HLTENN003 Perform clinical assessment and contribute to planning nursing care

Perform clinical assessment
and contribute to planning
nursing care
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Part A
Questions
1. Analyse Luke Parker’s health history and the above clinical assessment findings and
identify risks and likely impacts the surgery has on his ADLs. What healthcare is required
here?
Answer: As per the analysis of health history of Luke Parker, it is found that he was
completely fit, but he sustained an injury at the time of his Australian football league try-outs.
During the try out, he was injured and diagnosed with comminute fracture of shaft. Due to the
fracture, he underwent an open reduction and internal fixation surgery with bone grafting and
interlocking intramedullary nailing. The ORIF surgery is often done in an emergency when the
bone is broken in many pieces. The possible risks associated with ORIF includes bleeding,
infection, nerve damage, need for later surgery in case the bone does not heal properly, reaction
to anaesthesia and blood clots or fat particles that move to lungs. The likely impacts of surgery
on activities of daily life of Luke is that he was not able to mobilize for 6 weeks after surgery
due to which he is not able to perform daily life activities appropriately. Here, the required
healthcare is to do exercise and use wheelchair or crutches to move from one place to another.
2. Ouline a Nursing Care Plan using a problem solving approach. Ensure stratgeic care
planning approporiate to Luke’s needs.
Make sure you include his
-Physical
-Emotional
-Spiritual And/Or Religous
-Psychosocial Needs.
You will need to consider stress management strategies as he feels worthless and never be able to
play footie again.
Answer:
Nursing Care Plan
Diagnosis: Comminute fracture of shaft
Risk factors:
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 Reaction to Anaesthesia
 Nerve damage
 Infection
Possible complications:
 Arterial damage during treatment
 Life threatening systematic fat embolus
Assessment:
 Pain
 Loss of function
 Visible deformity
 Tenderness
Medical Interventions:
 Open Reduction and Internal Fixation (ORIF) with Interlocking Intramedullary nailing
and bone grafting.
 Maintain bedrest as indicated.
 Provide support to Fracture site
 Take mediciens timely.
 Review follow up and serial X-rays.
In order to manage the stress of Luke at the time when he feels worthless and never be able to
play footie again, it is necessary to ensure that he learn and practice relaxation techniques by
taking help of Yoga and Meditation. Moreover, eating healthy and well balanced meals will help
Luke in keeping physically fit and stress free. Apart from this, getting social support at that time
would also be beneficial for him.
3. How will you recognise the signs of a detoriorating patient and determine the levels of his
conciousness.
Answer: The signs of detoriorating patient will be recognised by analysing changes in his pulse
quality, abnormal swelling, breating rate, blood circulation, dizziness etc. and for determining
the levels of his consciousness, an assessment is done on changes in levels of irritability, lethargy
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and restlessness.
4. How, when and to whom should you raise concerns of Luke’s detorioration?
Answer: When Luke will be identified with changes in level of consciousness involving
irritability, restlessness, abnormal swelling, changes in pulse quality, breathing rate, blood
circulation then it is must for the family of Luke to raise the concers of his detorioration with
doctor in order to prevent him from arrest and provide him with appropriate treatment in timely
manner.
5. What intervention should be taken to manage the deterioration?
Analyse using critical thinking so as to why this decision was taken.
Answer: By proximally monitoring alterations in physiological observations as well as
interpreting early signs of psychological and physical decline is one of the way to identify and
manage and avoid serious negative events before they occur. By proper assessment of respiratory
rate, oxygen saturation, blood pressure, temperature, heart rate and level of consciousness, the
deterioration of patient can be managed effectively. The ABCDE approach must be followed by
nursing professionals for assessment of patients. Apart from this, appropriate senior help must be
called by nurses if required. Moreover, improve awareness and knowledge of deterioration signs
ensures proper management of it.
6. Given that Luke’s leg is now immobilised in a Plaster of Paris Cast, how will you
determine his nuerovascular status of the limb? Explain using problem solving approach.
Answer: In order to determine the neurovascular status of Luke’s limb, assessment of the pain
is one of the crucial indicator to deterimine it. Apart from this, loss of sensation and motor
function, numbness, dysesthesia, tingling of pins and needles are the ways to detemine the
neurovascular status of limb.
7. What is the current best practice to manage a patient with a POP Cast? Make sure you
include risk assessments in your answer:
Skin Assessment
Mobility Assessment
Falls risk Assessment
DVT risk Assessment
Pressure injury risk Assessment
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Answer: In order to manage the patient with POP cast, awaring patient about what to do or not
to do is very much important. The education of patient will do much better to prevent the
complications associated with it. Moreover, provide patient with pain relief measure will help in
managing the patient appropriately. While casting POP, it is necessary to ensure that a proper
assessment will be done by nusrse including skin assessment, mobility, falls risk, DVT and
pressure injury risk assessment.
8. If you find an discrepancy between the prescribed plan of care and the nursing care plan, to
whom should you consult?
Answer: If any discripency is found between priscribed care plan and nursing care plan, then it
is necessary to consult with doctor or senior professional. Consultation with them is very
necessary in order to enasure that patient will get proper treatment which is required by him to
ensure his improved health condition and speedy recovery.
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REFERENCES
Books and Journals
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