Assessment and Priority Nursing Interventions

In the process of planning of care to every patient, Holistic nursing is the most effective and helpful method to cater all the needs of each patient as holistic nursing focuses on the improvement and healing of an individual as a bio-psycho-social unity, from birth until death (Papathanasiou et al., 2014) Moreover, team approach is also vital in the delivery of care as team members from different disciplines work collaboratively, with a common purpose which is to set goals, make decisions and share resources and responsibilities in providing person-centered care for the patient.

This paper gives an in depth discussion in the provision of holistic nursing care suitable to the needs of the patient in the scenario, applying the nursing process. Furthermore, critical thinking skills will be used in the formulation of care plan based on the patient’s diagnosis, past and present medical history. Patient’s medications will also be discussed thoroughly including preoperative and post-operative nursing interventions to be given to the patient.

The patient in the scenario is Mrs. Audrey Smith, female, 75 year old patient who entered the Emergency department after she was found lying by a neighborhood on the kitchen floor due to slip-and-fall incident. She has been diagnosed with Fractured Neck of Femur hence Hip arthroplasty was ordered. She was also noted to have soft tissue injury and left shoulder bruising. GCS is 14 upon assessment in the emergency department, however neurological observation hourly was ordered since there is a small hematoma to her left forehead.

Safety

Always identify patient by checking ID band, asking her name prior to providing care. Ask Audrey if she has difficulty hearing, vision problem, and check if she uses necessary aids such as hearing aids and glasses for the patient to properly understand the instructions for the procedures to be done.

Orient patient to the surroundings, ensure safety by keeping side rails up, position the bed at its lowest, and lock wheels to prevent occurrence of fall whenever patient gets out of bed

Keep patient’s personal items and call button within reach to avoid patient standing and walking to get them.

Monitor activities and neurological status hourly

Hygiene and comfort

Rest, sleep, nutrition, hygiene, and dignity should be taken into consideration to promote comfort to patient because these elements have significant impact on the health outcomes and satisfaction of all patients.

Assess level of pain and administer pain medications as per doctors order

Encourage deep breathing, coughing exercises, and advise to do relaxation techniques such as guiding imagery

Practice bed sore prevention by repositioning patient every two hours, and hand hygiene to prevent transmission of health related infections to patient

Nutrition

Maintain a patent Intravenous line for proper IV fluid administration.

Weigh patient same time daily and note body mass index for provision of appropriate food to address her anorexia

Instruct patient to increase fluid and include protein rich food in the diet to promote recovery after surgery and to strengthen immune system

Monitor blood sugar level, make sure that it is in normal range due to her history of Diabetes Mellitus.

Elimination

Several conditions may contribute to the dysfunction of the bowel in geriatric patient, and one important way to maintain satisfactory elimination is observance of proper diet and a regular schedule of meals and intake of fluids.( Bargen, J.A 2016)

Administer laxatives per doctor’s order to correct constipation

Encourage regular period of elimination and advise to wear incontinent pads

Provide privacy when using commode/bedpan or urinal, cover a blanket over the person's lap to reduce embarrassment.

Activity levels

Orient patient frequently since neck fracture causes disruption vascular supply leading to delirium hence it should be taken into consideration

Encourage range of motion exercises to promote circulation

Work with a physiotherapist if necessary to furtherly monitor activity and motor function

Psychosocial needs

Asses for level of pain, and note for need to give analgesia for pain relief

Monitor patient’s cognitive state and assess her understanding about her condition because it might affect her cooperation with medical regimen and recovery

Refer to a social worker to address the Audrey’s problem about her dog

Maintain a reassuring attitude in providing care to promote comfort and security

Past medical history

Atrial fibrillation

AF is a common and important disturbance of the electrical system of the heart which is commonly referred to as arryth/dysrhythmias. This occurs when there are abnormal electrical impulses in the atria. (Heart Foundation 2016,p.2) Audrey needs to be monitored closely, obtain an ECG monitoring to prevent potential risk of stroke.

Hypertension

Hypertension, also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. This happens when the systolic blood pressure is equal to or above 140 mmHg and/or diastolic blood pressure equal to or above 90 mmHg. (World Health Organization 2013).

Audrey’s blood pressure should be monitored closely, and notify physician when abnormal findings are noted and/or administer anti-hypertensive medications as per doctors order.

Left cardiovascular accident

It is commonly known as Stroke. A stroke occurs when the blood supply to a part of your brain is interrupted, either by a blockage or rupture of a blood vessel depriving brain tissue of oxygen and nutrients. (Stroke: Mayo Clinic 2018).

Close monitoring of Audrey’s Neurological status is needed. She has history of Left CVA in 2008 which resulted to her right sided body weakness, she has high risk for fall thereby constant assistance is needed.

Type II diabetes mellitus

Type 2 diabetes is a serious and common chronic disease resulting from a complex inheritance-environment interaction along with other risk factors such as obesity and sedentary lifestyle. (Wu et al., 2014).

Monitor blood glucose level of Audrey before and after procedure, refer abnormal results to her Physician as it prolongs wound healing

Gastro eosophageal reflux disease

This refers to the regurgitation of gastric contents into the esophagus caused by lower eosophageal sphincter incompetence. Offer small frequent feeding with high calorie and high protein to Audrey.

Maintain head of bed slightly elevated at 30-45 degrees for at least 2 hours, and administer anti-reflux medication to relieve the symptom.

Osteoporosis

A systemic skeletal disease characterized by low bone density leading to weakening of bones which increases risk of fracture. (William Morrison, 2018)

Assess Audrey’s immobility and assist her with her activities.

Offer high protein, vitamins and mineral diet.

Total hysterectomy

A total hysterectomy means both the uterus and the cervix are removed surgically due to different reasons such as cancer, heavy and continuous bleeding, endometriosis and severe pelvic pain.

Depression

It is a cognitive disorder characterized constant feeling of sadness and loss of interest, hopelessness, pessimism, lowered self-esteem and heightened self-depreciation and out of proportion to reality. It is necessary to be a compassionate listener, show empathy to Audrey.

Medications

Digoxin 62.5 od

It is a cardiac glycosides used to increase myocardial force and contraction. (Tiziani,A Harvard,M 2017, p831). It controls ventricular rate in the treatment of chronic atrial fibrillation.

Monitor heart rate in one full minute, do not give if pulse is below 60.

Instruct patient to ask for assistance when going out of bed since it causes lightheadedness, drowsiness, and vision changes.

Warfarin 2mg OD

It is an anticoagulant/antithrombotic used to prevent certain types of blood clots in people who are at risk of blood clots or who already have thrombus.

Instruct Audrey to report bleeding gums, red or black bowel motions, easy bruising, trouble breathing or swallowing, hematuria as these are signs of bleeding

Consider Prothrombin time and INR check, and it should be stopped prior to surgery.

Coversyl 5mg OD

An anti-hypertensive drug that helps to control blood pressure by relaxing blood vessels.

Ensure safety, monitor blood pressure and report to the doctor if BP drops below normal.

Give the medication 30 minutes before meal, preferably in the morning

Vitamin D 1,000 units OD

Supplement that enhances absorption of calcium and phosphorus thus treats and manages osteoporosis.(Tiziani,A Harvard,M.2017, p1141).

Monitor BUN, Creatinine, serum calcium and phosphate levels, and encourage to take food rich in calcium and vitamin D.

Metformin 500mg BD (BSL5 @1200)

Antidiabetic agent that lowers blood glucose in insulin-dependent diabetes mellitus. Monitor blood for glucose, ketones as prescribed, and watch out for signs of Hypoglycemia such as sweating, visual and sleep disturbances, headache and palpitation.

Give tablets whole, do not cut, crush, or chew

Esomeprazole 40mg OD

A Proton-pump Inhibitor for treatment of GORD.

Obtain a baseline liver function test and monitor frequently throughout the therapy.

Give the medication 1 hour before meals, offer small frequent feeding if with nausea and vomiting.

Instruct Audrey to ask for assistance as it may cause headache and dizziness

Effexor 150mg OD

An antidepressant that treats major depressive disorder, anxiety and panic disorder.

Administer as prescribed to help Audrey boost her mood, but ensure safety and comfort as it causes dizziness and behavioral changes.

Caltrate 600mg OD

Calcium supplement that teats low calcium levels, thus needed for Audrey’s Osteoporosis

Give medication with meals, and advise Audrey to increase oral fluid intake as it causes constipation.

Watch out for signs of Hyperglycemia such as increased thirst, headache, trouble concentrating and Blurring of vision

Mylanta 15-30 mls PRN

Antacid given to neutralize acid in the stomach thus prevents heartburn. It should be taken 2 hours apart from other medication.

Instruct Audrey to drink plenty of fluids to prevent constipation.

Preoperative care

Preoperative care begins when the decision to have surgery is first considered and ends when the patient is transferred onto the operating table and the intraoperative period beings.(Health times, 2017)

Ø Firstly, provide education to Audrey prior to surgery to alleviate anxiety and to facilitate understanding of the procedure to be made. Then, she must sign an informed consent form to acknowledge that she fully understands the risks and complications of the anesthesia and the surgery, and that the surgeon has explained the operation to her.

Ø Past medical history, allergies are reviewed including medications she is taking.

Ø Preoperative assessment is done which includes brief head to toe assessment, baseline vital signs and GCS are taken, Laboratory exam must be done and checked to note for any abnormalities in the result, perform baseline ECG since she had history of AF.

Ø Ensure the patient is on NPO for 6 hours for solids and 4 hours for clear fluids to prevent aspiration intraoperatively.

Ø Check for presence of blood products for possible use since orthopedic surgeries result to significant blood loss.

Ø Promote hygiene to the patient, ensuring adequate skin preparation with soap or antimicrobial solution before surgery, nail polish should be removed to enable pulse oximetry reading, provide patient with patient’s gown and ID band, remove personal items like jewelry and dentures of the patients and keep it safely.

Ø Make sure that Intravenous lines are patents and give preoperative medications as ordered.

Post-operative care

Ø Upon transfer of patient from the post anesthesia care unit, the receiving ward nurse must monitor Audrey’s vital signs every 15 minutes for the first hour, then every 30 minutes for the next 3 hours.

Ø Assess for airway, breathing, circulation, pain level, neurological status of the patient, including wound dressing and its surrounding skin to note for signs of bleeding.

Ø Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate.

Ø Instruct to perform respiratory exercises to prevent pneumonia and atelectasis,

Ø Assist with mobility to prevent blood clots, enhance circulation to the extremities, and let Audrey understand that movement and respiratory exercises also underscores the importance of keeping pain under control.

Ø Administer pain medications as ordered. If patient is on PCA, ensure that she understands how to use it.

Discharge Planning

Ø Involve Audrey in making care plan to make sure that she properly understands the goal of care when she leaves the hospital premises. This includes the importance of recognizing signs of complications like bleeding, fever, difficulty breathing and notify her doctor immediately for management. In addition, Educate Audrey about her medications, and plan for medication monitoring to increase adherence, mobilization activities, wound care, hygiene, proper diet, and spiritual needs.

Ø Make a thorough assessment on the latest condition of Audrey including brief head to toe observation, the operative site for signs of infection, pain level, ability to take medications and mobility.

Ø Refer Audrey to a social worker for patient assistance like PCA and MOW since she leaves alone.

Ø Ensure that Audrey have a continuous social interaction to prevent her from getting back to depressive state.

The nursing care offered to Audrey came in a complex management since all aspects of nursing process was applied. Priority nursing interventions was presented in this paper as it relates to patient’s needs which includes safety, activity, comfort, psychological support, nutrition and elimination. In addition, preoperative and post-operative care has been delicately rendered to Audrey to reduce her anxiety, pain levels and achieve optimum recovery. Discharge plan was also made for smooth transition of care from hospital to home or rehabilitation facility. Team approach also played a big role in the care of Audrey since different health professionals took action. This summarizes the principle of holistic nursing where the patient was assessed and seen as a whole rather than just treating the symptoms she presented. Holistic nursing care, an individualized approach is strongly advised and advocated in the healthcare setting to achieve better patient health outcomes that is rewarding and may have positive impact on their life.