Assessment and Management of Acute Pain and Deep Vein Thrombosis in a Trauma Patient

Written Report

Patient’s Background Information
Mr Ben Casey is a 38 years old man, who was admitted to the Emergency Department after a
motor vehicle accident. Ben is an electrician and lives in a two bedroom unit with his partner and
a two years old son. Ben had an accident, while he was driving back to home from his mate’s
place. He also self-reported that he had lots of drinks at a friend’s party. While coming back to
home he was hit by an unidentified object on the road, due to which he lost control on the bike
and skidded into a metal fence. Due to this accident Ben had to suffer from the fractures in the
left tibia and left femoral bones. The wounds were open and the tibial bone could be seen. X-Ray
informed about the oblique fracture in the left femur and open displaced fracture in left tibia. The
surgery was conducted that included insertion of intramedullary rod in left femoral canal and use
of nails and plates to fixate the tibial fracture.
Patient’s Assessment
Assessment of the patient after the surgery was carried out in order to identify the significant and
potential risks that are affecting or could affect patient after the surgery. The observations
documented on the first assessment of patient on ward include the self reported pain score that is
7/10 in the left leg. The pain score of the patient can inform about the severity of pain.
The underlying pathophysiology associated with Pain on the wound site could be associated with
infection or could be due to the sympathetic nervous systems response and the potential tissue
damage at the surgical wound site (Carli, 2015). The main patho-physiological reason behind
this is the inflammatory response of the body that is directed by the sympathetic nervous system
and severity of this inflammatory response results in acute pain (Christiano et al, 2016).

However, the assessment of wound site, and psychological alertness of the patient informs about
the pain being a response process after surgery.
Skin assessment of the patient was also carried out that informed that skin of the foot is pink and
warm and no signs of swelling were identified. Patient was also assessed to inform, if he is
experiencing cramping pain in calf, foot or ankle. Heart rate and respiratory rate of the patient
were also assessed that informed that HR is 120bpm and respiratory rate is 24 bpm. Therefore,
HR and RR are found to be within normal ranges and no signs of complications were identified.
This assessment is also focused on early identification of Deep Vein Thrombosis (DVT).
Though, it did not occur in this case, risk of this complication is very high in the patients
experiencing trauma and surgery in Lower extremities (Auer & Riehl, 2017).
Two Major Health Problems
Acute Pain
The first identified health problem associated with the case of Ben is problem of acute pain. Pain
after the surgery is common, but acute pain can result delayed wound healing. Pain is a sensory
and emotional experience that can result in the development of stress and anxiety. Wound related
pain can result in negatively affecting the patient and threatening their quality of life (Upton, &
Solowiej, 2010). Also the experience of stressful event can negatively affect the patient and can
compromise with the patient’s recovery and wound healing. Pain can also affect functionality
and mobility of the patient and can cause activity intolerance (Mann, & Carr, 2018).
Intervention Type Example Required Information
Pain management is the first
strategy that would be applied
in the case of Ben
Vital sign assessment will be
carried out to analyze the
physical effects of pain.
Assessment of the pain
Assessment of pain is very
significant for planning the
pain management strategies
(Whiteing, 2008).