IntroductionFor this case I will be having a target patient to create

IntroductionFor this case, I will be having a target patient to create a holistic profile of their healthcare and I will also be including nursing interventions that were made to help the patient to reach their goals. The case study happened in the Orthopaedic ward at a public hospital. This is an inpatient ward which provides care for elective, acute orthopaedic and multi-trauma patients. Common situations seen on this ward are; open reduction internal fixation, bilateral/total knee joint replacement, total hip replacement and ankle fractures. This is also a dedicated education unit, so it allows student nurses, newly graduated nurses and enrolled nurses to have a space to learn with the senior nurses guiding them. I will produce a written clinical profile of the patient along with the holistic health assessment, nursing care plans, and a reflection on the practice. I will also explain how I gained informed consent whilst being able to gather enough information that would aid in creating a holistic profile. This case study interview took place on 10/09/2019.  Informed Consent The process of informed consent was done by informing the patient about the case study and that I needed to gather some information to make a health assessment profile of my patient. I let my patient know that I would be taking their vital signs and will be asking them a couple of questions regarding their health. I let my patient know that I was going to be creating a patient profile of them and any information that can be used to identify them, such as their name, would be restrained and replaced with a pseudonym to protect their identity and to maintain privacy. The patient was encouraged to ask any questions throughout the process, and I advised them that if they did not feel comfortable answering some questions, they were able to pass without any hesitation. I also let my patient know that I would inspect their notes/documents to help me create the patient profile. My patient was happy to go along with the procedure and told me that she was comfortable with sharing information to help me with my case study if personal details, such as her name, was coded. Patient ProfileMrs M is a female who is 68 years and 6 months old, Mrs M identifies herself as a European New Zealander, is an English speaker and religion was not specified. She is an NZ Citizen and lives with her husband. She described herself as a homemaker/house person. Regarding her health history she has been diagnosed with coronary artery disease (this is when the major blood vessels that carry oxygen and blood to your heart becomes narrow. That usually happens because of cholesterol build up on the inner walls of the artery. This is a long term/lifelong diagnosis and cannot be cured but can be helped with medication or lifestyle changes which is what Mrs M has chosen) and does not smoke. The reason for her admission was, she was walking down the stairs with socks on and her foot slipped, and she fell from x5 steps from landing. Her medical diagnosis was left ankle fracture which resulted in her surgery being a trimalleolar ORIF (open reduction internal fixation is a type of surgery that is to help with broken bones). A tri-malleolar fracture is when three malleoli bones that make up the ankle, break at the same time. According to research, ankle fractures are one of the most painful fractures and its recovery time takes roughly 6-8 weeks, however, in saying that, no two people have the same recovery rate. She had no known allergies and her current medications to aide with her post-surgery pain and inflammation were analgesia (regular pain reliefs such as paracetamol), IVAB (antibiotics are given 6 hourly) and morphine (pain medication charted for acute pain and chronic pain), other than that, she is not on any current medication. Mrs M was admitted on the 26/08/19. Holistic Health Assessment AssessmentComments/Problems/NeedsMaintaining a safe environmentFoot pumps on to provide comfort. Uses a wheelchair to move around with the assistance of a nurse or healthcare assistance. Was using a commode chair but feels more comfortable with the bedpan. CommunicationLanguage spokenSpeech Native English speaker Clearly spoken and easy to understand. Breathing and circulationBreathingSkin colour, cough, sputumSmoking historyRespiratory rate CirculationSkin colour, chest painBlood pressure and pulse rate Peripheral circulationColour, warmth, sensationSkin is intact, warm to the touch and skin colour is healthy-looking with a rosy complexion, smooth texture and was neither dry nor moist. The patient is a non-smoker. Respiratory rate was 16. No chest pain was voiced. Blood pressure was 128/63 and pulse rate was 63. Compared to her vitals that were taken on 08/09/2019, her RR was 16, BP was 121/60 and pulse rate was 63. Normal RR is between 12-20, BP 120-140/60-80 and pulse rate between 60-80, therefore looking at Mrs M’s vitals, she’s perfectly within these numbers which means her vitals are healthy. Nutrition – eating and drinkingRecent weight loss or gainAppetiteFood preferences/dislikesEating difficulties/assistanceFluids – intake/preferencesDrinking difficulties/assistanceWhen asked about her eating, she stated that before she was admitted, she loved eating and had an appetite however after being admitted, she doesn’t feel like eating but she still does. She has stated that she does not like hospital food. Mrs M requires no assistance with eating nor drinking. Her BMI is 26. EliminationMicturition patternNight/day ContinenceDefecation patternRegularityContinenceAids required – diet, medicationsUses bedpan to pass urine, more in the day than night. Does not want any medication to aid with bowel movements. Uses bedpan daily to help with bowel movements. Personal cleansing and dressingBath/shower Teeth: own, denturesHair, nailsSkin: integrityAppearance of fingers and toesShowers by herself with the help of a nurse or HCA to help her get to the bathroom, says husband will help at home. Own teeth, no dentures. Hair and nails look healthy and strong. Skin intact. The toes on the left leg appear to be red/purple and swollen due to the trimalleolar ORIF. Dressing on the left ankle is also intact.Controlling body temperatureSigns of infectionBody temperatureBody temperature is 36.4, compared back to 08/09/2019 which was also 36.4, the normal temperature range is between 36.1-37.5. There are no signs of an infection, if this were the case, her temperature would have been higher than 37.5. MobilisingBalance: sitting, standing, dressingTransferring, walkingAids/prosthesis usedFalls risk assessmentDependence/independenceIndependently mobilises with the use of a wheelchair. High falls risk. Working and playingSupport systems – family, friends, whanau, petsWork/studyInterests, activities: physical, social, intellectual, religious practices/beliefsA close relationship with her daughter. She is a housemaker. Stated that she enjoyed golf and played it three times a week and plays with her friends. Enjoys cooking for husband. No religious practices/beliefs were voiced. Expressing sexualityGrooming requirementsConcerns expressedWell-groomed, no concerns voiced. SleepingHours of sleep, day, nightBedtime – number of pillowsAids to sleep – drink, medications, positioningUsed to sleep for 8-9 hours before being admitted, and after admission says that she gets around 5 hours and it is a very disruptive sleep due to the vital signs being taken and medication rounds. Sleeps with one pillow. Analgesia helps her to sleep, “eases the pain”.DyingPerception of illnessConcerns expressed by family, patientResuscitation statusNo concerns were voiced by the family. Looking forward to getting better and going home to husband. Mental Status/CognitionPerception of health statusAlert/orientated to time and placeMemory No cognitive impairment. Alert and well orientated. Emotional statusCalm/anxious/agitatedA calm state of mind. Special sensesVision – spectacles, prosthesisHearing – aidsNo hearing aids in use. Uses reading glasses. Pain Assessment toolLocation, intensity, durationPharmacological and non-pharmacological relieving factorsLeft ankle surgical site pain 1 at rest and 2 at movement compared to 08/09/2019 which was 2 at rest and 4 at movement. Paracetamol( this is the first option of pain relief advised by doctors and nurses to give to their patients and is a very common drug used for pain relief, however, if it doesn’t relieve pain, stronger medications are usually administered instead) 1000mg given and if that doesn’t help, then morphine 1mg/mL given to help with the pain. Nonpharmacological relieving factor was to elevate leg to reduce swelling. Nursing Care PlanAssessment Nursing DiagnosisPatient GoalNursing InterventionRationale for interventionEvaluation of goalSubjective: “Can I get something, I am in a lot of pain,” as voiced by Mrs MObjective: Facial Grimacing Acute pain due to the ankle fracture post-surgery Mrs M wants her pain to come to a minimum with the use of medicationsMrs M was advised to keep her leg elevated on a pillow. Mrs M voiced after a couple of minutes that her pain was lessening but wasn’t reduced by a lot so regular pain relief, paracetamol, was offered. Mrs M was still a little uncomfortable due to the pain so her regular morphine 1mg/mL was given. Keeping the leg elevated would help in making the patient feel more comfortable and it will reduce the blood from coming towards the surgical site which would reduce the redness and swelling.Before giving any analgesia, it is important to give the most regular pain relief instead of going for something stronger. However, in this case, Mrs M still needed something stronger so the morphine would end up being the last resort to aid with the pain. Mrs M wanted to minimise her pain with the help of medications, and she was open to the idea of trying these nonpharmacological relieving factors. She wanted her pain to reduce and it did. Mrs M was comfortable, and her goal was achieved. Reflection – Gibbs Reflective CycleDescriptionMy preceptor told me to take vital signs for all our patients and everything was going accordingly except when it was Mrs M’s turn I was starting to struggle with finding her blood pressure. Mrs M’s daughter was present in the room and had told me that she is also a nurse. I had to try at least four times before I finally got a reading.FeelingsI was feeling very nervous and embarrassed because her daughter was also a nurse, so I started feeling this immense amount of pressure. I just kept thinking about how embarrassing this was because I couldn’t get the machine to work, I genuinely thought that I was doing something wrong. EvaluationI kept trying saying sorry to Mrs M and her daughter, and lucky for me, they didn’t seem to be too bothered by it and were encouraging me by saying, “it’s okay, try again,” I tried to lighten up the mood by making jokes and making the patient and their family laugh. After the third try, I went up to my preceptor and she told me that the cuff was broken and that it was not my fault so when I went back to try it for the fourth time with a new cuff, it worked, and I finally had gotten a reading. AnalysisI think I ended up having a mind blank and instead of taking a break after realising there’s no reading for the second time, I really should’ve just gone to my nurse right there and then. Instead of doing repeating myself and using up the patient’s quality time with her daughter. I also do think that just having a family member of the patient looking at me made me nervous. ConclusionSomething I could have done differently was instead of being so dependant on the machine, I could have taken the manual blood pressure because at that point I was rather confident with it. I have learned that I need to take my time with the vital signs and if I’m not getting a reading for something, the next best thing would be to do it manually, as it will prevent me from going back and forth with the patients arm and using less of their time. Action PlanIn the future, when I am faced with a similar situation like this, I have to remember that I am there for the patient and that it doesn’t matter if a family member is there looking at me, they’re interested and are eager to know if everything is healthy for the patient and so I need to reduce my nervousness when this happens with breathing and to check my cuffs, making sure that it isn’t broken; to check my equipment is in good condition before using it. ReferencesBraden, B. (2016). Skin Integrity and Wound Care. Retrieved from https://nursekey.com/skin-integrity-and-wound-care / .Crisp, J., & Taylor, C. (2013). Potter and Perry’s Fundamentals of Nursing 4th addition (chapters 6-7). Gibbs’ reflective cycle. (2019). Retrieved from https://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience/gibbs-reflective-cycle .Nunez, K. (2019). ORIF Surgery: Open Reduction Internal Fixation for Broken Bones. Retrieved from https://www.healthline.com/health/orif-surgery .Redpath, A. (2019). Informed Consent. [Canvas Slides]. Retrieved from https://canvas.manukau.ac.nz/courses/37472/files/2502746?module_item_id=602006

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