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- QUESTION
Scenario
One week ago, you started your dream job as an orthopedic nurse at a Level 1 Trauma Center in a metropolitan city of 3.7 million people. The hospital has ranked as the #5 Trauma Orthopedic Specialty Unit in the United States for eight years. At this point during orientation, you are permitted to care for one stable client per 12-hour shift. Today you start your shift with Ryan; a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room his first statement is, “Can someone please get me a cigarette or a patch; I have not had a smoke since yesterday morning!”Assessment Data:
The client is sitting up in bed with thigh-high anti-embolism stockings on the left leg only.
Dressings to multiple abrasions appear dry.
Urine in Foley Bag amber colored and urinary output in the past 2 hours 40cc
Pain reported as 8 on a scale of 10 with a goal of 5
Vital signs:BP 130/80
Heart Rate 92
O2 Sats 94% on 4L Nasal Cannula
Blood Gases:pH 7.32
PaCO2 53 mmHg
HCO3 22mmol/L
Pao2 84mm Hg
Physician’s Orders:Bed Rest Only
Clear Liquid Diet
Oxygen to maintain Spo2 of 92% or greater
ABGs repeated every 4 hours
Discontinue PCA and consult pain management
Administer tetanus and flu immunizations before discharge
Administer 1-2mg Morphine IV every 4-6 hours as needed for breakthrough pain
As you review the assessment data and physician orders, you plan client care and determine six nursing interventions you believe are appropriate and should be completed in this order within the next hour:Administer 2mg Morphine IV now for breakthrough pain
Apply anti-emoblism stockings bilaterally
Call the physician to get an order for Nicotine Patch and report decreased urinary output with amber urine
Input consult for pain management into the electronic order system
Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring
Administer tetanus immunization
Instructions
As you write down the proposed interventions, the nurse manager stops by to check on your progress and asks you a few questions regarding your decisions. The nurse manager is disappointed and states, “One of these actions is not correct I want you to write down what you believe is the best choice from your list to do immediately and the action you believe is incorrect and should not be done. I will be back in 10 minutes to discuss your thoughts.”On a document provide detailed responses to these questions:
What is the best action to perform first from the six actions identified as part of planned client care for this particular client?
What is the best action to perform second from the six actions identified as part of planned client care for this particular client?
What is the best action to perform third from the six actions identified as part of planned client care for this particular client?
What is the best action to perform fourth from the six actions identified as part of planned client care for this particular client?
What is the incorrect action?
| Subject | Nursing | Pages | 4 | Style | APA |
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Answer
Orthopedic Nurse
The aim of this paper is to analyze the provided scenario on an orthopedic patient admitted to a Trauma Orthopedic Specialty Unit. The scope is limited to re-evaluation and prioritization of the nursing care plan that I made earlier in my new role as an orthopedic nurse. The nurse manager had raised concerns about my nursing care plan; thus, I have to re-evaluate and prioritize it. The revised care plan will be as follows: The first step is to administer 2mg Morphine intravenously immediately for breakthrough of pain. The second nursing intervention is to apply anti-embolism stockings bilaterally while the third intervention will be to report decreased urine output with amber urine. The fourth step is to input consult for pain management into the electronic orders system. However, it is incorrect to call the physician to order for nicotine patch since nicotine may hinder the healing or recovery process. On the other hand, decreasing O2 to 2L nasal cannula is not necessary at the moment; whereas, the patient will be given tetanus immunization on the day of his discharge.
The first intervention is to administer 2mg morphine intravenously to relieve pain. The patient reports pain of 8 on a scale of 1 to 10 with 10 more severe pain, with a goal of 5. The rationale for this is that the reported severe pain (8/10) is the most immediate need that should be addressed. Pain may induce severe complications that may lead to further deterioration of the patient. Provision of timely and appropriate pain management to trauma patient prompts early healing and is also a patient right (Ahmadi et al., 2016). Besides, O2 therapy should be maintained at 4L nasal cannula since morphine has respiratory depressant effects and may increase arterial PCO2, which may increase intracranial pressure (Ahmadi et al., 2016).
The second immediate intervention will be to apply anti-embolism stockings bilaterally to prevent inflammation and thrombi formation that may lead to deep vein thrombosis (DVT). The rationale is that the patient is confined to bed rest only, which increases the risk of DVT. However, below know compression stockings are preferable for use on the injured leg to allow for management of surgical wounds on the thigh region. Immobilization of patients to bed rest for an extended period of time can increase risk of DVT (Rosendaal, 2016). Bed rest poses various risks that may lead to formation of DVT. It includes the fact that blood flow tends to slow at rest and there will be limited body movement, which are key risk factors for formation of DVT. Besides, the chances that a deep vein was injured during the surgical operation cannot be ruled-out; hence, bilateral anti-embolism stockings is indicated (Thompson, 2015).
The third nursing intervention will be to decrease urine output with amber color. For two hours, the patient has only produced 40cm3 of urine. Reduced urine output may be an indication of renal complications such as decreased kidney functions, chronic renal disease, and a problem with water-electrolyte balance (Hodel et al., 2018). Development of kidney complications may slow healing process; especially bone healing. Kidney is important in maintenance of bone health and in metabolism of minerals. Thus, kidney disorders may lead to development of kidney disease-mineral and bone disorder. Chronic kidney disease may in turn promote vascular calcification and soft tissue calcification (Mosbah, 2019).
The fourth nursing intervention will be to input consult for pain management into the electronic orders system. The rationale is to capture the attention of a multidisciplinary team to develop a sustainable, appropriate, and long-term pain management. Morphine is contraindicated for long-term use since due to high addiction and abuse potential. Besides, morphine is associated with adverse effects such as increase of intracranial pressure and respiratory depression (Ahmadi et al., 2016). Morphine is an opioid with strong analgesic effects. However, it can lead to decrease in cardiac contractility, which results in signs and symptoms such as hypotension, vasodilation, bradycardia, edema, syncope, orthostatic hypotension, and in worst case scenarios it may cause death (Chen & Ashburn, 2015). Therefore, an alternative pain management plan should be decided and put in place.
With review of evidence, it has been established that it was an incorrect decision to include the use of nicotine patch in the care plan. Cigarette smoking or nicotine replacement therapy is associated with poor healing; thus, surgical wounds and other wounds sustained from the accident may become chronic (McDaniel & Browning, 2014). Nicotine may increase the risk of complications, during or following a surgical operation such as cardiac complications, respiratory complications, and healing-associated complications such as wound dehiscence and surgical site infections (Nolan & Warner, 2015). The mechanism of harmful effects of cigarette smoke or nicotine replacement therapy include decreased tissue oxygenation, smoking-induced elevation of reactive oxygen species, smoking or nicotine-induced vasoconstriction, and indirect and direct cellular effects, for example, impairment of the endothelial nitric oxide release (Nolan & Warner, 2015). Therefore, nicotine patch should be dropped from the nursing care plan
Orthopedic Nurse
The aim of this paper is to analyze the provided scenario on an orthopedic patient admitted to a Trauma Orthopedic Specialty Unit. The scope is limited to re-evaluation and prioritization of the nursing care plan that I made earlier in my new role as an orthopedic nurse. The nurse manager had raised concerns about my nursing care plan; thus, I have to re-evaluate and prioritize it. The revised care plan will be as follows: The first step is to administer 2mg Morphine intravenously immediately for breakthrough of pain. The second nursing intervention is to apply anti-embolism stockings bilaterally while the third intervention will be to report decreased urine output with amber urine. The fourth step is to input consult for pain management into the electronic orders system. However, it is incorrect to call the physician to order for nicotine patch since nicotine may hinder the healing or recovery process. On the other hand, decreasing O2 to 2L nasal cannula is not necessary at the moment; whereas, the patient will be given tetanus immunization on the day of his discharge.
The first intervention is to administer 2mg morphine intravenously to relieve pain. The patient reports pain of 8 on a scale of 1 to 10 with 10 more severe pain, with a goal of 5. The rationale for this is that the reported severe pain (8/10) is the most immediate need that should be addressed. Pain may induce severe complications that may lead to further deterioration of the patient. Provision of timely and appropriate pain management to trauma patient prompts early healing and is also a patient right (Ahmadi et al., 2016). Besides, O2 therapy should be maintained at 4L nasal cannula since morphine has respiratory depressant effects and may increase arterial PCO2, which may increase intracranial pressure (Ahmadi et al., 2016).
The second immediate intervention will be to apply anti-embolism stockings bilaterally to prevent inflammation and thrombi formation that may lead to deep vein thrombosis (DVT). The rationale is that the patient is confined to bed rest only, which increases the risk of DVT. However, below know compression stockings are preferable for use on the injured leg to allow for management of surgical wounds on the thigh region. Immobilization of patients to bed rest for an extended period of time can increase risk of DVT (Rosendaal, 2016). Bed rest poses various risks that may lead to formation of DVT. It includes the fact that blood flow tends to slow at rest and there will be limited body movement, which are key risk factors for formation of DVT. Besides, the chances that a deep vein was injured during the surgical operation cannot be ruled-out; hence, bilateral anti-embolism stockings is indicated (Thompson, 2015).
The third nursing intervention will be to decrease urine output with amber color. For two hours, the patient has only produced 40cm3 of urine. Reduced urine output may be an indication of renal complications such as decreased kidney functions, chronic renal disease, and a problem with water-electrolyte balance (Hodel et al., 2018). Development of kidney complications may slow healing process; especially bone healing. Kidney is important in maintenance of bone health and in metabolism of minerals. Thus, kidney disorders may lead to development of kidney disease-mineral and bone disorder. Chronic kidney disease may in turn promote vascular calcification and soft tissue calcification (Mosbah, 2019).
The fourth nursing intervention will be to input consult for pain management into the electronic orders system. The rationale is to capture the attention of a multidisciplinary team to develop a sustainable, appropriate, and long-term pain management. Morphine is contraindicated for long-term use since due to high addiction and abuse potential. Besides, morphine is associated with adverse effects such as increase of intracranial pressure and respiratory depression (Ahmadi et al., 2016). Morphine is an opioid with strong analgesic effects. However, it can lead to decrease in cardiac contractility, which results in signs and symptoms such as hypotension, vasodilation, bradycardia, edema, syncope, orthostatic hypotension, and in worst case scenarios it may cause death (Chen & Ashburn, 2015). Therefore, an alternative pain management plan should be decided and put in place.
With review of evidence, it has been established that it was an incorrect decision to include the use of nicotine patch in the care plan. Cigarette smoking or nicotine replacement therapy is associated with poor healing; thus, surgical wounds and other wounds sustained from the accident may become chronic (McDaniel & Browning, 2014). Nicotine may increase the risk of complications, during or following a surgical operation such as cardiac complications, respiratory complications, and healing-associated complications such as wound dehiscence and surgical site infections (Nolan & Warner, 2015). The mechanism of harmful effects of cigarette smoke or nicotine replacement therapy include decreased tissue oxygenation, smoking-induced elevation of reactive oxygen species, smoking or nicotine-induced vasoconstriction, and indirect and direct cellular effects, for example, impairment of the endothelial nitric oxide release (Nolan & Warner, 2015). Therefore, nicotine patch should be dropped from the nursing care plan
References
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Ahmadi, A., Bazargan-Hejazi, S., Zadie, Z.H., Euasabhon, P., Ketumarn, P., Karbasfrushan, A., Amini-Saman, J., & Mohammadi, R. (2016). Pain management in trauma: A review study. Journal of Injury and Violence Research, 8(2), 89-98. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967367/#__ffn_sectitle Chen, A., & Ashburn, M.A. (2015). Cardiac effects of opioid therapy. Pain Medicine, 16(Suppl. 1), S27-S31. https://doi.org/10.1111/pme.12915 Hodel, N.C., Hamad, A., Praehauser, C., Mwangoka, G., Kasella, I.M., Reither, K., Abdulla, S., Hatz, C.F., & Mayr, M. (2018). The epidemiology of chronic kidney disease and the association with non-communicable and communicable disorders in a population of sub-Saharan Africa. PLoS One, 13(10), e025326. DOI: 10.1371/journal.pone.0205326. McDaniel, J.C., & Browning, K. (2014). Smoking, chronic wound healing, and implications for evidence-based practice. J Wound Ostomy Continence Nurs., 41(5), 415-E2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241583/ Mosbah, O. (2019). Chronic kidney disease-mineral and bone disorders (CKD-MBD). Archives of Nephrology and Urology, 2, 033-051. http://www.fortunejournals.com/articles/chronic-kidney-diseasemineral-and-bone-disorders-ckdmbd.html Nolan, M.B., & Warner, D.O. (2015). Safety and efficacy of nicotine replacement therapy in the perioperative period: a narrative review. Mayo Clinic Proceedings, 90(11), 1553-1561. DOI: https://doi.org/10.1016/j.mayocp.2015.08.003. Rosendaal, F.R. (2016). Causes of venous thrombosis. Thrombosis Journal, 14, Article number: 24. https://thrombosisjournal.biomedcentral.com/articles/10.1186/s12959-016-0108-y Thompson, A.E. (2015). Deep vein thrombosis . JAMA, 313(20), 717-728.
Appendix
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