Clinical Nursing Care Plan at an Acute Care Facility: James Johnson

This report details a clinical nursing care plan for an eleven-year-old boy named James Johnson, admitted to an Australian acute care facility post-ORIF surgery for a fractured radius and ulna. The care plan prioritizes immediate actions such as administering IV medications and checking vitals. It emphasizes patient education, cultural sensitivity, and communication with the patient and his mother regarding medication safety, post-operative precautions, and discharge instructions. The report covers medication safety measures, the six rights of medication administration, and provides information on Paracetamol, Ibuprofen, and Oxycodone, including their uses, contraindications, and potential side effects. The care plan also considers Aboriginal and Torres Strait Islander cultural considerations and the importance of occupational therapy for the patient's recovery.

Running head:CLINICAL NURSING
Care Plan at an Acute Care Facility
Name of the Student
Name of the University
Author Note

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Introduction
As a registered nurse in an Australian acute care facility with 0700 a.m. shift, my
duties include reviewing the ISBAR handbook and coming up with an appropriate care plan
for the patient in my care. The patient is an eleven-year-old boy named James Johnson,
whom I was injured due to slipping on the mountains and fractured his right radius and ulna
in the process. He was admitted to the care facility yesterday and is currently post-op for
ORIF. His mother Julie is here with him as an escort and caregiver, and the previous nurse
has included his information in the ISBAR handbook.
Part 1: Priority of Care
As the nurse currently in charge, my first action of care is to administer the necessary
IV medications, which could not be carried out by the previous nurse due to problems with
the intravenous cannula and pain. I also need to check whether the patient’s temperature is
standard with a replacement thermometer as the one used previously may not have been
working. According to the clinical reasoning cycle (Utas.edu.au.,2020), the RN should
consider the situation of the patient and collect cues first. The patient is currently asleep, and
according to the cues specified in the ISBAR handover, his dressings are uncompromised, he
has not had the necessary IV medications and his temperature measured (35.40C) is
abnormally low. On processing the information and analysing it, I can identify that the
problems that need my attention include missed IV medications and measuring the proper
temperature of the child. I will need to take the necessary precautions regarding administering
the IV and continuously monitor the child (Rch.org.au.,2020). The goal of this is to ensure
that the patient gets his necessary medications and his vitals are healthy enough for him to be
discharged. To do this, I must rouse the patient, readjust the cannula and take his vitals.

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Finally, I will be evaluating his condition in some time and decide whether he is healthy
enough for the discharge yet or not. The situation will be handled accordingly.
Part 2: Patient Understanding, Education and Compliance
Since James Johnson is going to be prepared for discharge, it is vital that I talk to him
and his mother regarding the precautions they should take and also regarding the missed IV
medication as well the checking of the vitals, especially temperature. Patient education is
critical and I must respect the culture and knowledge of the Aboriginal and Torres Strait
Islanders. There is a significant gap in communication between the indigenous Australians
and healthcare professionals, so that needs to be kept in mind while working with them
(Amery, 2017). It is crucial to remember that they may not have adequate information about
the procedures that are being done and maybe apprehensive. So I must build a rapport to
communicate successfully. First, I will rouse the patient and talk with him and his mother,
Julie. I will introduce myself and explain the previous problem with the cannula and
enlighten them on why we need to administer the IV. I will also tell them about the necessary
precautions that will be taken to deliver the IV successfully. I will emphasize to the child that
there is nothing to fear from an IV drip since children are usually afraid of needles. I must
seem reliable to them, and they can take my word seriously.
For this reason, I need to show them that I have done this before and I am fully
qualified to carry out the procedure. Then, I need to explain to them why I need to recheck
the temperature even though the previous nurse already did. The key is, to be honest to them
and to not make them seem inadequate for not knowing. They are not healthcare
professionals, and hence they are not supposed to have all knowledge anyway. It is important
to let them know what exactly I am doing and take consent before carrying out the procedure.
Aboriginals value independence and choice, so it must not feel like I am forcing them in any

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way. My care and communication must be culturally appropriate and holistic (Harfield et al.,
2018).
Since the patient is being discharged, they must be informed about the necessary
precautions and therapies the patient may have to undergo to restore the full functioning of
the right arm. It requires regular monitoring as it may have the risk of getting infected, so the
patient must come back at intervals to monitor it. I need to explain to them why this is
necessary. Pain is common after ORIF surgery, so it is essential to inform them that it is
normal (Miller et al., 2019). The child will also require to rest the arm for over six weeks
minimum to let it heal properly. Assuming that the right is his dominant hand, the child will
have a larger tendency to disturb it, so I must explain to Julie why she needs to ensure rest. I
must remember that James may not take the prospect of resting very well, so I need to
communicate the necessity very clearly. Post a period of rest he will require occupational
therapy to regain full functioning of his arm as it is generally very beneficial (Selles et al.,
2018). I must explain the necessities of the therapy and refer them to a professional. I will
assure them that this sort of treatment is safe, hugely beneficial and will help James regain his
strength rapidly.
Part 3: Medication Safety
Ensuring safe medication is of utmost important in Australian healthcare facilities.
Especially in the case of paediatric medicine, every medication is checked thoroughly before
administration by the RN and a countersigning nurse. In this case, I will be checking the
medicines. In the field of paediatrics, wrong medication administration is a serious issue and
may cause impairment as a result. It is essential to make sure that the right medication must
be given to the right patient. Paediatrics is especially vulnerable due to many factors. Among
medicine mistakes in clinics, about 69.5% victims were children. The need for different doses

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of the same medicine for children and adults cause errors. The major problems arise due to
wrong dosage, and the different distribution of body mass in children and adults and different
side effects in case of them. Apart from that, the children are not as capable of describing
what they are feeling. Hence the caregiver cannot understand what the children are
experiencing properly. They also do not know better and do not have a proper idea of what
medicines can have adverse effects on them. The mistakes may also occur from the source of
the medicine, rather than the healthcare professionals. The effects of such mistakes can be
extremely detrimental in a child’s health. Hence the medicines must be checked (Izadpanah,
Kashani & Sharif, 2015). The necessary medication safety measures must be done via the six
rights of medication administration (Ww2.health.wa.gov.au., 2020). In this case, it will
entail-
 Right patient: I will make sure that I am administering the medicine to James Johnson
by asking his name and matching his order.
 Right medication: I will triple check the medication names and timings with the
ISBAR handbook that was provided to me by the previous nurse on duty.
 Right dose: I will have to triple-check the medication dosage with the ISBAR
handbook before administering them to the patient.
 Right time: The medications should be given at the required time. The Oxycodone is
PRN, so it will be given if the patient needs it.
 Right route: I will make sure to that I administer the medications via the right route, in
this case, most of the medications will be administered orally.
 Right Documentation: I will immediately document the medication that I am
administering to the patient to avoid confusion.

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Part 4: Medications and Questions
The medications that are to be administered are – Paracetamol, Ibuprofen, and
Oxycodone.
Paracetamol
The medication is commonly known as Paracetamol and it belongs to the class of
medicine referred to as ‘aniline analgesics’.
As for the mode of action, this Paracetamol is an analgesic medication that works
based on the activation of certain pathways, namely the serotonergic pathway. I may also
occur due to the mobilization process of cyclooxygenases. This ultimately leads to the
inhibition of prostaglandins (Mallet, Eschalier & Daulhac, 2017). Prostaglandins are
responsible for the increase in pain and fever, and hence the process is inhibited.
Paracetamol is a drug that is frequently prescribed for pain. The patient went through
major surgery (Open Reduction Internal Fixation). The paracetamol has been prescribed to
him to combat post-operative pain (Who.int., 2020).
The contraindications of this medication include hypersensitivity and hepatic
insufficiency in patients. So I would not administer the medications if the patient had a
history of allergic reaction or liver problems, but he does not (Apps.who.int., 2020).
While paracetamols are considered to be reasonably safe medications, to be given to
children, they might have some detrimental effects if given incorrectly. Some possible things
I would warn the patient and his mother are –
 As the patient is a child, he should have a maximum of four doses in a day. The
correct time interval between the doses should be maintained.
 Over-use of paracetamol may lead to liver failure.

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 Even though James has no known allergies, I will explain that food-allergies does not
relate to paracetamols and does not make them unsafe. (Mullan, Burns & Sargeant,
2018)
 The patient should also be monitored for nausea or vomiting.
The correct dose and route do match the recommended amount, which is four doses per
day at maximum. If it did not, I would not administer it and report my superiors of the
error (Tariq & Scherbak, 2019).
Ibuprofen
Ibuprofen is known to consumers by the name ‘Advil’, Nurofen, Motrin and Brufen.
It belongs to the class non-steroidal anti-inflammatory drug (NSAID), and it is an analgesic
as well (Drugbank.ca., 2020).
Ibuprofen works by exerting an inhibitory effect on the cyclooxygenase enzymes,
namely COX-1 and COX-2. This stops the production of prostaglandins, reducing the pain in
the patient.
Ibuprofen has been prescribed to the patient for his pain as he went through a complex
surgery (ORIF). It is often prescribed in children after paracetamol (Moriarty & Carroll,
2016).
The major contraindications of Ibuprofen are NSAID hypersensitivity reaction and
salicylate hypersensitivity. However, the patient has no reported allergies so it can be
administered safely.
I would warn the patient’s caregiver, in this case, his mother not to give him non-
prescribed medications or certain herbal medications while taking ibuprofen as they can often

7CLINICAL NURSING
have negative drug-to-drug interactions. I would also warn her about the side effects,
including dizziness, constipation and possible bloating (Medlineplus.gov., 2020).
The recommended route and dose is correct, and if it is not, I will not administer it. I
would inform the superiors about the error (Tariq & Scherbak, 2019).
Oxycodone
Oxycodone is the common name of the medication and it is part of a class of drugs
referred to as Opioids or Narcotics.
Oxycodone is an opioid that works which has an inhibitory effect on adenylyl cyclase.
It also causes hyperpolarisation of neurons. This causes inhibition of acetylcholine,
dopamine, GABA, insulin, glucagon and vasopressin (Sadiq, Dice & Mead, 2019).
Oxycodone is prescribed to combat extreme pain, usually after a major operation. In
this case, the patient had a major operation (ORIF) and hence was prescribed the medication.
The major contraindications of Oxycodone are hypersensitivity to the medication,
respiratory depression, GI obstruction, and asthma. The patient has no such history; hence it
can be administered (Sadiq, Dice & Mead, 2019).
The oxycodone has been prescribed PRN, so I will warn the mother not to give it if
the patient is not in severe pain. The side effects that they need to be cautious about are
constipation and elevated blood pressure. It should not be used unless it is absolutely
necessary, as overdose and incorrect administration can cause detrimental effects (Sadiq,
Dice & Mead, 2019).
The recommended dose and route is correct. Otherwise, I would not administer it and
report the error to my superiors (Tariq & Scherbak, 2019).

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Conclusion
From this essay, I can conclude that the patient James Johnson is taken care of as per
the need and I have successfully educated him and his mother Julie of the necessary
precautions, referrals, and steps to be taken after a major surgery like ORIF. The ISBAR
handover has proven to be extremely helpful in fulfilling my goal of administering proper
care to the patient.

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