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Assessment and Prioritize Nursing Interventions

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Holistic nursing care approach is a comprehensive and multi-dimensional practice of nursing directing to achieve its goal (Zamanzedeh, 2015). It involves nursing principles gearing nursing assessment tool, implications and interventions towards attaining complete nursing care. This case would emphasize the ways and means in prioritizing the nursing interventions to be able to meet the patients’ needs. Then it will discuss an explanation of patient’s past medical history and diagnoses. It will enumerate her prescribed drugs and its nursing implications. The pre-operative nursing interventions for our patient. It will specify the immediate post-operative nursing interventions. Discharge planning for our patient will be discussed in preparation for rehabilitation. Therefore, these nursing interventions will help the patient achieved our holistic goal. The patient is Audrey Smith, a 75-year-old widow came to ED from an accident in her house and was diagnosed with a fracture of left neck of femur. She was oriented and alert with a GCS of 14. Audrey is scheduled for arthroplasty at 1700hrs.

Assessment and Prioritize Nursing Interventions

A) Safety

  • Assess for breathing and administer supplemental Oxygen if needed.
  • Monitor for the Vital signs and note skin condition.
  • Assess for the surgical site and wound drainage.
  • Assess for the Level of consciousness, orientation and ability to move all the extremities.
  • Check for the height of bed, put up the side rails and call bell within reach.
  • Check for the surroundings if there are possible danger.

B) Hygiene and Comfort

  • Assess for level of pain, location and characteristic.
  • Check for the last dose of the analgesia and the next dose to be given
  • Provide oral and personal hygiene to Audrey to prevent possible source of infection.
  • Repositioning Audrey with proper body mechanics to provide tissue perfusion and comfort thus preventing pressure ulcer.
  • C) Nutrition

    • Check Audrey’s blood sugar and inform doctor if below normal.
    • Get Audrey’s Body Mass Index to provide proper Nutrition
    • Encourage Audrey to increase oral fluid intake and high fiber diet to improve her chronic constipation.
    • Refer Audrey to Dietician and Nutritionist

    D) Elimination

    • Assess patient urine output and the urge to void.
    • Check if there is any bladder distention
    • Check for the frequency of the bowel movement
    • Administer Laxative as ordered by the Doctor
    • Render heath teachings regarding foods that may cause constipation and encourage increase oral fluid intake.

    E) Activity Levels

    • Assess Audrey’s level of mobility to assist on her needs
    • Identify what are the mobility aids that are available to provide assistance on her mobility to promote independence.
    • Refer Audrey to the Physiotherapist, Occupational therapist that will help her to gain more independence and promote self-esteem.

    F) Psychosocial Needs

  • Assess Audrey’s concern for the upcoming operation, give re-assurance that the operation will help her existing condition.
  • Assess for the Level of consciousness, orientation and verbal response. And refer to the doctor for significant changes in neurological functioning.
  • Refer Audrey to Medical Social Worker for her concerns regarding the safety of her dog, Rufus.
  • Refer Audrey to a social group who can give encouragement and support due to loss of a love one.
  • Past Medical History, Diagnosis And Nursing Considerations

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    Atrial Fibrillation – Atrial fibrillation is a type of abnormal heart rhythm (arrhythmia) of your heart. It can cause blood clots that can block blood supply to your vital organs and lead to a stroke. We need to monitor Audrey for any significant changes such as dizziness, shortness of breath, palpitations, fatigue and any abnormalities.

    Hypertension – is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. It’s a major risk factor for coronary artery disease, stroke, heart failure, atrial fibrillation, peripheral vascular disease, vision loss, chronic kidney disease, and dementia. It is important to monitor Audrey’s blood pressure specifically taking her baseline BP. Administer antihypertensive medications as ordered. Notify the doctor if there is significant downfall of BP.

    Left Cerebrovascular Accident – A poor blood flow to the brain results in cell death. The risk factor for stroke is high blood pressure, diabetes mellitus, and atrial fibrillation. It is best to assess Audrey’s level of consciousness and neurovascular status including Glasgow Coma Scale (GCS). Providing mobility assistance is mainly considered for her condition. It is best to include rehabilitation to Audrey’s case to for medical management.

    Type 2 Diabetes Mellitus – is a progressive condition in which the body becomes resistant to the normal effects of insulin and gradually loses the capacity to produce enough insulin in the pancreas.It is important to check Audrey’s blood glucose level pre and post-surgery and notify the doctor if there are abnormal results.

    Gastro Oesophageal Reflux Disease – is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications. Assess for Audrey’s nutritional status and position bed in upright position during feeding and remain on same position after. Small frequent feeding is highly recommended for Audrey’s diet.

    Osteoporosis – a disease where increased bone weakness increases the risk of a broken bone.Osteoporosis may also occur due to a number of diseases or treatments including alcoholism, anorexia, hyperthyroidism, kidney disease, and surgical removal of the ovaries. Provide safety measures in Audrey’s mobility to avoid any further accidents. Educate her importance of calcium rich foods. Total Hysterectomy – is the surgical removal of the uterus, cervix, ovaries, and fallopian tubes. Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as “surgical menopause”. Several other studies have found that osteoporosis increased risk of bone fractures are associated with hysterectomies. Urinary incontinence may be considered as one problem with this condition, therefore foley catheter insertion may be done to monitor Audrey’s intake and output accurately. Depression – a state of low mood and aversion to activity that can affect a person’s thoughts, behavior, tendencies, feelings, and sense of well-being. A depressed mood is a normal temporary reaction to life events such as loss of a loved one. It is also a symptom of some physical diseases and a side effect of some drugs and medical treatments. It is vital to monitor Audrey’s behavioral pattern by encouraging her to verbalize her thoughts and feelings. Set up a meeting a counselor my help the case of Audrey to avoid the reoccurrence of depression. It will be best to contact her daughter who lives in Queensland to aid her loneliness and re-assure her that Rufus is doing fine.

    Prescribed Drugs, Indication and Nursing Implications

    Digoxin 62.5 mcg OD – it is used for atrial fibrillation, atrial flutter, and heart failure. To treat Audrey’s atrial fibrillation. Take apical pulse for 1 full minute noting the rate, rhythm, and quality before administering. If changes are noted, withhold digoxin, take ECG and notify the doctor promptly. Since Audrey is taking Esomeprazole and Mylanta which might affect the absorption of digoxin it is best to monitor Audrey for signs and symptoms of Digoxin toxicity such as GI upset, bradycardia, arrhythmias and hypokalemia. It is important to check Audrey’s blood test. It’s important to inform the doctor of the significant changes in her condition. And suggest to team doctors to review Audrey’s list of medicine for the different timing of the drugs to prevent interaction with each other.

    Coversyl 5mg OD – an ACE inhibitors treats essential hypertension, stable coronary artery disease (reduction of risk of cardiac events in patients with a history of myocardial infarction and revascularization) and treatment of symptomatic heart disease or heart failure. Always check the blood pressure of Audrey before and after administering,assist her in mobility since it may cause dizziness headache and vision disturbance. We have to monitor Audrey’s electrolytes to eliminate possibility of having hyperkalemia risk factor include renal insuffiency, Reno-vascular hypertension (disc diuretics). .

    Warfarin 2 mg OD (INR result 2.0 in ED) – an anticoagulant. It is commonly used to treat blood clots such as deep vein thrombosis and pulmonary embolism and to prevent stroke in people who have atrial fibrillation.This treats the atrial fibrillation of Audrey and essential in preventing blood clot formation causing CVA. Assess for signs of bleeding such as unusual bruising, and black tarry stool. Monitor Audrey’s clotting factors (Prothrombin time and INR) and suggest to team doctors to review Audrey’s list of medicine for the different timing of the drugs to prevent interaction with each other since warfarin interacts with esomeprazole. If overdose occurs, administer vitamin K as ordered.

    Vitamin D 1,000 units OD – Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and multiple other biological effects. This helps in absorption of calcium to promote nourishment to the bone and skin. Calcium can enhance the effects of digoxin on the heart, using too much cholecalciferol can cause digoxin toxicity and irregular heart rhythm. Though it is used in treating Osteoporosis of Audrey. If the doctor prescribed these medications together, it may need a dose adjustment or more frequent blood tests to monitor calcium and digoxin levels. We need to educate Audrey to increase oral fluid intake and high fiber diet since this medicine may also cause constipation.

    Metformin 500mg BD (BSL 5 @ 1200) -It helps to lower down the blood sugar. Metformin is recommended to be temporarily discontinued before any radiographic study involving iodinated contrast agents, (such as a contrast-enhanced CT scan or angiogram), as the contrast dye may temporarily impair kidney function, indirectly leading to lactic acidosis by causing retention of metformin in the body. If Audrey might require a radiographic procedure, we need to notify the doctor to review Audrey’s current medications. Prior to her surgery we need to monitor her blood glucose level and inform the doctor of the significant findings.

    Esomeprazole 40mg OD – is a proton pump inhibitor that decreases the amount of acid produced in the stomach. Used to treat symptoms of gastroesophageal reflux disease (GORD).It interact with warfarin, digoxin; the concentrations of these drugs may increase if they are used concomitantly with esomeprazole. Advised Audrey it may be taken one hour prior to meal, avoid crushing or chewing it. thus increasing the risk of bleeding and digoxin toxicity; notify the doctor immediately if unusual changes occurred and suggest to team doctors to review Audrey’s list of medicine for different timing of the drugs to prevent drug interaction.

    Efexor 150mg OD – is an antidepressant belonging to a group of drugs called selective serotonin and norepinephrine reuptake inhibitors. Used primarily for the treatment of depression, general anxiety disorder, social phobia, panic disorder. Monitor Audrey’s appetite since it may alter taste and leads to anorexia. It is important to provide re-assurance since Audrey’s living alone. Comfort and proper hygiene as it may cause behavioral changes.

    Caltrate 600mg OD – a calcium supplement taken for her Osteoporosis. Encourage to increase oral fluid intake since it may cause thirst, dry mouth and constipation. Notify doctor with drug interaction to Digoxin as hypercalcemia increases risk of digoxin toxicity. It is best to take with food and full glass of water. A passive range of motion exercises would be helpful to prevent constipation.

    Mylanta 15-30mls prn – an antacid used for the treatment of GORD. Can hinder the absorption of the following medicines: digoxin, iron, tetracycline, antibiotics, and ciprofloxacin. Less serious side effects nausea, constipation, (Madineh, 2015)and diarrhea. It will be best to monitor Audrey’s digoxin level and bowel movement.

    Pre-operative Nursing Interventions and Rationale

    Audrey need to have a surgical clearance prior to surgery like cardiologist due to long term warfarin medication. Rationale: Audrey was on long term warfarin, there is a tendency of bleeding post-operatively. She need to be seen by the cardiologist due to her Atrial Fibrillation.

    Audrey need to have a certain test to perform such as ECG, blood test and check for blood glucose level. Rationale: ECG to detect if there is an impending cardiac problem. Blood test to check if there is an abnormality in Audrey’s electrolytes. We can also determine if there is a need for blood transfusion.

    Obtaining a signed consent form from Audrey and assessing her understanding for the upcoming surgical procedure including the risks and the benefits. Rationale: Informed Consent is a standard procedure to determine a patient’s knowledge for a certain procedure. Patient has the right to be informed in her health care decisions.

    Notify Audrey that she will be placed on Nil by mouth Rationale: To prevent aspiration and gastric reflux since esophageal sphincter will be relaxed during anesthesia.

    Conduct Cephalo-caudal assessment and record any significant abnormalities. Monitor her vital signs and compare it to her previous results. Notify the doctor immediately if abnormal results occur. Rationale: Physical assessment and vital signs shows any significant abnormalities that needs immediate attention prior to operation.

    Execute pre-operative skin preparation including bathing with clorhexidane preparation, and shampooing. Rationale: This will minimize the bacteria in the operation site.

    Assess the IV site of Audrey, administer pre-operative medicines as ordered and record. Rationale: Large bore IV cannula is needed for surgeries. Pre-operative medications should be given as ordered to create its desired effect.

    Immediate Post-Op Nursing Interventions

    Arthroplasty is a surgical procedure where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned. In Audrey’s case it is vital to consider her age and medical condition in rendering post-operative nursing interventions.

    Assess for any signs of bleeding at the operative site if noted, Notify the surgeon immediately. Rationale: Evidence of bleeding may cause hypovolemic shock in a long run if not addressed.

    Assess Audrey’s pains score including subjective and objective cues to provide immediate action. Administer analgesics as ordered. Document properly. Rationale: Pain impedes comfort thus it must be monitored and manage.

    Check Audrey’s vital signs every 15 minutes for first 30 minutes then hourly for two hours and every four hours thereafter until stable. Include Audrey’s level of consciousness and neurological assessment. Check Audrey’s oxygen level administer oxygen if needed. Rationale: Patient’s vital signs provide objective evidence of the body’s response post operatively.

    Re-educate Audrey for the use of PCA if there is any. Rationale: PCA should be instructed to patient properly to avoid toxicity and over dosage.

    Re-enforced the importance of deep breathing exercises. Rationale: This is to prevent hospital acquired pneumonia.

    Administer ordered medications such as blood thinner, antibiotics and analgesia as order. Rationale: Blood thinners helps to reduce blood clotting, antibiotics helps to prevent infection and analgesics for pain.

    Monitor Audrey’s intake and output every four hours. Rationale: To check if there is fluid deficit or excess fluid in the body after surgery.

    Encourage her to bed rest and provide call bell for assistance. Rationale: Audrey requires ample amount of time of recovery and mobility assistance is very vital.

    Discharge Planning

    Assess Audrey’s level of consciousness, vital signs, pain scale,post-op site, level of mobility, nutritional status and medications. Document it properly and ensured proper handover to the rehabilitation facility specially her medical history, current medications, surgical procedure and continuous plan of care to ensure correct nursing care will be implemented.

    Identify the appropriate mobility aids and level of assistance needed by Audrey that is recommended by the physiotherapist to promote independence and fast recovery. Recommended exercises must be done in relation to her current mobility and proper nutrition as well.

    Arrange a meeting with a social worker regarding Audrey’s concern with Rufus and contacting her daughter.

    Emphasize to Audrey the vital role of rehabilitation as this is a step-by-step process that is needed to improve her condition. Continuous nursing care is expected during this time and significant changes may it be physical or behavioral must be manage immediately.

    One of the most vital in nursing approach is holistic nursing care and teamwork from every health care facilities through this we can achieved the desired goal that the patient needs. Audrey was presented with her current conditions along with her co-morbidities. A well prioritized nursing intervention was done in its accordance. Both pre-operative and post-operative nursing interventions were performed to facilitate effective nursing care to Audrey including her current medication. Lastly, with the help of other health team members we can easily facilitate a fast recovery for Audrey along with her medical, physiological, social, mental, and nutritional needs.

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