NURS1202 Assessment 1 Case Study FInal PDF

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NURS1202 Assessment 1 Case Study...

Description

Health History Gender

Female

Age

28

Current Medical History

Bilateral knee surgery after netball injury 9/10/19:

What current medical conditions do you



have?

Anterior Cruciate ligament (ACL) reconstruction after a complete tear of right knee graft (previous reconstruction) with



I.

associated minor impact fracture at the central aspect of the lateral femoral condyle

II.

associated MCL grade 1 sprain

Irritated tibial staple removed from past left knee ACL reconstruction (July 2017) due to pain on pressure of scar & numbness up inside of lower left leg



Femoral nerve block used on right knee



Currently at home 3 days post op

Sexual health:

Past Medical/Surgical History



Birth control - IUD Mirena



STI - Herpes Simplex Virus 2 infection

Medical History 

Surgical History

Diagnosed depression & Anxiety 4



ACL Reconstruction Left knee July 2017 (netball)

years ago – medications were



ACL Reconstruction Right knee August 2018

1|Page

recommended however patient

(netball)

decided to remain non medicated.



Bilateral Cyclopes Lesion removal February 2019



Broken foot 2015 (non-surgical)



Broken right arm when approx 12yo (gymnastics)



Family history of diabetes and breast cancer

Medications

Paracetamol (Panamax) – 1000 Milligrams (2 tablets) QDS

What medications do you take?

Ibuprofen (Brufen) – 400 Milligrams (2 tablets) TID Oxycodone (Endone) – 5 to 15 milligrams (1 to 3 tablets) Q4H PRN

Do you live alone/with someone? Are you able to care for yourself?

Valacyclovir – 1 tablet BID PRN with someone Yes

Do you need help with showering?

No

Do you need help with toileting?

No

Do you need help with dressing? Do you have a vision impairment?

No No

Do you wear glasses?

Yes

What type of glasses are they? Do you have a hearing impairment?

Short sighted No

Do you wear a hearing aid?

No

Which ear do you wear them in? Do you wear dentures?

N/A No 2|Page

Are they upper/bottom dentures? Do you drink alcohol?

N/A Yes

How often do you drink?

Twice a week

How many drinks do you have each day? Do you smoke?

5-10 No

How many cigarettes do you smoke a day? Do you follow a special diet?

N/A Yes

What is the special diet?

Lactose and Gluten intolerance

What is your height?

170cm

What is your weight? Do you have any mobility issues?

85kg Yes

Do you use a mobility aid?

Yes

What mobility aid do you use?

Axillary crutches

Do you do any exercise?

Daily as per physiotherapist instructions

Do you have any wounds?

Yes

Where are they?

Right knee - 2 key hole wounds

1) Nursing assessment tool used – Wound

Left knee – 4cm incision Result –

assessment & management Form

Left Knee: Type - Surgical Description - Deep 3|Page

Appearance - Sloughy Surrounding skin - Inflamed Pain-Wound site - Intermittent Odour - slight Drainage – Purulent Right Knee: Type - Surgical Description - Deep Appearance - Epithelialisation Surrounding skin - Intact Pain-Wound site - Intermittent Odour - No 2) Nursing assessment tool used – PQRST

Drainage – Haemoserous Result – Left Knee P – pain on movement, comfortable when lying still with pain medications & elevation Q – Sharp pain over incision sites and aching in general knee area R – Pain travels up back of leg on movement only S – 7/10 T – Pain is constant Right Knee: 4|Page

P – pain on movement, comfortable when lying still with pain medications & elevation Q – Sharp pain over incision sites and aching in general knee area R – Pain travels up back of leg on movement only S – 6/10 T – Pain is constant 3) Any other nursing assessment tools used Result – - Depression, Anxiety and Stress Scale -

Depression = 27 – Severe

21 Items (DASS-21)

Anxiety = 8 – Mild Stress = 8 - Normal

Assessment 1 – Case Study Template 1) Consider the Individual Ms Jane Doe is a 28-year-old woman who underwent bilateral knee surgery 2 days ago at the orthopaedic hospital. Ms Doe underwent a reconstruction of the right ACL & a staple removal from past ACL reconstruction on the left knee following complaints of pain & numbness. Ms Doe surgery was successful and she is now resting at home 2 days post op.  Collect cues/Information Current information- including your 2 assessments:  History of knee injuries/reconstructions from netball injuries  Has had multiple past surgeries and knows the procedures for recovery  Right knee ACL reconstruction with femoral nerve block 5|Page

 Left knee irritated staple removal due to pain & numbness  Ms Doe seems talkative and comfortable during interview  Moderate pain level 6/10  Intermittent sharp pain on movement  Numbness due to possible nerve damage from past surgery down inside lower left leg  Left knee wound is slightly inflamed & sloughy with purulent discharge and a slight odour  Right knee wounds are normal and intact with haemoserous discharge  DASS-21 Severe depression score = 27  DASS-21 Mild anxiety score = 8  DASS-21 Normal stress score = 8  Diagnosed depression 4 years ago but Ms Doe refused to take recommended antidepressants (non medicated)  Lactose and Gluten intolerant  Mobile & allowed to weight bare but requires axillary crutches & independent EDA  Glasses required to see at distance  Multimodal approach to pain meds: -

1000mg Paracetamol QDS

-

400mg Ibuprofen TID

-

5 to 15mg Oxycodone Q4H PRN

 IUD contraceptive (Mirena)  Herpes Simplex Virus 2 infection 6|Page

-

Valacyclovir – 1 tablet BID PRN

 Family history of diabetes  BMI in high overweight range

Gather new information: Though the Ms Doe is young, mobile and independent for everyday tasks such as showering, toileting and moving around, the Ontario Modified Stratify Falls Risk Screen (REF) should be conducted as both legs would be weak from the bilateral surgery. Her pain level would also be a possible contributor to potential falls; therefore prevention should still be assessed. Due to Ms Doe’s family history of diabetes, it would be beneficial to conduct a Diabetes Risk Assessment (REF) to ensure that she is conscious of the appropriate risk level of developing diabetes. As she is overweight according to BMI, this assessment would be useful in educating Ms Doe on the potential problems that are associated with being overweight and contributing to a higher risk of diabetes. Neurovascular Limb observation assessments (REF) would be vital in the early detection of any neurovascular deficits in both Ms Doe’s legs post operation. Using the 5 P’s: Pain, Pallor, Pulses, Paraesthesia and Paralysis aid in the early detection & medical intervention to prevent any permanent deformity and dysfunction of the affected limb.

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Recall Ms Doe has a moderate pain score of 6/10, this accompanied by the weakness in her legs post bilateral surgery can increase the risks of falls, even with crutches. By conducting the Ontario falls assessment, nurses will be able to better evaluate her falls risk and put preventions in place to reduce this risk. As pain is an individual’s own assessment, Ms Doe verbal scoring has to be taken at her own word. However, when working with patients in pain benevolence and nonmaleficence form a basis of balancing patient safety with patient goals. Since many adverse reactions can occur when dealing with the dose of pain medications, this balance can be challenging (Quinan-Colwell, 2019). Ms Doe scored a 27 in the Lovibond & Lovibond (1995) Depression Anxiety and Stress scale for the subcategory depression, which places her in the severe category. Ms Doe has a history of diagnosed non mediated depression as per her own choice. Hagerty, et al (2018) discusses individuals concerns about antidepressants, declaring that it’s not always related to actual experience (e.g. Side effects). Ms Doe’s refusal towards being prescribed antidepressants could be a fear of needing medications, embarrassment, or being viewed as weak (Hargerty, et al. 2018). Ms Doe has a family history of diabetes and her BMI is in the high overweight range. While she maintains that she has a healthy diet, while being lactose and gluten intolerant, early detection of diabetes increases opportunities to reduce morbidity and mortality (RACGP, 2019).

2) Process information Interpret – I.

According to SAGO chart (NSW Health, 2013), a pain score of 3 or below is considered mild, from 4 to 6 indicates moderate pain and a score above 6 indicates severe pain. Therefore, it is clear that Ms Doe is in moderate pain with a score of 6/10, which is abnormal (LevettJones, 2018).

II.

Ms Doe has intermittent sharp pain on movement in both legs. While she is in pain, this cue can be considered normal, as having no pain after surgery could constitute a neurovascular deficit. 8|Page

III.

Ms Doe is 170cm tall and weighs 85kg, which places her in the overweight BMI range and at a higher risk of developing diabetes according to the Australian Government Department of Health (2013).

IV.

Lovibond & Lovibond (1995) Depression Anxiety and Stress scale - Depression score of 27 puts Ms Doe in the severe category. Therefore this is treated as abnormal and requires further investigation.

V.

Ms Doe’s left knee incision is slightly inflamed & sloughy with a somewhat purulent discharge, which is considered abnormal according to Benbow (2011). Benbow (2011) describes a normal healing wound as intact, epithelializing, without odour or any purulent discharge.

Discriminate – Pain Level 6/10 Ms Doe’s current pain level of 6/10 would be the priority in this situation as she is on a multimodal approach to pain medications; 1000mg Paracetamol QDS, 400mg Ibuprofen TID, 5 to 15mg Oxycodone Q4H PRN, which means Ms Doe should have little to no pain if she is taking medications correctly and as prescribed.

Left knee wound is slightly inflamed & sloughy with purulent discharge and a slight odour As Ms Doe is only 3 days post operation, the slight inflammation & odour could be an indicator of a possible infection. Early detection of infections can assist in prevention of pain, sepsis, or possible death or deformity.

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3) Identify problems/issues First Nursing Problem -

4) Establish Goals SMART Goals One Nursing Goal – For Ms

First action – Assess Ms

Rationale - Understanding the way pain management

Acute pain related to

Doe’s pain score to drop

Doe’s current use of her

works can get lost in translation between the doctor and

bilateral knee surgery

below 3/10 on the pain scale

prescribed pain medications

patient. Therefore, it is vital that Ms Doe has an

evidenced by Ms Doe’s

within the next hour.

to ensure she has been

understanding of how continuous and uniform

correctly educated.

administration of her medications will prevent a high

verbal report of a pain score

5) Take Action

of 6/10.

6) Rationalise your nursing action

pain level. Using a multimodal approach to pain relief post operation allows quality of pain relief while minimizing the side effects the may occur when relying Second action – Use non-

on a larger doses of a single medication (ASA, 2018). Rationale - According to Buyukyilmaz (2014), the use of

pharmacological pain relief

non-pharmacological interventions including; music,

methods (relaxation

relaxation techniques, back massage, breathing

exercises, breathing

exercises, guided imagery or a combination of some,

exercises, music therapy).

applied twice a day with quiet rest decreased the strength of pain levels and improved vital signs when taken over time after a surgery by increasing the release of endorphins and therefore boosting the therapeutic effects of pain relief medications.

Second Nursing Problem –

One Nursing Goal – For the

First action – Clean, dry and 10 | P a g e

Rationale – A noteworthy number of studies have

Left knee incision slightly

incision on Ms Doe’s left knee re-dress the wound to aid in

shown that health professionals are not correctly

infected related to staple

to be clean and dry without

applying the evidence based guidelines and

removal surgery evidenced

purulent discharge or odour

recommendations regarding the prevention of surgical

by slight odour, purulent

within the next 3 days.

wound infections (Boga, 2019).

healing.

discharge, sloughy and

In catching the early onset of infection in Ms Doe’s

inflamed appearance.

wound and cleaning, drying and re dressing, additional treatments, including antibiotics, readmission to hospital Second action – Ensure Ms

and possibly additional surgery can be avoided. Rationale – Tyrer (2019) discusses the need to improve

Doe is educated about the

care for patients who develop surgical wound infection

appropriate care of incision.

after discharge. By cultivating the quality of information provided to patients, the level of severity of infections and the quantity of readmissions due to infections could potentially reduce with earlier review and prompt treatment. Ensuring that Ms Doe understands how to appropriately care for her wounds and be aware of the warning signs of infection can possibly save her a readmission to hospital through early intervention.

8) Reflect on process and new learning

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On completion of this assessment, I have gained a higher knowledge of how the clinical reasoning cycle operates and its importance when assessing a patient’s health. When interviewing and assessing Ms Doe, I found that I need to improve on obtaining all the information in a sequence that builds on itself and is understandable to both myself and the patient. This assessment has also reiterated the importance of therapeutic communication and its ability to make the patient feel comfortable enough to share possibly embarrassing or personal health information. When creating the care plan for Ms Doe, I found that I had the most problems with the ‘recall of knowledge’ and ‘take action’ sections. In future, I believe I will have to undertake a more in depth research and expand my overall knowledge in order to provide the patient with the best possible care. I believe I had a good understanding of the patient’s health history, current situation and cue collection, however I believe I could have tailored the assessments I used to her a little more carefully. I am positive with more practice and experience this will come more easily in the future. Overall, I believe this assessment has shown me how to use the clinical reasoning cycle in a real situation, which has helped me gain a better understanding of why it is used.

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Reference List

Australian Government Department of Health. (2013). The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), Baker IDI Heart and Diabetes Institute. Retrieved from https://www1.health.gov.au/internet/main/publishing.nsf/Content/chronic-diab-prev-aus/ $File/austool5.pdf Benbow, M. (2011). Wound care: ensuring a holistic and collaborative assessment. British Journal of Community Nursing, S6–S16. Retrieved from http://search.ebscohost.com.ezproxy.newcastle.edu.au/login.aspx?direct=true&db=ccm&AN=104636428&site=ehostlive&scope=site Boga, S. M. (2019). Nursing Practices in the Prevention of Post-Operative Wound Infection in Accordance with Evidence-Based Approach. International Journal of Caring Sciences, 12(2), 1229–1236. Retrieved from http://search.ebscohost.com.ezproxy.newcastle.edu.au/login.aspx?direct=true&db=ccm&AN=138636118&site=ehost-live&scope=site Büyükyılmaz, F. (2014). REVIEW PAPER. Non- Pharmacological Intervention in Orthopedic Pain: A Systematic Review. International Journal of Caring Sciences, 7(3), 718–726. Retrieved from http://search.ebscohost.com.ezproxy.newcastle.edu.au/login.aspx? direct=true&db=ccm&AN=103900080&site=ehost-live&scope=site Hagerty, B. M., Williams, R. A., Aikens, J., Bathish, M. A., West, B. T., Fuller, D. S., & Kazemi, J. (2018). Assessing Cognitive Representations of Antidepressants: Development and Validation of the Attitudes toward Medication–Depression Inventory. Western Journal of Nursing Research, 40(8), 1220–1235. https://doi-org.ezproxy.newcastle.edu.au/10.1177/0193945917705136 Levett-Jones, T. (Ed). (2018). Clinical reasoning: Learning to think like a nurse. Frenchs Forrest, NSW: Pearson

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Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety & Stress Scales. (2nd Ed.) Sydney: Psychology Foundation. Retrieved from https://maic.qld.gov.au/wp-content/uploads/2016/07/DASS-21.pdf Lippincott Nursing Center. (2019). Neurovascular Assessment. Retrieved from https://www.nursingcenter.com/getattachment/ClinicalResources/nursing-pocket-cards/Neurovascular-Assessment/Neurovascular-Assessment.pdf.aspx NSW Health. (2012). Ontario Modified Stratify (Sydney Scoring) Falls Risk Screen. Retrieved from http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/258472/NH606658-ontario-modi-stratify-sydney-scoring-falls-riskscreen.pdf Clinical Excellence Commission (CEC). (2013). Standard Adult General Observation Chart. NSW Health. Retrieved from http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/between-the-flags/observation-charts Quinan-Colwell, A. (2019). ONTROLLING PAIN: Making an ethical plan for treating patients in pain. Nursing2019, 43(10). Retrieved from https://www.nursingcenter.com/journalarticle?Article_ID=1603855&Journal_ID=54016&Issue_ID=1603669 RACGP. (n.d). Identifying risk of diabetes in asymptomatic patients. Retrieved from https://www.racgp.org.au/clinical-resources/clinicalguidelines/key-racgp-guidelines/view-all-racgp-guidelines/management-of-type-2-diabetes/screening,-risk-assessment/identifying-riskof-diabetes The American Society of Anesthesiologistsm (ASA). (2018). Multimodal Approach to Pain Management Reduces Opioid Use, Prescriptions After Joint Replacement. Retrieved from https://www.asahq.org/about-asa/newsroom/news-releases/2018/03/multimodal-approach-topain-management-reduces-opioid-use 14 | P a g e

Tyrer, J. (2019). Service improvement study to improve care for patients who developed a surgical site infection after discharge. British Journal of Nursing, 28(15), S6–S19. https://doi-org.ezproxy.newcastle.edu.au/10.12968/bjon.2019.28.15.S6
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