Nursing Diagnostic Assessment Answer

Observations - The observation of symptoms as that are associated to the patient encompass pain in lower leg. 

Background - The background is an associated with pain felt by Mike after he fell while motor biking. 

Recommendation - In order that the relief is brought from the symptoms associated with the condition of Mike it can be recommended that the diagnosis of open fracture of fibula and tibia and he has to undergo surgical procedure for open reduction and internal fixation of the fracture. Post observation too is very crucial in Mike’s case.

Management

Assessment
Assessment: Mike stated that his pain is 10/10. Mike's pain is in the lower leg. Mike is able to describe his pain. The pain is sharp. The pain is localised. Mike is drowsy. Mike is responsive of voice,

Allergies: Mike is allergic to latex. It causes pruritus and welts. The colour identification band has to be ensured for Mike and the documentation should mention the same.

Medications: Prophylactic Cefoxtin 2g IV,    Paracetamol 1g IV/PO, Ibuprofen 200-400 mg PO TDS, Tramadol SR 100 mg PO BD, Cefroxotin 2g IV/IM, IV Compound Sodium Lactate.

Mike was asked about the OTC medication. Mike also asked about any illicit drug use or he does not have any other use of medicine.

Past Health History: Past Medical History was validated for Mike with any serious conditions if it pertained. Mental health along with perception of Mike was known. Home support and the coping mechanism for him is relevant too. Working situation and occupation of Mike was enquired.

Last Meal: Mike's last meal was enquired. It was necessary to understand as to how long fasted before surgery and whether Mike is having any vomiting or nausea conditions.

Events leading up to presentation: Mike complained of severe pain in the lower leg. He was admitted for pain post-accident. ED x ray confirmed that the diagnosis of open fracture of the left tibula along with fibula pertains. The review done by the orthopaedic team concluded that Mike had to undergo for open reduction and internal fixation of the fracture

Central Nervous System - Level of Consciousness: Mike was drowsy and responsive to voice. With regards to sensory/visual/hearing/speech impairment/ effects, they were assessed post-operatively to ensure there is no change to pre-operative assessments. The potential depression of CNS is due to the impact of anaesthesia.
    
Pain Score and Analgesia: Mike stated that his pain is 2/10. The same was documented in the patient Adult Patient Record. Current analgesia is impacting condition of Mike. It is effective. Pain was to be regularly monitored for Mike as his sleep would be impacted due to pain. There was a risk that Mike will encounter more pain as the impact of anaesthesia wears off. If pain is not well administered, it could have turned into chronic. Neurovascular observation was not assessed. No risk is identified for the patient. Mike's intravenous insertion along the line in his left arm was assessed. Examination of the insertion site was done for inflammation and peripheral intravenous assessment score tool was utilized to monitor and manage the IV line. Site was scored utilizing the PIVAS tool. There was risk of infection at the site where insertion was done

     
Cardio Vascular System - Mike's heart rate is 66 beats per minute. It is within the expected acceptable range. The same was being documented too on the vital signs assessment chart. Risk of bleeding can be there. Mike's Blood Pressure is 109/71 mm Hg. It is ideal and within normal acceptable range. This was documented on the vital assessment chart. Risk of hypertension as a result of surgical procedure. Circulation and hydration to the upper and lower extremities: not assessed. The risk pertaining to hypovolemic shock can be present. Diaphoresis, a common side effect of drugs or anaesthesia is not assessed. Shock complication post-surgery is not present.

Respiratory System - Overall appearance: not assessed. It was observed that % on RA. He is drowsy. Mike's respiratory rate is 18 beats per minute. The rhythm and depth is not assessed. Respiratory effort and work of breathing: not assessed. Risk pertaining to respiratory depression. Tracheal position, symmetry and shape of chest is not assessed. Chest sounds are not assessed. Risk pertaining to ineffective breathing pertains. 

Gastrointestinal System (GI) - Food allergies: not known, should be assessed on admission. Elimination issues are not known. Bowel sounds are not assessed. Risk of surgery complication.

Psychosocial - There was no nausea and vomiting. The mood, emotional state, and mental status: unknown. Coping strategies and response to illness/ surgery is unknown. Risk of impacted mood. Sleeping Habits is not known. Risk in condition post operation.

Patient's ADL

Assessment of Patient Activities of Daily Living
Activity and its Effects        
Maintaining a safe environment - Mike is experiencing dizziness        
Communicating- Mike was responding in low voice        
Breathing- Pain would affect normal breathing        
Eating and Drinking- Would have decrease in appetite        
Eliminating- Risk of constipation due to the medicines taken        
Personal cleansing and dressing- Sanguineous ooze is evident on dressing of lower leg        
Controlling Body Temperature- Assessment of body temperature was done on regular basis        
Mobilising- Movement can be with crutches only for time being        
Working and Playing- Mike would require time from work routine. HE has been into motorbike sports. He would be restricted now with the mobility concern        
Expressing Sexuality- Mike should be able to express        
Sleeping- Surgical wound would hamper Mike's sleep. He is prone to feel pain too        
Dying- Mike does not show any anxiety

Nursing Diagnostic I

The first nursing diagnosis pertains to the acute pain
Goals
The goals are linked to being patient centric and measurable. The goals can be summarized with respect to the below considerations - 
•    The use of systematic and dynamic approach in the provisioning of care in dressing
•    Assessment of patient pain done accordingly and appropriate pain management coordinated
•    Meeting potential care needs for the patient

Implementation

The implementation of the nursing intervention based on the goals has to consider the potential complication that the patient along with the nurse has to be aware of. With the regulated monitoring of the care plan and the intervention matching the goals, it is essential that the post-operative education to the patient is being provisioned. (Herold-Majumdar, A., Schaller, M. et al., 2016) 

Evaluation

The evaluation of intervention needs to be well documented. The evaluation of the clinical setting is significant. The criterion referenced scale which has an appropriate rating methodology has to be well incorporated. The feedback basis the evaluation done also needs to be documented. The documentation as part of the medical records has to be saved as a soft copy in the database of the patient. The statistical approach with the success of adherence of fundamental skills and the conceptual framework well exhibited through the intervention is essential (Schneider, M. A., & Ruth-Sahd, L. A., 2015).

Nursing Diagnostic II

The physio orthopaedic diagnostic as that would be needed post-operative sessions due to the lack of immediate regulated mobility. 
Goals
The goals linked to the nursing diagnosis are related to - 
•    Adherence to the diagnosis with the monitoring done in an effective manner
•    Promoting advanced evaluation techniques (Schneider, M. A., & Ruth-Sahd, L. A., 2015).
•    Identifying the essential intervention and adhering well to the care needs of the patient

Implementation

The implementation of the nursing intervention with the diagnosis identified pertains to the regulated care needs of the patient met with the well managed patient care plan adhered. There is a need well recognized to ensure that the goals of the program are well met ad the education is provisioned to the patient along with the members of family of patient.

Evaluation

The evaluation will be based on the ability to identify the nursing intervention well and documenting the facts. The evaluation of the clinical performance would be judged with the expected change in behaviour and essential considerations well kept under control. The evaluation has to be computerized with the available software in order to maintain greater adaptability.

Potential Complication and Post-Operative Education

The nurse should be aware of the infection post operation. The root cause analysis done basis the diagnostics in adults is necessary. The flexibility in the approach aids in the development of the program with the inclusion of various strategies to match the goals and objectives (Swift, M. C., & Stosberg, T., 2015; Ciemins, E. L. et al., 2015; Lewis, A. L., & Tavares, G., 2016). The implementation of the diagnostics basis the goals pertaining to diagnostics do need to bring about the crucial prioritization of the various processes and sub processes. Post-operative education that would be provided to Mike would entail taking care of the position while he sleeps. Also the patient has to be educated on the procedure he has been operated for.

Involvement of Interdisciplinary Team

The interdisciplinary team that would be involved would include the nursing staff, the dietician to understand the needs of the patient with regards to the food he can consume post-surgery. The psychologists would have to visit Mike to understand that his mental capabilities are not impacted and as to if Mike is not deeply affected with the trauma (Ahmed-Sarwar, N. et al., 2015; Pannick, S. et al., 2015; Ritchie, C. et al., 2016).The physicians would be required to access the response of Mike in recovering and if due care is being provisioned post operation. The physicians would also monitor the abrupt readings if any linked to the Adult patient summary for Mike. The attention of nurses in the ward has to check that the dosage of medicines is in accordance.

Conclusion

The nursing diagnosis plays a crucial role. Basis the case of Mike identified, who met with an accident, the subjective assessment with the allergies identified and the medication considered in the case is significant. The body system assessment done for the patient and assessment of patient’s Activities of Daily Living provision the various activities and the associated effects. 

References

Ahmed-Sarwar, N., DeCaporale-Ryan, L., Woz, S., Lashway, K., Mahler, K., Lewis, T., & Upham, R. (2015). Too Many Cooks in the Kitchen? Interdisciplinary Team Discharge Clinic Prevents Hospital Readmissions.

Ciemins, E. L., Brant, J., Kersten, D., Mullette, E., & Dickerson, D. (2015). A qualitative analysis of patient and family perspectives of palliative care. Journal of palliative medicine, 18(3), 282-285.

Herold-Majumdar, A., Schaller, M., Fleischer, S., & Behrens, J. (2016). Effects of nursing care planning tools on nurses’ and residents’ quality of life in long-term care facilities: A literature review. Journal of Nursing Education and Practice, 7(4), 32.

Lewis, A. L., & Tavares, G. (2016). This Workshop Will Be Improvised: Using Improvisational Skills to Become a Better Communicator, Clinician, and Teacher. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S352.

Nursing Process (2018). Nursing Process Steps. Retrieved from:

Nursing World (2018). The Nursing Process. Retrieved from:

Pannick, S., Davis, R., Ashrafian, H., Byrne, B. E., Beveridge, I., Athanasiou, T., ... & Sevdalis, N. (2015). Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA internal medicine, 175(8), 1288-1298.

Ritchie, C., Andersen, R., Eng, J., Garrigues, S. K., Intinarelli, G., Kao, H., ... & Tunick, E. (2016). Implementation of an interdisciplinary, team-based complex care support health care model at an academic medical center: impact on health care utilization and quality of life. PloS one, 11(2), e0148096.

Schneider, M. A., & Ruth-Sahd, L. A. (2015). Fundamentals: Still the building blocks of safe patient care. Nursing2017, 45(6), 60-63.

Swift, M. C., & Stosberg, T. (2015). Interprofessional simulation and education: Physical therapy, nursing, and theatre faculty work together to develop a standardized patient program. Nursing education perspectives, 36(6), 412-413.