NURS-3001 Actual Nursing Concerns and What are The Potential Nursing Concerns- Report Writing Nursing Assignment Help

Assignment Task

Read the scenario below and answer the following questions

Scenario

You are a 3rd year student nurse in your 1st semester, final year placement on the Orthopaedic ward. It is now 1030 on your early shift and one of your allocated patients is Mr Jones who is a 75-year-old man. He returned from the Operating theatre at 1000 this morning following an Open Reduction Internal Fixation (ORIF) to his left ankle under GA. Mr. Jones fractured his ankle in the early hours of this morning after a fall at home. He has a PMH of Diabetes Mellitus type 2, AF, MI 6 months ago with subsequent APO 48 hours after his MI, and hypertension. On return to the ward at 1000 he was alert and orientated, his first set of vital signs was RR 16, SpO2 98% on 2L via nasal specs, HR 75 and regular, BP 110/75, temp 35.8. His wound dressing was dry and intact, wound drain was patent and draining with 50mls of blood present in the drain. His neurovascular observations were intactPulse present, skin warm to touch, movement present (he can wriggle his toes), sensation present, and pink in color. At 1000 you commenced the new IVT bag of Normal Saline at 80mls/hr and he has not yet voided post-op. He has just rung the bell and reports feeling very SOB and is complaining of chest pain and severe pain in his operated leg, you notice that he is breathing rapidly, speaking in short sentences, looks very panicked and his IVT bag is empty.

Using the template provided to you on FLO please address the following questions

1. List your nursing concerns for this patient. What are the actual nursing concerns? What are the potential nursing concerns?
2. Provide a brief reason (rationale) for each of these nursing concerns
3. List a minimum of 4 interventions that need to be instigated to provide safe and effective nursing care for this patient for the remainder of your shift
4. Provide a rationale/reason for each of these interventions. Demonstrate your understanding of the relationship between pathophysiology, pharmacology and evidence-based practice for this scenario in your rationale/reason. Your rationale/reason must be nursing focussed

Provide a rationale/reason for each of these interventions

Vital signs should be assessed when a person has a change in health status or like in Mr Jones’ case when he reported of chest pain and difficulty breathing (Kozier et al, 2018). Vitals signs are an important factor when it comes to safe patient outcomes (Kozier et al, 2018). Vital signs are taken manually or on an automatic machine when connected up to the patient, it measures blood pressure using an arm cuff, pulse oximetry using a finger sleeve, respiratory rate is assessed manually by visualisation of the nurse while timing the breaths per minute, temperature take via ear probe or infa-red, heart rate read on the machine or taking pulse manually, pain score asking the patient out of 10 for a rating and consciousness score (Gulanick & Myers, 2017). These must be documented by the nurse assessing the patient taking these observations immediately. It is clear and comprehensive documentation for the nurse and other staff to accurately see how the health of their patient is and whether or not they are deteriorating (Kozier et al, 2018).

Shortness of breath: The nurse should observe and assess a patient’s respiratory rate, rhythm and quality by watching, listening and timing respiratory breaths, noting the position the patient assumes for breathing (Kozier et al, 2018). In the inflammatory response it can cause narrowing and obstruct the bronchial passages and alveoli (Gulanick and Myers, 2017). During observations the use of accessory muscles may be present, and cyanosis may be evident, 10- 20 breathes per minute is the average for adults (Kozier et al, 2018). Any changes that are seen are early warning signs that the patient is in respiratory distress/ clinical deterioration, anxiety may indicate worsening hypoxia (Levett-Jones, 2018). Visual assessment of skin colour is done to observe if the patient is pale or cyanotic (shade of blue), this indicates that there is an increase in concentration of deoxygenated blood and the breathing pattern is no longer effective at providing oxygenation of tissues (Gulanick & Meyers, 2017). The nurse should then auscultate, listen with a stethoscope, to the patient’s chest to assess if the breath sounds are normal beats of equal time or abnormal random out of time beats whether there are any crackles, wheezes, dyspnoea or reduced spo2 (Kozier et al, 2018). Using pulse oximetry is a non-invasive way of checking a patients oxygen saturation by the nurse. It measures the oxygenation of arterial blood through a patient’s finger or ear lobe when the small device is placed over the skin. Oxygen saturation should be above 90%, below is respiratory distress (Kozier et al, 2018). Position the patient sitting upright to allow for maximum chest and lung expansion, this opens the airway allowing for adequate diaphragmatic and lung excursion promoting lung expansion (Gulanick & Meyers, 2017). The nurse could change Mr Jone’s oxygen delivery from nasal specs to a full mask covering his nose and mouth allowing for deeper oxygen inhalation and faster flow, which can be implemented if required by a doctor (Gulanick & Meyers, 2017).

Myocardial Infarction: Mr Jones is experiencing chest pain and he has a history of having a pervious myocardial infarction and atrial fibrillation. The nurse could investigate this further by doing an electrocardiogram. The nurse will place the electrodes with leads that connect to a monitor onto the patient’s chest in correct sequence of positioning to read the hearts electrical impulses. It is then recorded on a monitor for a certain amount of time and printed out to be examined by the nurse and or doctor to determine and abnormalities in the heart’s electrical activity (Kozier et al, 2018). Mr Jones may be put on further cardiac monitoring due to concerns about his chest pain and given his previous history. Cardiac monitoring is three to six electrodes with leads that are placed on the patient’s chest and connected in sequence from the patient’s skin, connecting to the monitor for continuous observations of cardiac rhythm in the heart. The monitor is set to alarm at any potential problems it detects from any changes in heart rhythm (Kozier et al, 2018). In this case with Mr Jones and his previous heart history he could already have a nitro-glycerine (GTN) spray prescribed by his doctor to use if he experiences any chest pain, this could be implemented I hospital. GTN is used to treat and prevent heart related pain. When taken it relaxes smooth muscle, causing vasodilation of peripheral veins and arteries. This slows down the cardiac output and arterial pressure, which results in decreased oxygen demand on the myocardium (Tiziani, 2021). It is fast acting being absorbed by oral mucosa, bypassing the liver and going straight into the vascular system (Havard & Tiziani, 2021). It is to be taken on the first sign of chest pain with a clear dose and instructions from the prescribing doctor. Onset of action is 1-3 minutes with a lasting duration of 30-60 minutes. If there is no immediate relief within 15 minutes and the chest pain continues the doctor needs to reassess straight away. The nurse needs to watch for any changes in the patient’s behaviour and if the patient experiences any side effects of headache or dizziness to call the doctor straight away (Havard & Tiziani, 2021).

Compartment syndrome: Mr Jones is at risk his age and having his open reduction internal fixation (ORIF) surgery done. He is at risk of ineffective peripheral tissue perfusion. With his severe leg pain in his operated leg the nurse should do a set of neurovascular observations every 1-2 hours for any signs of neurovascular compromise and damage. To do this the nurse should check for pain, asking the patient for a pain score especially in that leg, what it feels like whether the pain has changed or intensified. Touch the leg to feel the temperature (poikilothermia) as less perfusion would lead the extremity to feel cold to touch (Gulanick & Myers, 2017). The nurse can check for capillary refill on nail beds of both feet to compare them, if the operated on is slower it should be reported straight away to the doctor (Gulanick & Myers, 2017). Check for skin colour (pallor) in that leg for any signs of paleness and physically check for a pulse in the operated leg to make sure there is still adequate blood flow (pulselessness). The nurse should ask the patient whether there is any numbness, tingling or feelings of pressure (parasthesias) this would indicate impaired perfusion or the start of compartment syndrome and should be noted and reported (Gulanick & Myers, 2017). Any changes that the nurse finds in the assessments could indicate the onset of compartment syndrome, peripheral arterial embolism or deep vein thrombosis (DVT), this is why it needs to be recorded by the nurse and spoken about with the Registered nurse in charge or call the MET call if worried with supporting evidence ie: vital signs documentation. (Gulanick & Myers, 2017)

List a minimum of 4 interventions that need to be instigated for the remainder of your shift

• Patient positioning for shortness of breath.
• Checking vital signs and conducting an ECG.
• Pharmacological treatment per doctor's order for potential concern of pulmonary oedema.
• Pain assessment and management.

Q1. Shortness of breath is the sensation feeling of not breathing deeply enough and the feeling of running out of air. The pathophysiology is complex and results from multiple different interactions of receptors and signals in the central nervous system (CNS), mechanoreceptors which include the lungs, chest wall and upper airway and peripheral chemoreceptors (Hashmi et al, 2022). Peripheral chemoreceptors are responsible for stimulating breathing located in the carotid in response to hypoxia (Martin, 2017).

Patient positioning directly disturbs respiratory muscle function, performance, and patterns of breathing hence, why body positioning is effective in improving respiratory function (Sonpeayung et al, 2018).

A position that can potentially help increase the comfort for SOB is the semi-fowler position which is defined as the patient's head of the bed elevated at a 30-degree angle (Kiyak et al, 2019).

The semi-fowler position contributes to reducing shortness of breath (SOB) because when in this position the diaphragm moves downward decreases lung volume, promoting lung dilation, and increasing ventilation (Zhu et al, 2020). Which promotes improving oxygenation and increasing the patient's oxygen saturation (Zhu et al, 2020).

Q2. Vital signs which include oxygen saturation, respiratory rate, blood pressure and temperature need to be conducted as Mr jones has presented many different signs and symptoms. Through checking vital signs, the nurse will be able to recognise early deterioration and abnormalities relating to the concerns presented and for the nurse to provide further advanced care and intimate treatment immediately (Breeke et al, 2019).

The nurse should also conduct an electrocardiogram (ECG) immediately for the chest pain experienced. This intervention is used in tracing the heart which is recorded from the surface of the body (Satter & Chhaabra, 2021). The monitoring of the ECG will allow immediate analysis and treatment to reduce any abnormalities detected before any significant implications occur such as mortality or morbidity from cardiovascular complications (Satter & Chhabra, 2021).

For example, the patient has a medical history of recent MI only 6 months prior, if the chest pain indicates another heart attack the ECG readings will present ST elevation in all the leads from V1 through V6 (Bansal et al, 2022). The ST segment on the ECG is a representation of various waveforms that potentially indicate injury to the myocardium (Kashou et al, 2021).

MI is initiated by thrombotic occlusion of coronary vessels which occurs by rupture of a vulnerable plaque. Moreover, ischemia induces metabolic and ionic perturbations which affect the myocardium causing depression of systolic function (Frangogiannis,2015). The pathophysiology for a MI event to cause ST elevation on the ECG will be persistent and complete occlusion of blood flow (Akbar et al, 2021).

Q3. Pulmonary Oedema is found to be caused by increased workload or a decrease in myocardial contractility. The decrease in cardiac output increases the pressure of the pulmonary vascular system triggering an increase in blood volume and heart rate which increases workload on the heart (Lemone et al, 2020).

Acute pulmonary oedema (APO) if present requires immediate medical management this is where administrating medication is important only per the doctor's order (Purvey & Allen, 2017). An example of a potential medication the doctor may order could be loop diuretics such as frusemide which is administered through intravenous injection (Purvey & Allen, 2017). However, this is only one example of pharmacological management of APO (Purvey & Allen, 2017).

The mechanism of action for frusemide is inhibiting the reabsorption of sodium and chloride in the distal tubes, proximal tubes, and the loop of Henle which results in excessive excretion of chloride, calcium, water, and sodium (Khan et al, 2022).

The half-life of furosemide is an estimated 2 hours and its therapeutic effect last approximately 6 to 8 hours (Khan et al, 2022). Moreover, the absorption of frusemide is found to be slower in patients presented with oedema but still absorbs normally (Khan et al, 2022)

Once a medication is administrated nurses must assess , reassure the patient, and observe for any adverse effects that might occur these include muscle cramps, dehydration, headaches, orthotopic hypotension and many more to avoid further complications from arising (Khan et al, 2021). The nurse must also monitor the patient's fluid intake and urine out throughout the shift (Khan et al, 2021). Furthermore, also monitor the patient's kidney function via a blood test for serum blood urea nitrogen and creatinine (Khan et al, 2021).

Q4. A pain assessment should be conducted, and the patient should be continuously assessed throughout the shift to further provide appropriate pain management (Jensen, 2018). Performing a pain assessment will allow the nurse to localize the acute pain, indicate any patterns, for example, knowing where it originated and if the position has changed and allowing the patient to describe the pain for example if it feels like a cramp, sharp or dull (Jungquist et al, 2017)

This is an important nursing intervention as this will allow the patient to receive optimal care for his pain and will allow the nurse to collaborate with other members of the health profession to form a care plan promoting the patient's emotional health, physical health, and comfortability (Jungquist et al, 2017).

After further assessment per the doctor's order nurses may be informed to administer prescribed analgesia which could include non-opioid which are non-steroidal anti-inflammatory drugs (NSAID) and opioid analgesics (Small & Laycock, 2020). Further observing side effects and impact the medication could potentially have and reporting these findings immediately to the doctor (Jensen, 2018).

Opioids such as morphine are considered as a choice of analgesia, with the binding to kappa, delta and mu-opioid receptors (Murphy et al, 2021). The analgesic effect is mainly produced with the affinity on mu- receptors at the central and peripheral nervous system, leading to reduced nociception, hence reduced pain (Murphy et al, 2021). The most common adverse effects of opioids include nausea, vomiting, constipation, respiratory depression, and bradycardia ( Cohen et al, 2021).

The mechanism of action for NSAIDs is to block cyclooxygenase (COX) which makes prostaglandins in the body. Moreover, COX comes in two forms COX-1 and COX2 2 and by inhibiting these enzymes, nociception is reduced, along with inflammation (Tiziani, 2017).

NSAIDs are highly effective for pain management and thus come with very serious effects that could potentially occur such as hypertension, gastrointestinal bleeding, nephrotoxicity, and atrial fibrillation which nurses must always be observing and monitoring (Wongrakpanich et al, 2018).

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