Question

Marita sustained the following injuries in the fall:

-Two deep lacerations to her right leg

-Grazes to the right side of her face, shoulder, arm, leg, and torso

-Severe injury to her right wrist and upper right arm

-She had no altered conscious at the time of the accident

-Marita denied any neck pain and denied any altered sensation in her limbs.

Marita was taken to hospital via air ambulance. Where she had multiple Xrays that showed:

• Fractured Right humerus,

• Fractured Right radius

• Fractured Right 3rd & 4th ribs.

• There were no other injuries

• Head CT showed no signs of bleeding or trauma to her brain.

Surgery Marita required surgery under general anaesthesia to clean and suture her multiple wound lacerations and reduce her fractures. A plaster cast was applied to her right arm. She has sutures in her right thigh wound and a Jackson Pratt drain to her thigh, and sutures to her calf laceration. The operation was mostly uneventful apart from approximately 300ml of blood loss from her lacerations. She was given 1 unit of packed red cells, and 1 litre of Hartmann’s solution intra-op. Marita was transferred to the orthopaedic ward from theatre last night at 10:30pm. It is now the following morning and you are assigned to care for Marita. You assess Marita at 08:00 hours and your assessment findings are:

- Marita is awake and alert. She is orientated to time, place & person.

- Her right eye is bruised and almost shut due to an extensive haematoma. She is quite teary & asks if she is going to be ugly due to the facial grazes and her other scars. She’s extremely worried she’ll never get full use of her right arm back. She is also very concerned that she won’t be able pay for this as she’s not covered by Medicare.

- There is blood staining the dressings on her leg. The right leg drain has about 70ml of frank blood in it. Her right arm is swollen and bruised. The fingers on her right hand are also swollen. She has good movement and normal sensation in the fingers of her right hand. The skin is the same colour as her left hand apart from some bruising. The fingers to her right hand are cool to touch, and the capillary refill time is 3 seconds. Marita is complaining that the cast feels tight.

-  Her vital signs are: Temperature: 37.6C, Pulse: 115 & regular, Blood Pressure 92/58 mmHg, Respirations: 20 & shallow, Oxygen Saturation: 95% on 3LNP. She says it hurts to breath. • Marita is complaining of a dry mouth and being thirsty. There is no record of her passing urine since her return from surgery. Marita can’t remember when she last used the toilet

- She did not eat much of her breakfast but drank some of the orange juice and half a cup of coffee. She said it hurt her face to eat and the coffee was cold and not real coffee.

- She has a PCA in place and says her pain is bearable at the moment if she doesn’t move too much or try to breathe deeply or cough. Her PCA and IVT are connected to the cannula in her left arm. She has a litre of Normal Saline running at 40mlshr.

1. Using the case study information above, identify and justify three (3) important health issues that you need to address for Marita during your shift. Identify and explain the significance of the clinical cues you have used to prioritise your selection.
2. Provide an explanation of the action you will take to manage each health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.

Answer 1

The improtant health issues that need to address the patient are regarding

1. acute pain in the surgery site related to presence of surgical incision as evidence by verbalized of pain in the surgical site by the patient.

Nursing intervention:

- Assess the pain level by using numerical pain scale of facial pain scale to identify the level of pain suffer by the patient.

- Provide a comfortable position to the patient

- Avoid unnecessary movement of the surgical part to prevent pain.

- Administered analgesic if the pain is severe and it should be administered after advice by the doctor.

- Provide diversional therapy like music therapy, deep breathing exercises and provide psychological support to the patient.

- Provide proper rest and prevent noise environment.

2 Fluid volume deficit related to restriction of oral intake due to surgery as evidence by no urine output, feeling

thristy and dry mouth.

Nurisng intervention

- Assess the patient for the dehydration signs.

- Administer the patient with liquid diet only as the patient just come out from the surgery.

- assess the intake and output chart. Advice the patient to inform after passing the first urine after the surgery because it is necessary to pass the urine within 8 hours after the surgery.

- Start infusion of IV fluid to hydrate the patient.

- Provid small and frequent liquid diet to the patient to prevent from thirsty and dry mouth.

3. Activities intolerance related to pain in the surgical site as evidence by verbalized for pain in movement.

- Assess the condition of the patient

- Assisst the patient in doing the daily activities as the patient cannot do alone

- Avoid unnecessary movement of the surgical part.

- Help in mobilizing the patient once the doctor advice to do it.

- Provide the passive exercises or movement of the fingers or toes to maintain proper blood circulation in the extrimities.

- Raise up the siderails to prevent fall from the bed.