon palpation, with the symmetrical expansion of both lungs noted.
Renal system
The kidney function was normal, demonstrated by the reasonable rate of urine production. Urine was of normal volume, opacity, and color on gross examination. No tenderness was elicited upon palpation of the kidneys. The patient reports no pain or difficulty during voiding, nor does he have symptoms of urgency.
Musculoskeletal system
Patient’s fall risk was assessed and was established as moderate, owing to a score of 2. The patient has a history of a fall in the past year and needs monitoring and assistance as he moves.
Integumentary system
The integumentary system was in good shape, aside from the skin tear at fracture wound and later incision site of the surgery. Pressure injury evaluation was performed in which the patient scored 14. This indicates a moderate risk of pressure injuries formation following the guidance of the Braden scale. The patient’s ability to react to discomfort from pressure was slightly limited. The patient was on bed rest and thus not active, and his mobility was limited. His skin was rarely moist, and his nutritional status was evaluated as likely to be inadequate. Despite the absence of pressure sores, the patient was deemed to be at a high risk of developing pressure injuries.
Endocrine system.
The patient reported to having type 2 diabetes, which he managed through diet. His blood sugar levels were within normal range and had no complications relating to the metabolic condition.
Psychosocial wellbeing
The patient related freely with the medical personnel creating a good rapport with them during his treatment. He was of good spirits when his wife visited on multiple occasions. He showed no signs of depression concerning his condition and was hopeful for recovery. A discharge plan was prepared owing to the support system he has in his wife to help him with self-care and managing of wound treatment and medication.
Medication
The list of prescribes pharmacological agents and their dosage are present in the appendix.
Nursing diagnosis.
Note: The patient diagnosis and associated evaluation, management plans, and treatment are made within the writer’s scope.
According to the North American Nursing Diagnosis Association (NANDA), 2017, the patient’s actual diagnosis is acute pain resulting from tissue damage from the fracture and subsequent THR surgery. This is evidenced by the patient’s numerical pain score of 7/10 and the patient’s reactions by wincing ( facial expression) and the evidence provided by the accepted pain-related behavior checklist.
The potential nursing diagnosis is an increased probability of infection (NANDA, 2017). The patient’s state of health supports this. The patient has diabetes mellitus, type 2, and hypertension, which may complicate the healing process and predispose them to a higher risk of bacterial infection and related comorbidities.
Patient goals and planning
For the treatment plan to be executed, the aim and objective of management should be evaluated in conjunction with the patient to formulate goals that are patient orientated. Expectations of management are that with appropriate treatment and interventions, the patient’s debilitating pain will be managed for Mr. JO to regain pain-free functionality of the left leg while ensuring the vital signs are maintained within acceptable ranges with sustained asepsis at the surgical site to prevent bacterial infections.
In reference to acute pain, the care plan involves the nurse’s keenness in noting the need for pain medication and the non-medical related techniques to provide pain relief.
The second plan involves minimizing the chances of infection. The intervention chosen was the maintenance of selected aseptic technique to reduce the transmission rate of bacteria between medical personnel and patients they handle.
Implementation
Acute pain
Intervention involves, first, the performance of a complete evaluation of the patient in terms of the site of injury, pain characteristics, and the frequency. This will ensure that the patient gets the most potent pain-relieving medication following the level of pain demonstrated. During the assessment, the patient’s non-verbal cues were taken into account to certify the presence or absence of pain. It is also necessary to check for the vital signs which are usually altered in the presence of pain. Following an assessment, the patient was administered with oxycodone given per orally four times a day at a dose of 5-10mg. During every round evaluation, the nurse inquired about the pain rate the patient had.
In addition, non-pharmacological interventions were applied. These included ensuring the patient environment was free of stressors, such as noise that would alter the patient’s pain tolerance and perception. Also, the use of relaxation activities such as music therapy and breathing exercises has been proven to increase endorphins, further potentiating the effect of pharmacological interventions. Pain relief was also mediated by providing the patient with the required prescription at the right time of the day. Moreover, the efficiency of medication was assessed by reviewing patient records and from the patient feedback to evaluate the effectiveness of the management plan.
Aseptic technique was applied to reduce the risk of infection development. Healthcare-associated infections (HCAI), occur mainly due to the transmission of disease-causing micro-organisms between patients and health care professionals. Aseptic means the absence of micro-organisms with the potential of causing diseases. Hygiene has been linked to decreased rate of infections, and with the current dilemma of resistance to antibiotics, it would help reduce the need for antibiotics by preventing HCAIs. Aseptic technique involves a process that eliminates the transfer of micro-organisms to an immunocompromised and as such susceptible host.
The intervention involved many stages. Hand hygiene was emphasized upon. Hands were washed before any procedure. Hand hygiene utilized soap and water and, in other instances, the use of sanitizers (alcohol-based). Another aspect of it was performed during storage, whereby they are kept in a dry and clean environment (National Health and Medical Research Council, 2019). When preparing the equipment, a surface is disinfected by the use of detergent. To prevent contamination of equipment, Preparation is performed at a distant points from sinks. Following the aseptic technique, wound cleaning and dressing were performed in clean environments using clean equipment. Also, the site of invasive devices were kept clean and disinfected continuously.
Before any wound cleaning and dressing procedure, risk assessment was used to determine the key areas that need to be protected and handled carefully. Consent is an integral part of the technique. The procedure is clearly explained to the patient so that they are involved in the healing process. Patient education on the aseptic technique and hand washing is an essential aspect of decreasing infections. Poor hygiene is considered a contributing factor to hospital infections, together with immobility. Teaching the patient on the importance of hygiene before and after handling his wounds, after visiting the toilet and before eating would enforce the ‘ four moments for patient hygiene’ model (Sunkesula, 2015). Patient hygiene has been proven as an essential factor in reducing hospital-acquired infections. This will help in maintain the state of health of the patient and prevent further complications that may result from subsequent infections.
Evaluation/ expected results.
It was expected that after the execution of the care plan, Mr. JO’s pain would be alleviated, and he would be able to regain full free range mobility of the affected leg. The risk of infection was expected to the significantly decreased in order not to complicate the healing process. The interventions were applied successfully with routine patient assessment to determine the efficacy after medication with proper documentation occurring in the process. The records show that the pain management was successful with the drugs being administered as per the required dosage and time. The patient reported a significant reduction in pain, which was evidenced by the decrease in oxycodone dosage and the ability to gain mobility until the time of his discharge progressively.
The practice of aseptic technique proved effective in reducing patient’s infection. Proper handling of equipment and dressing the wound ensured that the bacterial load was decreased, and the probability of infection was drastically decreased. Patient education also provided hand hygiene by the patient was maintained and reduced the chances of self-infection. No infections were observed by assessing the wound site and constant cleaning and changing the dressing, enabling a quick and speedy recovery of the patient.
Conclusion.
The nursing process was employed in the formulation of the nursing diagnoses, determination of patient-oriented goals, and care-plan that utilized the best nursing practices in managing patient conditions. The steps demonstrated the aseptic technique were effective in minimizing infection risk in offering quality patient-oriented care. Intervention was successful in the treatment of the patient’s condition following the assessments and evaluation. The patient health outcome proved the invaluable role of the nursing process in diagnosis and patient treatment.