CNA253 Clinical Assessment: Evaluation of Miss Jane Green's Case

This case study presents a clinical assessment and evaluation of Miss Jane Green, a 30-year-old female admitted to the ward after being hit by a car, resulting in a left lower leg fracture. The assessment includes subjective data, such as the patient's concerns about her mother with dementia, and objective data, including vital signs, pain score, and neurovascular assessment. The analysis interprets normal and abnormal findings, relating them to underlying pathophysiology, particularly chronic pain and anxiety. It predicts potential negative outcomes if no action is taken and identifies key nursing problems like risk of infection, self-care deficit, and constipation. The study establishes goals and outlines related nursing actions with rationales, focusing on monitoring, infection control, and promoting self-care. The evaluation reflects on new learning and the importance of post-fracture management and patient awareness to prevent future fractures. The document concludes with a list of references.

Clinical assessment and evaluation 1
CLINICAL ASSESSMENT AND EVALUATION
Name
Department:
School:
Course:
Date:

Clinical assessment and evaluation 2
Clinical assessment and evaluation
Case study: Miss Jane Green
patient situation Subjective data
Miss Jane Green is a 30-year-old female who was hit by a car that ran a red light while she was crossing at a pedestrian crossing. The
impact caused Jane to be thrown into the kerb resulting in an apparent left lower leg fracture. She has just arrived on your ward from
the emergency department. She winces visibly but answers that she is worried about her mother who is in the early stages of dementia
and for whom she is the sole carer. Upon clinical assessment, the nurse release that she has a bad graze on her left shoulder. The time
is 0800.
Collect Cues OBJECTIVE DATA
patient assessment : Miss Green information:
Vital signs
BP: 155/90
Pulse: 107bpm
RR: 22
Sa02: 97%
Temp: 36.6

Clinical assessment and evaluation 3
Other data
GCS: 15
Pain score: 9/10 on movement. 8/10 on rest
Patient is becoming anxious in regards to her mother’s welfare.
Neurovascular assessment
Capillary refill rate of >3 seconds.
Complaining of tingling in the toes of the left leg
Increased pain at rest and upon passive movement of the affected limb
Left leg appears paler than right leg
Process
Information
Interpret:
normal/abnormal
Normal Abnormal
Bp, pulse rate, RR, saturation 02, temperature, capillary refill rate GCS: 15, and pain score, patient becoming anxious regarding
the mother's welfare, complaining of tingling in the toes of the
left leg, increased pain at rest and upon passive movement of an
affected limb, left leg appears paler than the right leg.

Clinical assessment and evaluation 4
abnormal findings to the underlying physiology/pathophysiology
It is evident Jane has both chronic pain and anxiety due to high pain score. For the caregivers to accurately evaluate and manage a
patient with chronic pain and simultaneous mood disorder; it essential to apprehend the similar pathophysiological process underlying
the conditions. Chronic pain is explained as pain that persists beyond the projected course of normal healing. Chronic pain and mood
disorder such as anxiety usually cohabit due to the pathophysiological matches connecting to neurotransmitter in the CNS (Taylor
2014, pp.48). Evaluation of pain in patients with the anxiety is done broadly taking into account numerous aspects such as social,
emotional, and psychological matters. Patients can be hard to cure due to a variance in view of pain and negative handling skills.
Treatment of prolonged pain in patients with anxiety is excellently done by a pain managing team that concentrate on the patient's
obligation to enthusiastically take part in the therapy process (Taylor 2014, pp.48). For the Jane to reach her goals, it is crucial to
ensure she is adequately well-versed of the state, and genuine expectation of pain controls is set. Dispensing chemist can play a vital
role ranging from inpatient to ambulatory setting and health to the psychiatric surrounding. The incidence of the anxiety and chronic
patient due to the fracture of the bone in hospice is high, and pain is correlated with the cognitive impairment (Cooper et al. 2012,
pp.98). Since the anxiety accompanies the patient with chronic pain due to the rupture of the bone, health care provider should
comprehend that and offer psychological interposition such as cognitive behavioural healing as well as anti-depressants or anti-anxiety
treatment at the early phases. Health care group should admit that pain is one of the most prominent factors aggravating mood
illnesses, and should pay particular consideration to pain controlling.

Clinical assessment and evaluation 5
Predict:
What may happen to Jane if NO action taken and why?
Some fractures need not to be cured as they can be left to mend without the support of the medical interference. Medical professional
may resolve it is the best option specifically when small bones are cracked such as in the case Jane (Department of Health 2012).
Another scenario is where medical professional makes a mistake during the x-ray examination. If the fissure is not handled correctly,
it can possibly lead to some problems such as infections specifically of the bone or bone marrow. It can also grow into a persistent
contagion called osteomyelitis; eternal nerve injury; distortion where bone heals in the wrong site; splitting of muscle or ligament'
blood clotting; finally avascular necrosis where the bone loses blood supply (Brukner 2012, pp.20).
Identify the
Problem/s
Three key nursing problems
Risk of infection
Self-care deficit
Constipation
Establish Goals & nursing problems, goals, related actions, and rationale

Clinical assessment and evaluation 6
Take Action
Problem 1 Goal Related Actions Rationale
Risk of infection
Patient rests free from
infections as showed by
healing the incision or wounds
that are free of swelling,
redness, pus-filled discharge,
and pain. The normal
temperature within two days
postoperatively (Baer 2015,
pp. 33).
Monitor temperature; assess
incision for the redness,
increased pain and swelling.
Instruct the healthcare giver to
wash hand. Teach the aseptic
technique during the dressing
of wound, or manipulation or
handling of drains. Instruct
caregiver in the supervision of
antibiotic and antipyretics as
prescribed.
For the initial one day to two
days postoperatively,
temperatures of up to 38.50C
are expected as usual due to
reaction to surgery on the toe
(Wedel and Galloway 2013,
pp. 31). Beyond two days the
temperature should return to
the patient’s reference line.
The openings that have been
closed with staples should be
free of swelling, redness,
drainage. Incision discomfort
is projected. An incision is
kept covered by an adhesive
bandage for 24hours to two

Clinical assessment and evaluation 7
days, afterwards no need for a
dressing. Hand washing is an
active method of infection
control. Reduce the risk of
infection and fever.
Problem 2 Goal Related Actions Rationale
Self-care deficit
Short-term:
The patient shall have
verbalised knowledge of care
practice.
Long-term:
Patients shall have
demonstrated techniques of
lifestyle change to meet the
self-care needs.
Monitor and record vital signs
Establish rapport
Assess patients general
condition
Determine the strengths and
capacities of the clients
Promote client participation in
the decision making
Encourage fluid and food
choices
Develop the plan of care
To gain the patient cooperation
and trust> base data
To offer appropriate nursing
interventions
To assess the degree of
disability
To enhance commitment and
optimising outcomes
To discover barriers to
participating in the regimen
To conform to clients regular
schedule

Clinical assessment and evaluation 8
To assist in dealing and
correcting with cognition
To reduce the risk of injury
To
Evaluate outcomes
& Reflect on new
learning
Evaluation
Bone fracture among adults is significant health care concerns globally (Sale et al. 2011, pp.2067). In the present clinical surrounding
of care for the rupture actions, health care providers often disregard the patient risk for the imminent fractures, and therefore they need
to speak the threat. The evaluation of after fracture management and patients awareness is essential to prevent future rupture, but, not
sufficient. The occurrence of bone breakage in adults needs to be related with the post-fracture evaluation to prevent secondary
fractures (Song X et al. 2011, pp.828). But, prosperous secondary preclusion measures rely not only on examination and
commencement of the cure but to the upkeep of treatment: loyalty and acquiescence, which poses extra concerns. A range of
execution challenges and investigation concerns lie onward. Beginning with health structures embracing continues expansion in
various environment and sharing the experience

Clinical assessment and evaluation 9
References
Baer, R.A. ed. (2015). Mindfulness-based treatment approaches: Clinician's guide to evidence base and applications. Elsevier, pp. 33-37.
Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill, pp. 18-25.

Clinical assessment and evaluation 10
Cooper MS, Palmer AJ, Seibel MJ. (2012). Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture
prevention study. Osteoporos Int.;23(1):97–107.
Department of Health., (2012). Falls and fractures: effective interventions inhealth and social care. London: Department of Health, NHS; Available from:
<http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_103151.pdf2009>.accessed on 5 March 2018.
Sale .JE, Beaton D, Posen J, Elliot-Gibson V, Bogoch E. (2011). Systematicreview on interventions to improve osteoporosis investigation and treatment in
fragility fracture patients. Osteoporos Int.;22(7): 2067–82
Song X, Shi N, Badamgarav E, Kallich J, Varker H, Lenhart G, Curtis JR. (2011). Cost burden of second fracture in the US Health System. 48(4):828–36.
Taylor, S. ed. (2014). Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. Routledge, pp. 47-59.
Wedel, V.L. and Galloway, A. (2013). Broken bones: anthropological analysis of blunt force trauma. Charles C Thomas Publisher, pp. 30-33.