Case Study: Introduction to Specialty Nursing - Semester 2, 2019

This case study analyzes the assessment of a patient, Mr. Dean Parker, who sustained severe injuries in a high-speed car accident. The assessment encompasses vital signs, Glasgow Coma Scale (GCS), and physical examination findings, including fractures, paradoxical breathing, and low blood pressure. The pathophysiology section explores the mechanisms of injury, linking the accident to the patient's critical condition. The nursing notes section emphasizes the importance of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handover for effective communication and patient care in the Emergency Department (ED). The case study highlights the need for immediate interventions, including cervical precautions, pain management, and fluid resuscitation. The analysis covers the patient's low GCS score, respiratory distress, and multiple fractures, emphasizing the need for surgical interventions and continuous monitoring in the ICU. The document provides detailed information on the patient's condition, assessment data, and the application of nursing principles to ensure the best possible outcomes for the patient.

Running head: INTRODUCTION TO SPECIALTY NURSING
INTRODUCTION TO SPECIALTY NURSING
Name of the Student
Name of the University
Author Note

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Introduction
Mr. Dean Parker has experienced a sudden accident while driving his car in a high speed
and the car crash has affected the health condition of the patient. It has been seen from the
assessment of the vital signs and other observational data that the care process should consider
the consciousness of the patient (Canham et al., 2018). Moreover, the patient should be assessed
based on the consideration of the health condition improvement. The vital signs and the
handover of the patient would be assessed as well. Furthermore, the aspect of the care should be
considering the factor of the pathophysiology and the assessment of the patient. Hence, it can be
stated that the patient is in a critical condition and also the improvement of the patient would not
be seen very significantly. However, the assessment of the patient and the care process is
interconnected. Thus the proper assessment of the data found is required as there is no medical
history found. In the following section the assessment, pathophysiology and the nursing notes
considering the ISBAR handover chart would be discussed in details.
Patient assessment data
Following admission to the Emergency Department (ED), the patient was accessed for
checking and monitoring his vials according to which intervention strategies are to be planned. It
is important to conduct head to toe assessment in order to understand the patient’s condition
more comprehensively and accurately. It includes a detailed examination of the patient’s vitals
and addressing symptoms correlating with the current health status of the patient. Nurses
working in Emergency Departments must possess the skill set required to interpret and
understand the patient’s condition through thorough analyses, conducting assessments and
monitoring of their vitals (Toney-Butler & Unison-Pace, 2019).

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Prior to putting him on treatment, the objective data collected showed contusions and
bruises to his face and neck and his Glasgow Coma Scale gave the score of 7 with eyes 2, verbal
2 and motor 3, indicating his level of consciousness and the ability to respond. Although, no
skull fracture was palpable, cervical precautions were initiated. Evidences suggest that it is
important to initiate cervical collar in both pre and during the course of stay in the hospital to
prevent any further deterioration arising due to neurological weakening with spinal cord injury
(Aci.health.nsw.gov.au, 2019). Paradoxical breathing and a reduced air entry on the right side
was also noticed implicating weakening of the inspiratory muscles due to injury. Thus it can be
stated that the breathing rate of the patient is very much decreased due to pressure over the lungs.
Moreover, the blood loss due to the accident the blood pressure of the patient is also low. On this
context it can be seen that different doses of saline has been provided to the patient that will be
effective in the maintenance of the blood pressure of the patient. On the other hand the
medications are provided in this case has been seen to develop sedation and also pain relieve of
the patient as the primary concern for this patient is the pain. Other data that were collected
include deformity of his left forearm, shortening and external rotation of his right leg indicating
the severity of his wound due to injury.
Emergency nurses must access the patient’s condition properly and must be competent
enough to understand and comprehend what those signs implicates or interprets. This enables the
nurses to effectively manage and control the patient’s conditions by implementing the nursing
intervention strategies for an improved health outcome of the patients (Ghanbari et al., 2017). As
per the case study, the patient was accessed well and his vitals that were recorded showed heart
rate of 112 Sinus tachy, respiratory rate of 12 with air entry diminished on the right side, blood

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pressure of 90/50 indicating a very low blood pressure and his oxygen saturation was recorded as
86% indicating a lower oxygen saturation since the normal range varies between 96% to 99%.
His x-ray reports show that he was mildly comminuted impacted and an angulated
fracture of his right mid-shaft femur. His x-ray report also showed that he was having
comminuted fractures of the distal radius which are caused by trauma and they present as shear
and affects the fractures of articular surface of the distal radius by displacing the fractures. The
severity and pattern of the articular fracture is determined by the force of the injury, hand
position and carpal bone (Mader&Pennig 2006). Concomitant fracture of the ulnar styloid
process was found from the x-ray report. The proximal radius/ulna and elbow articulation was
intact. He was also found with the condition of flail chest which was caused by the breakage of a
segment of the rib cage resulting into trauma. It can also occur if 3 or more ribs are broken. It is
important to clinically diagnose and monitor fractures through x-ray since every patient who
have got fractures do not develop this condition (Perera& Daley, 2018). However, the patient in
the case study, had fractures both posterior and laterally to the right 2nd, 3rd, 4th and 5th ribs
causing a segment of the chest wall to move away characterized by significant respiratory
disturbances affecting the patient’s respiratory pathophysiology and can also lead to further
complications.
His peripheral pulses were present in all the four limbs. A peripheral pulse refers to the
high-pressure wave palpation of blood moving away from the heart through vessels in the
extremities following systolic ejection (Zimmerman & Williams, 2019).
His vitals also show ABG pH 7.21, PaO2 60, PaCO2 56, HCO3 22. It is important to
conduct assessment and monitor these vitals in the Emergency Department to monitor the acid
base balance of patients, gas exchange effectiveness and to understand in what state their

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voluntary response controls are in. The normal range of pH of blood ranges from 7.35 to 7.45,
whereas, the patient was having blood pH 7.21 which means the blood was acidic (Singh,
Khatana & Gupta, 2013). PaCO2 was 56 indicating an insufficient acid secretion due to renal
disturbances (Madan, 2017).
The patient was put on Fentanyl to control his pain (Drugabuse.gov, 2019). However,
while administering this drug, nurses must ensure that the prescribed doses or indications are not
exceeded since overdose can lead to severe complications and even mortality of the patient
(Cdc.gov, 2019). He was also put on Normal Saline 1000ml running at 60 ml/hr.He was also
given Urinary catheter on free drainage considering the severity of his condition. Pupils equal
size 2 reactive Capillary refill 3 seconds peripherally and <2 seconds centrally which was normal
and does not show any abnormality (Fleming et al., 2015).
Pathophysiology
The condition of the patient highlights that the patient has several fractures, breathing
issues and the patient is also unconscious. Hence, on this context it can be stated that the process
of development of these issues are from the car crash. The high speed of the care and the crash
with a high speed vehicle is the primary cause of the condition as the accident impacted over the
rib and the leg bones of the patient (Yoneda et al., 2017). Moreover, the pressure of the accident
and 3rd, 4th and 5th bon of the rib broke and pressurized the right lung and the thus the oxygen
intake by the right chest is reduce to almost nil (Asefa, 2017). The IMISTAMBO model of the
assessment highlighted that the patient is unconscious and the vital signs such as heart rate 112,
respiratory rate 12, blood pressure 90/50 and oxygen saturation 86 per cent. Thus it can be stated
that the breathing rate of the patient is very much decreased due to the effect of the accident and
the pressure over the lungs. Moreover, the blood loss due to the accident the blood pressure of

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the patient is also low. On this context it can be seen that different doses of saline has been
provided to the patient that will be effective in the maintenance of the blood pressure of the
patient. On the other hand the medications are provided in this case has been seen to develop
sedation and also pain relieve of the patient as the primary concern for this patient is the pain.
According to the case study Dean Parker is a 55 year old person and after accident he has been
admitted in the emergency unit and the X-ray results highlighted angular fractures on the right
mid shaft of the femur and concomitant fracture on left ulnar styloid process. Based on this X-
ray report it can be stated that the accident occurred and the patient was driving the car (Daia et
al., 2018). Moreover, the GCS result of the patient has been seen to be very much low (GCS=7).
His pupil was equal and reactive (Jitpanya, Kinklaykan & Puengching, 2019). His x-ray report
also showed that he was having comminuted fractures of the distal radius which are caused by
trauma and they present as shear and affects the fractures of articular surface of the distal radius
by displacing the fractures. On this context it can be stated that the patient experienced as severe
brain trauma due to the accident. Thus it can be assumed that the patient experienced a
concussion in the accident as well (Welch Bacon et al., 2018). Other than all these the bruises
and the condition of the leg highlights that the accident affected the four limbs of the patient. On
this context it can be stated that the patient needs surgical treatment for the betterment of the
condition (Sun & Liu, 2019). Furthermore, the condition of the breathing of the patient should
also be considered as it is affected by the rib breakage of the patient and also the pressure on the
chest (Phillips et al., 2015). However, the patient’s past medical history is missing and the
patient is not conscious as well. Thus the assessment of the patient should be based on the vital
sign and the improvement through the surgery. The heart rate of the patient and the respiration
rate has been developed after providing the saline and the medication although the changes have

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not been significantly effective for the patient. On this context it can be stated that the process of
the assessment of the patient should be recorded and also communicated to the doctor for the
betterment of the condition (Spooner et al., 2016). On the other hand the brush marks, cold skin
and low ABG of the patient would be caused by the low blood pressure, low oxygen saturation
and the internal bleeding caused by the breakage of the bones (Mohamed, 2018).
Nursing notes
Based on the pathophysiology and the assessment data of the patient the nurse should be
able to develop a health record of the patient. The condition of the patient is severe and should be
transferred to the ICU. Thus the nurse should be able to develop an ISBAR. In the ISBAR the
patient should identify the patient’s condition, situational analysis of the patient including the
assessment data and the changes of the patient’s health condition, background of the patient,
detailed assessment data and also the requirements of the patient should be recorded
(Ramasubbu, Stewart & Spiritoso, 2017). Considering the doctor’s decision and the condition of
the patient the nurse should be able to demonstrate the situation of the patient. The requirements
and the medication of the patient would be recorded in the report (Lee et al., 2019).
On this context it can be stated that the ISBAR would be developed with the name, age
and sex of the patient for the identification; The vital signs including heart rate, respiratory rate,
GCS scale, temperature, oxygen saturation rate, observational data such as the skin colour, brush
marks and cut marks of the patient as the symptom; The accident report and the admission time
of the patient and also if any kind of medical history can be obtained would be reported for the
background of the patient; The changes of the patient’s health condition, medication, X-ray data,
and other factor of the observational changes identified in the health condition of the patient
would be recorded for the assessment data development of the patient; The possible requirements

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of the patient and also the care plan of the patient should be recorded as well (Shah, Alinier &
Pillay, 2016). Hence, the condition of the patient and also the changes of the patient should be
recorded properly with proper medical terms without using any medical jargons would be
recommended (Beauchamp et al., 2017). Moreover, the process of the handover of the patient
should be considered the factor of the improvement of the health condition of the patient. The
process of the handover of the patient should be considering the safe health outcome as well. The
ventilation of the patient also should be considered in order to provide the safety of the patient.
However, the factor of the nursing record would also be considered for the proper
communication of the condition to the doctor. The assessment of the Tidal volume of the
ventilation is very much important in the aspect of the sustainability of the patient. Moreover, the
condition and the effects of the changes in the Tidal volume of the ventilation is also calculated
properly so that the providence of the health sustainability regarding the critical condition of the
patient (Aminiahidashti et al., 2018). Hence, on this context the proper nursing record is required
for better assessment of the health and providing improved care to the patient as well.
Conclusion
Based on the above discussion it can be concluded that the process of the care for Mr.
Parker should be considered in order to assess the condition. The assessment data would be
helpful in the understanding of the situation of the patient. Moreover, the understanding of the
pathophysiology of the patient and also the nursing record would play a crucial role as well.
Hence, it can also be stated that the process of the care is including proper assessment and
effective observation or advocacy. On the other hand the process of the nursing observation
should be dependent on the objective data such as the vital signs and the consciousness
identification as the patient is not conscious and the subjective data cannot be collected.

8INTRODUCTION TO SPECIALTY NURSING
Furthermore, the process of the care of the patient should be dependent on the pain and pressure
injury management of the patient and considering the consciousness improvement of the patient.
Thus the ventilation of the patient is required with highest priority. Moreover, the condition of
the patient should be analysed with proper nursing skill implementation. However, the patient
should be transferred to the ICU and the ISBAR should be developed in order to handover the
patient as well. This process will be helpful in the sustainability and improvement of the health
condition of the patient as well. Hence, based on this case study and the discussion the factor of
the patient care in this kind of severe accidental cases the idea about the care process has been
developed.

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