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CAP203 Care of The Person with an Acute Illness Case Study Sample

Assessment Task

This assessment is designed to further assess your knowledge of pre-operative nursing care. This assessment follows on from Assessment 1. From your analysis of the case study you will answer a series of questions. Please refer to the Task Instructions for details on how to complete this task.

Context

The Registered Nurse plays an important role in the preparation of a person for surgery. This assessment provides you with the opportunity to apply theory to a clinical scenario. To complete this assessment you will need to apply clinical reasoning processes as you continue to examine the case study from Assessment 1.

You will be required to integrate the information from analysis of the data provided together with your knowledge of pathophysiology, clinical manifestations and legal and ethical principles to the holistic nursing care of a person during the pre-operative period of an acute surgical admission.

You will need to use the following processes from the clinical reasoning cycle to complete the assessment:

- Establish Goals

- Take action

Instructions

To complete this assessment, you will need to examine and analyse the case study presented below and provide responses to the questions asked.
This assessment continues on from Assessment 1 and now requires you to identify the appropriate nursing interventions and specific goals required for the patient problems identified in Assessment 1.

The case study is provided below for your further analysis.

Case study

Maria Romano is a 76 year old woman admitted to the Emergency Department via ambulance. Maria fell when watering her garden and was unable to get up. She was lying in her garden for 3 hours until her daughter came home from work and found her. Maria's medical history includes osteoporosis, glaucoma and she has recently been diagnosed with early dementia. She has no significant surgical history. Maria lives with her daughter Paulina and Paulina's husband, Sam. Maria's current medications include Aspirin 75mgs daily, Alendronate Sodium 10mg orally daily & Latanoprost eye drops to both eyes nocte. She was administered Intravenous Morphine and inhaled Methoxyflurane by the paramedics.

Assessment data:

Airway: patent

Respiratory rate: 18 breaths/min Oxygen saturation: 97% on room air Heart rate: 90 beats/min Blood pressure: 110/70 mmHg Capillary refill: 2 seconds

Right leg shortened and externally rotated Right hip bruised and oedematous

Right foot pink, cool to touch, no paraesthesia or abnormal sensation, pedal pulse present

Alert: orientated to time and place Pain score: 5/10 on rest, 7/10 on movement

Temperature: 35 C

Small laceration to lower left leg

Blood glucose: 9 mmol/L

Intravenous cannula inserted Cephalic vein Left arm

X-rays reveal an Intertrochanteric fracture of the Right femur. Maria is seen by the Orthopaedic surgeon and is scheduled for an Open Reduction and Internal fixation (ORIF) of the fracture. She has been placed on the Emergency Operating List. The Registered Nurse has just administered Intravenous Morphine 2mg and the anaesthetist has been contacted to perform a femoral nerve block. The orthopaedic registrar will visit Maria in the next 10 minutes to gain consent for the surgery. Maria is accompanied by Paulina, who is clearly upset about her mother's hospitalisation. Paulina informs you that she is so worried about how thin Maria is.
She is also concerned that Maria has been falling frequently over the past few months, she purchased a walking frame for Maria but she rarely uses it. You note that Maria is upset that she is going to require surgery. She is worried about her garden and who will water it while she is in hospital.

Questions

- Discuss the Registered Nurse's role regarding the issues related to informed surgical consent, confidentiality and privacy that were identified in Assessment 1 (120 words)

- Develop four short term goals to be achieved in the pre-operative period. These goals should relate to the problems identified in Assessment 1. Discuss who must be involved in the development of these goals (80 words)*

- Discuss the nursing interventions required to meet the identified goals and pre-operative patient problems (from Assessment 1). Ensure that rationales are provided for these interventions (400 words)*

- Answers to Questions 2 & 3 can be presented in a table (see a suggested format below)

Solution

Registered nurses’ role

In the case of Maria, consent issues arise in terms of accompanying her immediate family, her daughter Paulina, in the surgical process and recovery from her current cognitive condition. For Assignment Help, Maria's current cognitive condition interim of dementia has made informed consent difficult, and her daughter Paulina is also upset about the hospitalisation; thus, there is needed to manage the situation for informed consent. As per Australian healthcare guidelines, informed consent is taken only after giving accurate and relevant information regarding intervention and outcome, as well as ensuring privacy and confidentiality to the individual (Australian Commission on Safety and Quality in healthcare, 2022). The role of the RN here is to delegate and provision the informed consent process and ensure that the patient and immediate family has enough knowledge of the process to give informed consent (Queensland Government, 2022). Also, maintaining privacy and confidentiality related to patient’s problem help in the healing of the problem quickly. Similarly, in the case of Maria, the RN has to follow the same.

Short term goals

- Providing energy to the body
- Increasing haemoglobin in the body before surgery
- Managing pain associated with fracture
- Assuring Maria to avoid preoperative distress

While developing the goals, surgeons, orthopaedics, nutritionists, general physician as well as registered nurses are needed to be involved.

Nursing intervention

References

 

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