Nursing Care Plan Report - Nursing Assignment Help

Assignment Task

CASE STUDY: Christopher Collins

Location
Surgical ward
Introduction
Christopher Collins, is a 54 year old, male who was diagnosed with early-stage osteoarthritis in the left knee, causing pain and affecting mobility. Surgery was planned to take weight/pressure off the damaged side of the knee joint and therefore relieve pain and also help improve joint function. Chris was admitted for a left high tibia knee osteotomy 5 days ago. A plate and screws were used to stabilise the tibia as part of the procedure. Antibiotics were given by the anaesthetist on anaesthetic induction. He had an uneventful post-operative period and was discharged two days later. Chris was discharged with non-steroidal anti-inflammatory medication for pain relief, non-weight bearing on crutches and fitted for a supportive knee brace until his planned outpatient review in two weeks time.

Situation
This evening Chris re-presented at the ED. Complaining of pain at incision site, nausea and feeling shaky/shivery. Wound site left knee, sutured, skin appears ‘tight’, shiny and red. There are several small areas were dehiscence is evident with pus present. Oxygen therapy has been commenced.

Background
PMH: Osteoarthritis, asthma since child hood
Drugs: NSAID, Ventolin, Seretide accuhaler
Allergies: Nil known
Chris is a non-smoker and regular swims (3-4 times a week) and occasionally participates in kayaking.

Assessment/Observations:

A – patent

B – RR 29, Sp02 94% on 60% oxygen, equal air entry, nil adventitious sounds on auscultation, no mucous or sputum production, chest is clear. Verbal report of feeling breathless
C – HR 135, BP 98/57, cool peripheries, temp 38.9 o C
D – GCS 15, PEARL. Patient states that he feels dizzy and ‘vague’. Pain score - left knee 7/10
E – Wound site left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present
F – IV cannula inserted
G - Glucose 5.1. Nil hx diabetes

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