Normal/Abnormal Data in the Physical Conditions

Student number:
CNA253 AT2 Scenario: Mrs Gwen Boren
Interpret:
In the following table, list the data that you consider to be normal/abnormal (not included in word count)
Normal (Subjective & Objective) Abnormal (Subjective & Objective)
SpO2=99%
Temperature=37.5
Pupils: R) 3+ L) 3+
Swelling: cannot assess
Blood loss: nil
Limb movements: Arms – left) normal power,
GCS=14
Blood pressure =170/95mmHg
Respiratory Rate=21
Pulse rate =108 bpm
Neurovascular Assessment: Left toes
Colour: blanched
Warmth: cool
Pulses: not accessible
Limb movements: Arms-right) mild weakness; Legs (R limb only) – mild weakness
Movement: wiggling toes – A+ and patient is reluctant
Sensation: pins and needles in all areas
Pain: 10/10
Capillary refill: 5 seconds
Relate & Infer (550 words):
She suffered from Cardiovascular arrest which can be a result of high heart rate and pulse rate (Laborde, Mosley and Thayer, 2017). The blood pressure of
the patient is high as a result the heart rate is also high in the patient. The patient fractured her leg by falling from the armchair. More specifically, her ankle
was fractured and back slab was applied to treat her. Early confusion of the patient was resolved in the patient. The patient was given paracetamol which can
be the reason of her disorientation. The patient had a history of cardiovascular accident with mild right sided medical deficit. Therefore, the movements of
right limb and leg can might be affected. Due to the fracture she was feeling severe pain by scoring 10/10. The patient was administered with paracetamol
and sub cut morphine so that the patient might be get drowsy by the high dose of the medicines .AS per the pulse rate and respiratory rate along with the
reference of
Premedical history it can be inferred that the patient was having tachycardia and hypertension. The patient has the sensation of pin and needles in all areas
and this sign can be related to the nerve injury. This sensation can be found as a result of neurological issues or injury. On the contrary, the CT scan report
has shown no evidence of abnormalities. Gwen’s peripheral circulation represents that blood flow is not enough in her legs that is why his foot is cool during
the assessment. The patient has numbness along with pin and needle sensation for presence of paraesthesia. The patient’s ankle was fractured therefore her
nerves were impaired and injured. Numbness and moderate swelling is the result of poor blood flow and defective neve impulse. The fracture causes
musculo-skeleton distension which increases the intensity of pain in the patient. Hypothermia will result into decrease in the temperature and sensitization in
limbs. The right limbs are affected as per poor condition of heart and due to paraesthesia , the limb movements are affected. There is a probability of necrosis
in Gwen’s leg which can lead to gangrene and impaired peripheral blood flow (DeWolf et al., 2019). This is another cause of hypothermia in patient.
therefore we can inferred that the patient has Paraesthesia with hypothermia (Deer et al., 2019). Impaired nerve impulse and dysfunctional nerves are the

major causes of sensation in the patient (Prabhakar and Ali, 2018). The patient also has unilateral lymphedema which can reduce the temperature of blood in
limb (Cheng et al., 2018). The patient is suffering from muscle distension which is the cause of increasing pain in her legs. Due to the ankle fracture her
nerves get affected and (pin and needle) sensation is present (Deshmukh et al.,2017). The patient is reluctant as per the increasing pain in her legs. There is a
chance of necrosis or infection which can lead to numbness and loss of sense in her leg. According to neurovascular assessment, it can be observed that the
sympathetic nerves are affected and the patient is showing poor motor movements.
The patient also has impaired blood flow in periphery which causes temperature dropping in her legs. Severe pain might increase the heart rate and
respiratory rate as defence mechanism of body. Blood pressure and pulse rate, respiratory rate which is also high due to trauma led - sympathetic activation in
this case. The blood flow (the local circulation) in the ankle area is disrupted that has caused the capillary refill to take up more time than needed that is 5
seconds (normally it is 2s) During neurovascular assessment pulse was not present in in right leg of the patient. This can be result of poor blood flow in
Limbs and legs.
Predict (150 words):
The patient has ankle fracture which has led to impaired nerve impulse as the nerves got injured. As a result numbness and feeling of pin and needles in
the fractured area can be observed. The numbness is a sign of paraesthesia in the leg of the patient. She has unilateral lymphedema with skin and muscle
distension. There is a probability of necrosis in in fracture area as impaired peripheral blood flow with hypothermia has been detected. Moderate swelling
and severe pain are two significant physical condition in this case. Paraesthesia has been detected as numbness and sensitization are observed in
neurological assessment. In this case the patient has faced cardiovascular accident with right atrial fibrillation therefore tachycardia and hypertension are
common symptoms. Poor blood flow can be result in necrosis in the leg so that the peripheral blood circulation is decreased. It is to be noted if the
condition is not treated on time then, the gangrene might other. Compartment syndrome has occurred due to occlusion and accumulation of the blood
within the muscles increases the pressure, thus increasing the severity of pain and paraesthesia.
Develop, Articulate and Prioritise Nursing Diagnoses – at least 3 (not included in word count)
Diagnosis 1 lateral malleolus fracture with nerve impairment
Diagnosis 2: Impaired tissue perfusion
Diagnosis 3: Lymphedema
Goals, Actions and Evaluation 2 highest priority diagnoses only (550 words)
Diagnosis 1 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
DO NOT REWRITE
DIAGNOSIS
The patient would move
legs without any pain
and discomfort.
Pain management: for pain
management Paracetamol
and sub-cut morphine have
been given(Skidmore-
Roth, 2018).
Post-surgery recovery
involves plaster back slab
with bandage. Bracing and
proper support should be
given for rehabilitation
(Kearney et al., 2018).
Braces for explain help to hold the
affected leg with proper position to
improve muscle function and
laugh impulses. Electrical
stimulator will help the muscle for
better movement. Therapies health
in preventing stiffness and
restoring the functions with
reducing numbness in in the
patient for Stuff electrical
stimulator can active the nerve
Outcomes will be evaluated
by different pain
management scales for pain
assessment tools. The patient
will be checked by physician
and the therapist regularly.
Moreover the improvement
the improvement of
Ambulatory movement must
be recorded in the nursing
registers for tracking the

Electrical stimulator with
physical and occupational
therapy will be given.
Ambulatory movement
exercises and physical
therapy will be suggested.
impulses in muscles and for
Regrowth of nerves.
condition of patient.
Diagnosis 2 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
DO NOT REWRITE
DIAGNOSIS
Impaired tissue perfusion 1. Massage and foot
exercises (in
collaboration with
a physical
therapist)
\
2. Rest, Ice,
Compression and
Elevation (also
known as RICE
Light exercises can encourage
drainage of lymphatic fluids.
Bandaging limp encourages the
Fluids to flow back towards the
body massage also show important
for regularising the flow of limbs
in limb. Local massage in the
surrounding areas (without causing
any irritation or disruption) to the
fractured area, can improve the
local tissue perfusion. Massage
techniques such as muscle rolling,
kneading and skin rolling are vital.
Other than these, the foot exercises
of dorsiflexion and plantar flexion
can help to improve the local
circulation and the systemic
circulation as well thus assisting in
venous return by activation of the
soleus. The mobility and stability
exercises have to be started in the
mobilization phase ((Bjork and
Hettrick, 2019).
 Regular dressing and
proper bandaging
checks has to be done
properly.
 Swelling and
sensitivity will be
observed and
assessed by
physician.
 If the patient ask or
tell something
significant that would
be recorded as a
feedback.
 Discomfort pain
inflammation
irritation must be
recorded for
evaluating infection
in patient’s les and
the necessary steps
will be taken.