CAP203 Care Of The Person With An Acute Illness Case Study Assessment

Assessment Task

In this assessment, you will apply your knowledge and understanding of post- operative nursing care. After analysing a 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 postoperative care of a person. 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 examine and analyse a case study. You will be required to analyse the data provided, research the surgical procedure and anaesthetic administered as well as post-operative nursing care principles. This information will then be used to discuss the holistic nursing care of the person during the post-operative period of an acute care admission.

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

• process information
• Identify problems/issues
• take action
• evaluate outcomes
• reflect on process and new learning

Instructions

To complete this assessment, you will need to examine and analyse the case study presented below and provide responses to the questions asked.

Case study

Maria Russo is a 76 year old woman who sustained an Intertrochanteric fracture of the Right femur after she fell when watering her garden. She sustained a small laceration to her Right Shoulder when she fell. Maria could not remember what happened before she fell. Maria's medical history includes osteoporosis, prediabetes and depression. She has recently been experiencing some orthostatic hypotension. She has no significant surgical history. Maria's current medications on admission are Aspirin 75mgs daily, Citalopram 20mg and Alendronate Sodium 10mg orally daily. Maria lives alone, her husband died 6 months ago. Maria's adult children live interstate. Pre-operatively Maria shared her concerns about her pet dog, Bonnie, and who will care for her while she is in hospital. Maria has undergone an Open Reduction and Internal fixation (ORIF) of the fractured Right Neck of Femur under Spinal and General Anaesthesia. Maria was nauseated in the Post anaesthetic care unit (PACU) and vomited a small amount of green fluid. IV Metoclopramide was administered with good effect. Post-operative surgical antibiotic prophylaxis and pharmaceutical and mechanical thromboprophylaxis are ordered. An intravenous PCA of Morphine is ordered together with regular intravenous Paracetamol.

The surgeon has ordered the drain tube to removed on Post-Operative day 2 (after) review) Discharge is scheduled for post-operative day 5. Observations on return to the ward Airway: patent Respiratory rate: 16 breaths/min Oxygen saturation: 97% on room Heart rate: 84 beats/min (irregular) Blood pressure: 100/60 mmHg Capillary refill: 2 seconds Intravenous therapy Cephalic vein Left arm: Hartmanns solution 8 hourly Dressing to Right hip: Intact with small amount of bright red ooze on dressing Redivac drain tube in situ: patent-200 mL of bright red drainage Bromage score: 2 Dermatome level: L2 Right foot pale, cool to touch, pedal pulse present, slight paraesthesia in toes Graduated compression stockings in situ Alert: orientated to time and place Pain score: 1/10 on rest, 3/10 on movement Temperature: 36 C BGL:9 mmol/L Maria sustains a skin tear to her lower right arm as you release the bed rails after transferring her to her room.

Questions

1. Discuss the elements of open disclosure that are required in this situation. (100) words).
2. Identify four postoperative/anaesthetic actual or potential patient problems or issues from the data presented. Briefly discuss the factors that pre-dispose Maria to these problems (200 words).
3. Discuss the nursing interventions that you would employ to prevent/manage the Identified problems. Ensure a rationale is provided for each intervention" (650 words)
4. Discuss how you would evaluate the effectiveness of these nursing interventions (150 words)" *Answers to questions 2, 3 & 4 must be submitted in a table (suggested format below) Patient problem. Nursing Rationale Evaluation Intervention
5. Reflect on what you have leamt from completing this case study and how this learning will inform your clinical practice (100 words)

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