Question

CLINICAL CASE SCENARIO

Kodjo, 15 years old boy, is admitted to the medical ward with burns on the trunk and arms by Dr. Edinam Insoko. Kodjo came with the history of wound on the trunk, dizziness, painful arms and trunk, fever (38˚C) and insomnia. His folder number is 102/06-2020. Kodjo is a Catholic with allergy of ripped plantain. Kodjo was at home for social distance as a student of the L/A Basic School at Fiayase. Kodjo was nurse in bed M7. The physician ordered the following; diagnostic investigation; Blood for full blood count, fasting blood sugar, liver function test. Urine for urinalysis, BUE, ESR, medications prescribed included Tab Amoxiclav 312.5mg daily x 7, Suppository Paracetamol 1g PRN x 72 hours, Iv Normal Saline 500mls start, Ringer Lactate 500mls start. Dr Edinam Insoko scheduled her for nutritionist specialist review on Mondays and Wednesdays for a month then physiotherapy Tuesdays and Thursdays for three (3) months as well as the plastic surgeon every Friday for three (3) weeks. You are the student nurse in the male ward working for 24 hour period work scheduled due to the COVID-19. Demonstrate your care within the 24 hour care of Kodjo on the ward using the nursing process as a guide and follow all the MOH/GHS/WHO protocol for COVID-19 complete the Nursing Care Plan for Kodjo.

As student nurse in the male ward working for 24 hour period due to the COVID-19. Demonstrate your care within the 24 hours of Kodjo on the ward using the nursing process as a guide complete your Nursing care plan for Kodjo. Also follow all the MOH/GHS/WHO protocol for COVID-19 in your care.

SECTION A

1. Complete the personal data of the Kodjo
2. Clearly detail the medical orders for Kodjo
3. State five (5) patient problem
4. State the patient allergies   
5. State the patient strength in-line with the stated problems   
6. State the nursing diagnosis for each patient problem
7. Explain in detail objective/outcome criteria for each problem in (6) above
8. Give your nursing orders to manage Kodjo
9. Write your nursing intervention provided for Kodjo with evidence-based
10. Evaluate each objective set

Answer 1

1.The personal data of Kodjo are

• Name:Mr.Kodjo
• Age:15 year
• Gender :Male
• Profession:Student
• Community /Religion:Catholic

2.The medical orders for Kodjo are

• T. Amoxiclav 312.5 for 7days (to prevent any infection)
• Paracetamol suppository 1gm as required for 3 days(yo relieve pain)
• IVF:NS:500ml,RL:500ml (to maintain fluid balance)

3.The 5 patient problem are

• Burn wound on trunk and arm
• Pain
• Dizziness
• Fever
• Insomnia

4.The patient is allergic to ripped banana (This is because of a specific protein latex produced in these tree making them allergic to it)

5.The patient's strength in line are

• His age can help him to physically accept the treatment to the best and give the most positive result to any procedure
• The patient has a 27% of burn which can be treated effectively with medical and surgical interventions .

6.Nursing diagnosis

1. Impaired tissue integrity(trunk and arm) related to burns as evidence by burn wound,observation
2. Acute pain related to burn /wound as evidenced by facial grimace ,observation ,verbalisation
3. Impaired thermoregulation related to direct skin exposure to external environment as evidenced by elected temperature
4. Impaired sleep pattern related to wound ,hospitalization ,pain as evidenced by verbalisation
5. Risk for fall related to loss of strength ,inadequate sleep as evidenced by verbalisation

7.The outcome are

1. The patient will have intact skin with medical and surgical interventions
2. Patient will verbalize decreased level of pain
3. The patient will exhibit normal body temperature
4. The patient will have a good sleeping pattern
5. The patient will be able to mobilise steadily

8.The nursing orders are

• Medication
• Wound care
• Nutritional support
• Assisting in mobilisation
• To maintain normal body temperature and symptomatic care
• Infection control practice
• Psychological support

9.The nursing interventions required are

• Daily wound care or dressing to progress the wound healing
• Monitor vital signs to get baseline patient information and plan for care
• Administer medication as per order to provide symptomatic relief
• Maintain intake and output records to assess for any homeostatic changes in the body
• Follow aseptic techniques in procedure to prevent cross infection
• Assess the patients neurological status to rule out any cause of dizziness related to CNS

10.The evaluation if the patient are

• The patient will be able to do daily act without any dizziness
• The patient will have normal body temperature
• The pain level decreases and improves the patient comfort zone
• The skin starts to show healed sign