Question

Marita was transferred to the orthopaedic ward from surgery theatre , as she had fracture due to falling, 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:

She 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.

She 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 40mls/hr.

1. Identify and justify three (3) important health issues that need to be address. Identify and explain the significance of the clinical cues you have used to prioritise your selection.

2. Provide one SMART Nursing goal each for three health issues identified.

3. Provide two nursing interventions on the basis of current evidence-based literature and explanations of the actions to manage each of the health issue.

Answer 1

1.The patient is having hypovoluemic shock ,ischemia of the affection limb, hypoxemia likely due to fat embolism. These are very important serious complications. Since the patient is having low bp and tachycardia it explains shock. Since the patient is having feelings of tight compression of limb and skin changes indicate ischemia. Since the patient is having difficulty in breathing or pain while breathing indicate possibility of fat embolism because there is history of fracture. The priority of management should be first to correct the shock then release the compressing slab and then management of fat embolism.

2.The goals are to correct shock, prevent from complete ischemia of limb and management of fat embolism.

3.For the management of shock ,two large bore cannula should be inserted and fluid administration as prescribed. Periodic monitoring of bp and heart rate. For limb ishemia, removal or loosening of plaster slab/cast .It will relive the ishemia .Periodic monitoring of the oxygen saturation of the affected limb .The saturation monitoring should be done continuously to inform the physician at right time.