Nursing Case Study Report
Introduction
Background: The said story takes place against this background whereby Mr Palmer's medical history includes Type 2 diabetes, high total blood cholesterol levels and hypertension with a smoking habit as well. Nevertheless, he had several physical traumas with the large wound on his left leg and the abrasions on his right forearm resulting from the fall. It turned out that the scan of the patient's brain showed no abnormalities but showed a noticeable swelling in the lower left leg.
Assessment: Presently, Mr Palmer experiences concerning symptoms: including a sudden headache, laboured breathing, slurred speech, pain, sweating, nausea and often an aversion to direct light.
Recommendation: He needs urgent clinical attention in order to address its overall symptoms which are major cause of his health issues.
The ISBAR framework in this report is applied to methodically and accurately detail Mr Palmer's condition and provide proper information to enhance the level of communication and continuity in care. This report will include primary nursing assessment matters, including two identified nursing problems, proposed intervention methods, discharge planning, and the reflective statement regarding the care Mr. Palmer has received. Core for Mr Palmer's healthcare team of organised approach in the short term will increase the collaboration that is efficient and the care production is tailored to the needs that are complex.
Primary admission
Mr Robert Palmer, as a result of falling from a ladder, broke some bones and his head hit hard, both of which were quite painful. Normally, the main cause of admission was to check his trauma symptoms and especially to treat his leg wounds and arm RH wounds. A compression of 2 meters resulted in a large wound on the left leg, and on the right forearm, there were abrasions. Pathophysiological disorders, tissue damage, the risk of infection, and wound repair are some aspects of his injuries.
The laceration on his left limb along with fairly swollen tissue would indicate some tissue trauma and possible blood circulation problems- which might predispose Mr. Palmer further to complications including infections and worse impaired tissue repair. Next, the scratches on the back of his right arm imply abrasion, the possibility of infection hazard, respectively.
Nowadays, the current evidence-based literature substantiates the significance of the timely evaluation and administration of traumatic injuries with compulsive complications to extend immediate recovery and speedy healing. Shaikh et al., (2022), examine such significance of early wound care measures, which include; immaculate cleansing, debridement, and the utilisation of the appropriate dressing, for the reason of cutting off the risk of infection and allowing the healing process. This is further reinforced by the research conducted by Rodrigueset. al., (2019) which highlights the reason for taking into consideration factors that impair wound healing along with those like impaired blood flow amongst others that are at play in Mr. Palmer's case.
Mr Palmer's admission to the hospital was the result of the goal to better understand the mechanisms of the injuries he had sustained, implement evidence-based techniques for his treatment, and take all measures to ensure his recovery and prevent complications from developing.
Identification of two nursing problems
Wound infection risk and impaired perfusion of tissue are key deficits of Mr Robert Palmer and are going to be focused on during the care plan.
Wound Infection Risk: Given that Mr Palmer has a significant wound on his left leg covering the damaged tissues as well as being exposed. Sandpaper skin on his right arm also renders the area more susceptible to diseases. Because of his family history which includes Type 2 diabetes and hypertension dependent on the mechanism for the speedy healing of wounds.
The statistics in the medical literature of today periodically say that protected wound care is essential. However, in light of the study posted by Phoon and Hwang (2020), meticulously cleaning wounds and debridement and dressing with the correct technique prevent infection distribution. Moreover, another investigation by Miraj et al., (2022) reveals that breakthroughs on antimicrobial dressings and preventive antibiotics are the best ways to help.
Impaired Tissue Perfusion:The swelling in the lower left leg noticed by Mr. Palmer indicates poor circulation and exacerbates the tissue cells insulted topped by the chances of complications like necrosis and delayed recuperation jeopardising further the situation. In addition, disturbing tissue perfusion can also exaggerate the problem of Mr. Palmer`s underlying medical illnesses.
These scientific methods are striving for the best means of getting the blood/fluid to the damaged area, which in turn will assist the healing process to take place. Urbanek et al., (2020) reported interventions including limb elevation, compression therapy, and pharmacological agents, that can be used to improve the vessels' blood perfusion and decrease swelling. Moreover, ongoing performance of serial checks of tissue perfusion as manifested by the hue of skin, temperature of touch, and capillary refill time is critical to timely diagnosis and prompt actions (Pressman et al., 2020).
Nursing Management
Nursing Management: Wound Infection Risk
Assessment and Rationale:
A meaningful nurse evaluation for risk assessing skin wound occurrence in Mr. Palmer is an in-depth screening for wound assessment. The assessment involves examining the area of the infected wound for swelling, redness (warmth), and discharge or odour; and, checking the surrounding area to determine the presence of erythema and warmth which are signs of infection. Furthermore, searching for signs of systemic infection like fever and tachycardia in Mr. Palmers vital signs is needed.
The aim of this assessment will then be to detect any signs of wound infection promptly. This will allow the implementation of precautionary measures for the infection to be stopped early. The detection of infection at its early stage by the nursing team helps the implementation of timely relevant measures that can help in the healing of the wound and prevention of complications.
Intervention and Rationale:
About intervention in Mr Palmers wound infection risk, effective intervention options for his proper nursing include wound care and hygiene. The intervention under consideration would include rinsing the wound with a suitable cleansing solution, for example, one based on saline solution, so that possible debris and bacteria can be eliminated (Murphy et al., 2020). A useful solution could be to apply an antimicrobial dressing on the wound to mitigate bacterial colonisation and a moist environment to the wound.
The main objective of the antibacterial method is to reduce the risk of infection by eliminating of bacteria from the wound area and making the environment clean inhibiting the growth of bacteria. Antimicrobial dressings would successfully Lower bacterial propagation and infected wound rates, as a study by Church et al. (2019) indicates.
Nursing Implications for Medication Management:
During the infection risk management common in wound care medication management is pivotal. Mr Palmer may be administered antibiotic therapy to prevent infection and will be given antibiotic therapy directly if the infection is suspected or confirmed. The selection of antibiotic treatment should be regulated by blood/surgical site culture & sensitivity testing to obtain the ideal antibiotic to which the causative pathogen is susceptible and to minimise the risk of antibiotic resistance (Pamu, 2019).
An extremely urgent task is to keep the nursing team observing Mr. Palmer for any of the adverse effects of antibiotic therapy, for example, allergic reaction and GB disturbances, as well as provide education on medicine intake and their side effects symptoms (Angelopoulou et al., 2022). Furthermore, providing adequate nutrition and hydration helps to cope with immunity and accelerate the processes of wound healing.
Adopting the outlined nursing interventions, and comprehension of the medication regimen will assist in diminishing the chances of wound infection and hastening the healing process for Mr. Palmer.
Therefore, it can be started that the continuous monitoring and wound healing processes will help in the progression of the entire assessment. Therefore, any kind of or any sign of infection and re-occurrence or the compliment communication could be addressed significantly. Regular assessment is very much essential in evaluating, the opinions on the patients vital and responding towards his appearance with respect to the future intervention.
Nursing Management: Impaired Tissue Perfusion
Assessment and Rationale:
A competent nursing assessment to be carried out on Mr Palmer and checking the tissue perfusion through neurovascular of the limb that impairment has involved involves taking regular neurovascular assessments (Owens et al., 2022). Such testing includes the evaluation of sensory function (for example of the effects of touch and temperature of humidity), of motor function (for instance of the toe and foot movements), and of the capillary refill time. Upon patient examination, physicians will take accurate vitals of the affected limb and measure the colour, temperature, and pulse strength (Flateland & Moi, 2022).
It aims to identify conditions when the tissue perfusion is compromised early on, lucidly undertaking measures to decrease the level of tissue damage and bring healing forward. Early identification of poor circulation in the tissues helps the nursing staff to promptly perform adequate measures which include improvement of blood flow and prevention of complications such as the death of the cells and delayed wound healing.
Intervention and Rationale:
Limit the effect of impaired blood flow in Mr Palmer by lifting the body part and using compression therapy. Placing the limb above the level of the heart can be effective in decreasing swelling further as drainage back into the heart would become easier which in turn helps in improving tissue perfusion (Wilk et al., 2020). Compression therapy, eg, bandaging with compression garments, or stockings can help venous return to be effective thereby lessening the volume of oedema (Kankariya et al., 2021).
This will be carried out with the whole aim of optimising tissue perfusion with the assistance of minimising tissue swelling and enhancing blood flow to the affected limb. The efficacy of limb elevation and compression treatment in increasing tissue perfusion and reducing oedema was proved in studies by Ahmadinejadet al., (2022), where they analysed lower extremes of patients with acute injuries.
Nursing Implications for Medication Management:
Although medication management has a limited role to play towards the management of impaired tissue perfusion, it is an essential part of overall care. Mr. Palmer may gain from the medication including platelet inhibitors, or anticoagulants that will curb the formation of thrombus and blood circulation to the affected limb (Weissler et al., 2021). Moreover, the medications needed to manage comorbidities like diabetes and hypertension are basic requirements to keep vascular health optimal, thus, ensuring the right tissue perfusion.
At this point, the supervision of the nursing team and medical monitoring of Mr. Palmer who is taking medication therapy is important, which will involve the assessment of any undesirable effects or complexities (Muth et al., 2019). Education on medication adherence, possible side effects, and lifestyle changes (smoking cessation and dietary adjustment) Mr. Palmer to read and follow instructions. By doing this, he can be an active participant in his care and improve his vascular health.
By adopting these aforementioned nursing interventions and medication management techniques, the nursing group will successfully deal with the circulation problem in Mr Palmer, improve his wound healing and ensure that the complications that come with inadequate circulation do not compromise his health (Peddle et al., 2019).
Discharge Planning
One of the goals of the discharge planning for Mr Robert Palmer, is to facilitate an easy transfer of the patient from the hospital to his community. Mr. Palmer's care plan is a very intricate one, considering that multiple nursing issues need to be managed(Zumstein-Shaha & Grace, 2023)..
Interdisciplinary practice means having different healthcare professionals work together to enable the patient to cope with the different patients' demands effectively. The administrating nurses (RN) role is viewed as focal by coordinating and managing the flow of information between the team members and the patient's interests and making sure that the patient has proper healthcare.
The multidisciplinary healthcare team involved in Mr. Palmer's discharge planning includes:
Physician:The doctor monitors the medical regimen and does individualised medicine work which involves the input of medication adjustments, wound care and further appointment adjustments (Amutah et al., 2021). Concerning Mr Palmer, the physician's job entails prescribing medications, frequent review of laboratory findings and, if needed, coordinating referrals of specialities.
Wound Care Nurse:A wound care nurse focuses on evaluating and managing besides dealing with terrible wounds (Kielo-Vijamaa et al., 2022). That level of the team member would coordinate with the RN to devise a personalised wound care program for Mr. Palmer, containing specific dressing selection, wound surveillance, and self-care instructions.
Physiotherapist:The therapist evaluates Mr. Palmer's mobility and functional status, and the therapist makes a particular rehabilitation program which explains to him about safe moving and exercise. Thus, healthcare experts should include physiotherapists in discussing possible interventions for Mr Palmer to promote additional independence and prevent further snag of this problem.
Occupational Therapist:The OT evaluates how Mr Palmer does with personal living activities and recommends devices or adaptations to be installed to increase safety and independence in his house. In addition to Mr Palmer and his family, the care team member will work with him to create a toolkit for his daily activities and his self-care.
Diabetes Educator:Considering that Mr. Palmer has a history of type 2 diabetes, the diabetes educator provides not only education on diabetes management, such as medication usage, blood glucose monitoring, and lifestyle adjustments, but also several opportunities for him to participate in pre-diabetes classes (Hales et al., 2020). This fellow member would contribute to Mr. Palmer's designing and adherence to diabetes management plans as well as assist him in the control of the disease and suppression of complications.
Social Worker:The SSW measures Mr Palmer's social and support network, notes the psychosocial issues, concerns and obstacles for discharge and provides community support resources. This team member is going to cooperate with Mr Palmer and his family to handle any psychosocial issues arising and ensure smooth discharge if he is being discharged.
Being a member of a multidisciplinary healthcare team during discharge planning will cover all his diverse needs comprehensively thus, he can live happily at home after the transition stage and this will be beneficial to him in the future (Yang et al., 2020).
Conclusion
Thus, the case of Mr Robert Palmer shows the difficulties that are faced while managing traumatic injuries and concomitant medical conditions as it is presented within a hospital environment. The report identified two prioritised nursing problems: septic wounds, ischemic tissues and occlusions in the peripheral circulatory course are the reasons for express AMI and then CHF. Using the nursing process, I stated that the proper evaluations and interventions should be made that revolve around infective control, good circulation, and wound healing. The interdisciplinary approach to post-acute care organised the care-related professionals and agencies into an efficient teamwork that met Mr. Palmer's disparate needs at full length. Through multi-disciplinary healthcare team engagement comprising doctors, wound nurses, physical therapists and social workers a discharge plan was customised to itself the process of the hospital to home transition. However it is evident that this case report stresses the importance of evidence-based practice nursing, interprofessional cooperation, and patient-centered care in the total provision of improved outcomes for people who have complex healthcare needs. Thus, the RN becomes the lynchpin in creating the interdisciplinary team that uses the collective efforts of its members to manage the disease in Mr Palmer, placement is the coherency of the care and continuity.
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