CAP203 Care Of The Person With An Acute Illness Case Study

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 Russo 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 discovered by her neighbour.

Maria's medical history includes osteoporosis, prediabetes and depression. She has recently been experiencing some orthostatic hypotension. She has no significant surgical history. Maria lives alone, her husband died 6 months ago. Her adult children live interstate.

Maria's current medications include Aspirin 75mgs daily, Citalopram 20mg and Alendronate Sodium 10mg orally daily.

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 (irregular) Blood pressure: 104/70 mmHg
Capillary refill: 2 seconds
Right leg shortened and externally rotated Right hip bruised and oedematous

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

Maria informs you that she "can't remember what happened when she fell. She woke up on the ground and could not get up''

Pain score: 5/10 on rest, 7/10 on movement

Temperature: 35 C

Small laceration to right shoulder

Intravenous cannula inserted Cephalic vein Left arm

Weight: 54 kgs Height: 174cm

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 to gain consent for surgery.

The Emergency Department is extremely busy and Maria is positioned on a trolley in the corridor while she waits for the Registrar to come. Maria's neighbour, Francesco has arrived at the hospital and keeps asking you what is wrong with Maria and demanding to speak to the doctor. Maria is upset that she is going to require surgery and is worried about her pet dog, Bonnie, and who will care for her while she is in hospital.

Questions

1. Discuss the Registered Nurse's role regarding informed surgical consent, confidentiality and privacy in this scenario (120 words)
2. 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)
3. Discuss the nursing interventions required to meet the identified goals and preoperative 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)

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