Assessment item 3- case scenario
Mr David (Dave) Porter, is an 83-year-old widowed man who lives alone on his farm. He has a son who is ma
ied (no names have been provided by Mr Porter) and they are a four-hour drive away from Mr Porter.
Mr Porter was head butted by a horned ram yesterday, whilst in the sheep yards, preparing them for the shearers. A shearer called an ambulance and Mr Porter was transfe
ed to a large rural hospital and a
ived in ED at 1800 hours. An x-ray at 1900 hours in the Emergency Department (ED) confirmed a closed transverse fracture to the shaft of the right femur. Staff in ED prepared him for surgery and awaited advice from the Orthopaedic Surgeon.
Mr Porter is allergic to Morphine, reporting a history of a severe rash on two separate occasions when previously given this medication. He has a history of:
PmHx-
Hypertension;
Osteoarthritis;
Gastro-oesophageal reflux disease;
Atrial fi
illation; and
Congestive cardiac failure.
Mr Porter’s usual medications include:
Meds-
Apixaban 5mg PO BD;
Metoprolol 25mg PO BD;
Digoxin 62.5mcg PO daily;
Frusemide 40mg PO BD (mane/midi); and
Nexium 40mg PO nocte.
Pre-operative (baseline) observations:
BP: 170/65 mmHg;
HR: 98 bpm (i
egular);
RR: 20/minute;
SpO2: 96% on room ai
Peripheral pulses present R=L;
Cap refill <3secs R=L;
GCS 15/15; and
Temp: 36.0°C.
Mr Porter was administered all of his regular morning medications, except Apixaban 5mg, prior to theatre at 0630 hours this morning. At 0800 hours, Mr Porter was taken to the Operating Theatre (OT) from Emergency for an open reduction and internal fixation of the fracture. Following this operation, he was transfe
ed to the Post-Anaesthetic Care Unit (PACU) at 1200 hours. Post-operative orders include:
VTE prophylaxis;
Triflow / deep
eathing exercises;
Bellovac wound drainage, hourly checks until review by Orthopaedic team;
Leave dressing intact until Ortho Team review;
Bedrest until Physio review;
Analgesia as charted;
IV fluids as charted;
Prophylactic antibiotics for 48 hours post OT as charted;
IDC q1h measures;
Blood transfusion as per orders;
Light diet and fluids orally as tolerated.
You are working as a Registered Nurse in the Orthopaedic Surgical Ward and you have been allocated Mr Porter for your shift. You receive a call from Mr Porter’s son at 1200 hours, he states his name is John. John has asked you to call him when his father a
ives on the ward to be given an update on Mr Porter’s condition. There is no indication on record of who is Mr Porter’s next of kin.
The PACU Registered Nurse (RN) accompanying Mr Porter a
ives on the Orthopaedic Ward and is handing over to you at 1400 hours. All of the observations last taken in the PACU until were within the normal ranges for that unit. The nurse mentions Mr Porter had all of his regular medications prior to theatre at 0630 hours, the Apixaban was withheld, and in the PACU post operatively, he was administered:
Cefazolin 2g IV BD;
Heparin 5000 units SC BD; and
PRN orders include Fentanyl 50mcg IV every 3/24.
There are two peripheral intravenous cannulas inserted (one in each forearm). Mr Porter has received in OT:
2 litres of Sodium Chloride 0.9%;
1 unit of Packed Red Blood Cells (PRBC); and
Cu
ently has 1 litre of Hartmann’s solution running over 4 hours that was commenced at 1300 hours.
The PACU RN also states in the clinical handover that Mr Porter complained of pain about ten minutes ago but the staff in the PACU determined not to give him analgesia due to his observations being within normal limits and “he didn’t look like he was in too much pain”. She also mentioned that Mr Porter’s haemoglobin result was 72 Hb g/L just before he was transfe
ed and he has been ordered another unit of PRBC that is ready at the Blood Bank to be collected and commenced as the blood from the Bellovac is not able to be used.
This patient is now under your care.
Observations taken by you after a
ival to Orthopaedic Ward at 1415 hours:
BP: 103/50 mmHg;
HR: 81 bpm (i
egular);
RR: 22/minute;
SpO2: 94% with Nasal Prongs 3L/min;
Temp: 36.1°C;
Pain Score – 7/10;
GCS - 13/15.
When you speak to Mr Porter he wakes to your voice and answers simple questions appropriately yet is slightly confused saying that he was “just about to close the yard gate”, he obeys your commands, and returns to sleep when you stop speaking to him.
Question 1: Apply the A2K Assessment Framework (Primary and Secondary Survey) to Mr Porter's case and differentiate between the normal and abnormal clinical findings.
Propose at least two (2) nursing assessments that are indicated based on the abnormal findings and explain why these assessments are necessary.
Question 2: Identify one (1) nursing intervention (medication OR Intravenous fluid OR blood product) that has been prescribed for the patient and explain:
· why the intervention is specifically indicated;
· the safety considerations (including the '5 Rights') needed when a nurse is administering this intervention;
· why a nurse should administer the intervention OR why a nurse might choose to withhold the intervention and seek clarification.
Question 3: Identify and relate one (1) Standard of Practice (NMBA, 2016) AND one (1) fundamental responsibility from the ICN Code of Ethics for nurses (ICN, 2012) to the nursing care of the patient in the scenario.