NS2881 - Nursing Practice 3 - Mr Davis - Case Study Assessment Answer

Subject Code: NS2881

Case Study Assessment Answer

Assignment Task: NS2881 Case Study You are the registered nurse on the am shift in the orthopaedic unit. You receive handover for your patients, one of which is 25-year-old male, Mr Davis, who was admitted at 1900hrs the previous evening following a motor vehicle accident. His legs were trapped for several hours prior to extraction from his vehicle by the emergency services. He sustained fractures to both legs – R) mid-shaft femur. L) proximal tibia. Mr Davis has not had any oral food or fluids since his accident due to nausea and is now fasting while he waits for investigation and theatre. Handover of your patient is as follows: CNS: Mr Davis is alert and orientated, pain initially 7/10 is now 4/10 since the commencement of morphine PCA at 0200hrs. Grimacing on movement. CVS: Blood pressure currently 100/65, P 105 T 37.3. ECG shows sinus tachycardia. IV cannula inserted in the emergency department in the R) cubital fossa. Resp: RR 24, O2 saturations 98% on 6 l via Hudson mask. GIT: Remains nauseated, metoclopramide 10 mg administered IV with minimal effect. Currently NBM. The patient states weight approx. 90kgs. IVT in progress N/saline 100ml/hr. Bowel sounds present. GUT: IDC inserted in the emergency department, urine output 500mls since admission. Urinalysis – Amber, pH 5.0, a blood trace, SG 1.025, ketones trace. Musculoskeletal/skin: Currently rest in bed with R) leg in traction. L) Leg in backstab, elevated on pillows. Patient last rolled 0300hrs for pressure area care. Neurovascular observations – • R) leg pulses strong, normal sensation, warm to touch, the colour pink, currently complaining of pain but not exacerbated by passive movement. • L) Leg - foot cool to touch, pulses audible with Doppler, increased pain on passive movement, colour – toes dusky. Social: Patient has good family support with mother and fiancé present. Medical plan: Pt is to remain NBM for CT scan prior to the theatre this am. Harding (2015). The importance of nursing. In D. Brown, H. Edwards, L. Seaton, & T. Buckley (Eds.), Lewis's medical-surgical nursing: Assessment and management of clinical problems (5th ed.). Chatswood, N.S.W: Elsevier Australia.

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