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NSB024: Nursing & Health Care - Case Study Assessment Answers

December 29, 2017
Author : Charles Hill

Solution Code: 1ACGC

Question: Nursing Case Study

This assignment is related to “Nursing Case Study” and experts at My Assignment Services AU successfully delivered HD quality work within the given deadline.

Nursing Case Study Assignment

Case Scenario

Mr George Jensen, a 65-year old male, was brought into Emergency Department with an open fracture of his right tibia and fibula after falling from his roof while clearing the gutters. The following data were obtained on his admission:

Objective Data Past Medical Admission History Social History

  • Weight 122 kgs
  • Height 190 cms
  • BMI 33
  • Diminished peripheral pulses
  • eGFR 78mls/min/1.73m
  • Hb 11.3gms/dl
  • BP 155/100
  • HR 110

  • Diagnosed with type 2 diabetes mellitus 2 years ago – on oral hypoglycaemics
  • Hypertension

Current Medications:

  • Glibenclamide, 5mgs, Mane
  • Captopril, 50mgs, BD
  • Simvastatin 40mgs, Nocte,
  • Rantidine 150mgs, BD
  • Aspirin 75mgs, Mane

  • Has 3 children and an ex-wife who live out of state;
  • Has been working as a real estate agent 20hrs/wk.
  • Consumes 15units of alcohol/day
  • Smokes 20 roll-up cigarettes per day for last 10 years.

He was taken to theatre as an emergency case where he had an open reduction and external fixation of his fractures. He has returned to your ward at 5.30am post-operatively. You have arrived on the morning shift to find:

  • His right leg is cool to touch;
  • Pain Score is 7 on a scale of 1-10;
  • Fracture site and pin sites are serous ooze with notable swelling of his right leg;
  • Blood glucose level of 17mmols/ltr;
  • His post-operative vital signs are currently, HR 107BPM, BP 104/55mmHg, temp 37.9°C Axilla, SaO295%, FiO26ltires via Hudson mask, Resp rate 24BPM;
  • Hartmans solution running at 125mls/hr via triple lumen central line situated in the right internal jugular.
  • Insulin and dextrose infusion running at 2mls/hr (2 units/hr);
  • Urine output via a Foley IDC is >1ml/kg/hr and dilute.

Q1:Is asking you to consider how the stress of the operation might affect his blood pressure. Donotconfuse this with how diabetes and hypertension will affect his wound healing that is not what the question is asking you.

Q2:Is asking you to consider themost important problems- rememberABCDE.

Q3:Is asking you to identify patient centred nursing goals for the problems you have identified from Q2 - I would strongly urge you to review thePowerPoint on Goal Settingas to how to write a concise patient centred nursing goal.

Q4:Is asking you to only pick 2 of those nursing goals (any 2 the choice is yours) and using the literature provide an evidenced-based rationale as to why these interventions are appropriate in this case.

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Solution:

Question 1

Mr. Jensen visited the hospital due to the fracture he had suffered due to a fall from his roof. On admission, he undergoes an emergency open reduction as well as a fix up of all his external fractures. However, from his surgery, he has started demonstrating symptoms of post operative hypovolemia which is evidenced by his medical exam readings on the morning after his surgery. Post operative hypovolemia typically occurs when a patient undergoes a rapid loss of either blood or other fluids while undergoing surgery. Unchecked, it can develop into hypovolemic shock that could lead to the shutting down of vital body organs of the patients and may lead to eventual death (Jacobi et al., 2012)

As a diabetic undergoing surgery, Mr. Jensen is prone to stress and this stress may render insulin less effective. This is because stress causes the release of stress hormones that reduce the effectiveness of insulin in the body. Consequently, insulin is unable to help the body burn the glucose in the body and convert it to energy. Due to this, the body will start burning fat as a way of compensating for this. Once fats start being burned, toxic acid by-products start being produced, and they get released into the blood stream where they can be fatal if unchecked. They also contribute to dehydration of the body and consequently hypovolemia (Telgi et al., 2013).

In Mr. Jensen’s case, he is a diabetic who is prone to excessive bleeding and fluid loss during surgery. On losing fluids, his body becomes dehydrated, and consequently, there is inadequate water in the blood which then affects the hearts’ ability to push fluids around the various blood vessels in the body. Once this cardiac output is decreased, the heart beats also increases as evidenced in the post op assessment information gathered (Chen et al., 2012).

Mr. Jensen’s hypovolemia could have occurred due to the trauma that his body endured after the fall. His fall from the roof led to a fracture occurring on both his tibia and his fibula; this led to blood loss. Further blood loss occurred during his emergency surgery, and he seems to be losing fluids further through his fracture site even after his operation is completed. This physical trauma on his body could have contributed to the hypovolemia because it led to a blood loss which leads to hypovolemia (Car Peterko et al., 2012).

Dehydration is also a major contributing factor to hypovolemia. As a diabetic, Mr. Jensen is more predisposed to dehydration because his kidney functions are not optimal, and he may be predisposed to frequent urinations which will lower both his sodium and plasma levels. As a result, he loses more fluids than he is taking in, and this contributes to dehydration and results in hypovolemia (NICE-Sugar Study Investigators, 2012).

His blood pressure levels are 104/55mmHg which is indicative of hypotension. This implies that he is suffering from low blood pressure, and his heart is pumping blood to his other body parts at a slower pace. This could be one of the main contributing factors of hypovolemia due to the fact that his body is not pumping enough blood to the rest of the body causing the body to be hypovolemic (Kolecki, n.d.).

The serious oozes occurring on the site where the fracture occurred and where the pins have been placed could be a major contributor to the hypovolemic shock. The fluids oozing from the fracture sites are contributing to the overall fluid loss, and as a result, further loss of fluids of occurring which is contributing to the hypovolemia (NICE-Sugar Study Investigators, 2012).

Physiologically, once the body realises that it is low on fluids, it starts making gradual compensations for the fluid loss. For instance, the body will release hormonal mediators to the blood stream which will assist in increasing both the retention of both salt and water in the body. They will therefore lead to an increased heart rate as well as an increased cardiac contractility. These changes will lead to fluid redistribution to the body’s vital organs (Car Peterko et al., 2012).

The body also compensates by increasing the fluid retention capabilities of the kidneys. This ensures that the kidneys retain fluids that can then be redistributed to vital organs. Once the body experiences hypovolemia, it also responds by moving fluids to the intravascular part of the body. This occurs due to the adjustments that occur in the transcapillary pressure (Chen et al., 2012).

Question 2

Mr. Jensen’s blood glucose levels are worrying. This is because they fall way below the acceptable glucose levels for a diabetic patient. They imply that he is running low on insulin, and this affects his bodily functions because his body doesn’t have the requisite energy to perform basic fictions. Currently, his blood sugar level is17mmols/ltr which falls below the acceptable glucose levels in an adult patient. It is therefore imperative that this issue be addressed to avoid further complications in his recovery (Krinsley et al., 2012).

The blood loss from his fracture site is a major priority problem. This is because it could lead to a major fluid loss which could severely limit his chances of a favourable health outcome. Further to this, it could become an infected area and could lead to further complications down the road. It is therefore imperative that this area be dealt with, and the oozing stopped immediately (DeWit & O'Neill, 2013).

The swelling of the leg and its current temperature is also a core problem area for Mr. Jensen. As per the data collected, his right leg is cool to touch and also has noticeable swelling. This could prove problematic because it could be a sign of improper blood flow to the leg or internal bleeding. Due to this, it is vital that this issue be addressed promptly (Schauer, 2014).

His blood pressure is also a problem area that needs to be addressed promptly. As per his current readings, it falls under 104/55mmHg. This is indicative of hypotension where his heart is not pumping blood to his body at the optimal pressure. Consequently, if it goes unchecked, it could lead to some body parts not receiving blood and oxygen as required which could affect their normal functions (Kirkman, 2012).

His pain levels are also a core problem area for him. Rated 7/10, it could mean that he is in a large amount of pain. It is imperative that the nurse finds out the exact cause of pain because it could be signalling that a part of his body may have gotten infected. Pain could also affect his blood pressure and heart beat, and it is therefore important that this be dealt with promptly (Kirkman, 2012).

His right leg is exhibiting swelling and is also cool when touched. This could be a potential problem area because it could imply that there is a lack of blood circulation in the leg. As a diabetic who is a heavy smoker and drinker, he could be prone to Limb Ischemia which if left unchecked could result in loss of function of the entire leg. It is therefore vital that he undergoes further check-up and treatment to prevent this from occurring (Schauer, 2014).

Question 3

As a diabetic with a long history of both smoking and alcohol use, Mr. Jensen is a high-risk patient and requires excellent nursing care to ensure that he doesn’t succumb to the risk factors associated with his pre-existing condition and the risk factors associated to his age and lifestyle. Stabilising his glucose levels is the main nursing goal for his post-operative care. A stable glucose level will ensure that the body has enough glucose that can be converted to energy and this would improve the blood pressure as the body will have enough energy to pump blood to the rest of the body. Adequate glucose levels will also stabilise the insulin levels in his body (Rydén et al., 2012).

Ensuring proper hydration at all times is a core goal for his care. Currently, he is exhibiting dehydration and to counter this he needs to be constantly monitored and hydrated to ensure that despite his numerous urinations, he gets body fluids replaced constantly (Brown et al., 2014).

Eliminating blood loss is also a core goal for his post-op care. Currently, he is losing blood via the fracture site, and this is contributing to his hypovolemia. The source of the blood loss has been identified as the fracture site. This wound needs to be closed, and further blood loss stopped. If this is done, he will stop losing blood, and his blood volume levels will be optimal once more. This will address his pain levels as well as his swollen leg. Optimal blood levels can also help counter his blood pressure and glucose issues (Brown et al., 2014).

Question 4

Nursing interventions are core in post op care because they have been found to severely reduce the fatalities that occur when diabetics undergo surgery. For any diabetic, glucose regulation is vital. If there is an imbalance, they are prone to further complications some of which could be fatal. In Mr. Jensen’s case, his glucose levels have not been well monitored both during and after surgery, and this has contributed to most of his current post op complications. Although he is received insulin intravenously, his glucose levels had not improved mainly due to the stress hormones that could have been released when he was put in surgery (US National Library of Medicine, 2012).

During surgery, stress may have made insulin ineffective, and this could have contributed to his eventual low blood sugar levels. To address this, it is vital for nursing professionals to keep glucose regulation as a core requirement for diabetics both before and after surgery. Before surgery, they know that the surgery stress could render insulin ineffective; therefore, they should offer medications that ensure that despite the ineffectiveness of insulin, the glucose and energy levels of the patients will be well regulated. Further to this, after surgery, it is imperative that glucose levels be regularly monitored, and appropriate medications offered to the patient to counter the stress hormones associated with trauma (Centre for Nursing Classification & Clinical Effectiveness, 2013).

To achieve this, a nurse should perform hourly checks to ensure that his glucose levels remain optimal. Further to this, insulin, stress relieving supplements as well as glucose supplying supplements should be offered intravenously to ensure that he remains glucose –regulated (Thede & Schwirian, 2013).

Diabetics have meal requirements that are supposed to be administered according to specific timings. Glucose regulation can also be achieved by ensuring that the patient remains well fed at the required timings because if this is not adhered to, he may suffer from energy loss which would affect t his glucose levels (Grove, Burns & Gray, 2014).

Fluid management is also core in managing a diabetic in his post op phase. This involves ensuring that they are constantly hydrated and that they receive constant infusions of all fluids they may have lost either during or before surgery. As a diabetic, Mr. Jensen is prone to fluid loss either through blood loss or metabolically through urine. Due to this, he is at risk of getting dehydrated and developing hypovolemia (Australian Practice Nurses Association, 2013).

Dehydration can be fatal for any patient after surgery. It implies that the body lacks enough fluids necessary for normal bodily functions. Fluid management is therefore very vital because it will ensure that Mr. Jensen has enough electrolytes, plasma, sodium as well as other components necessary for normal body functionality. Fluid management has been found to be effective in post op diabetics care because it ensures that in spite of the fluid loss, they still stay adequately hydrated (Butts, Bandhauer & Rich, 2013).

Due to the emergency nature of his surgery, Mr. Jensen was not put under the procedural activities that other diabetics go through before they are admitted for surgery. For instance, due to their condition, they are predisposed to many complications both during and after surgery. As a result, it is recommended that they are put under overnight monitoring and glucose regulation before they are admitted for surgery (Umpierrez, 2012).

Mr. Jensen was not subjected to these checks, and this has increased his risk of complications significantly. Further to this, he is a smoker and an alcoholic. All these are warning signs that he requires further monitoring and care should be taken when he is undergoing surgery. Due to this, it is vital that he is put under fluid and glucose management to ensure that he doesn’t develop further complications as a result of his surgery (Barry & Edgman-Levitan, 2012).

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