Detailed Nursing Assessment: Sepsis, Care Plan, and ADL Impact

This report presents a nursing assessment focused on a patient, George, experiencing complications related to a fractured ulna and radius, further complicated by sepsis. It details the pathophysiology of sepsis, explaining its systemic inflammatory response and potential organ failure. The assessment prioritizes care using the DRSABCDE approach, emphasizing infection elimination and maintaining tissue perfusion. Multidisciplinary collaboration with an intensivist physician and emergency care nurse is crucial for comprehensive care. The report further explores the potential physical and psychological impacts of sepsis on George's activities of daily living (ADLs) and outlines a nursing care plan with goals and interventions focused on pain management and assistance with daily activities. The assignment is contributed by a student and available on Desklib, a platform offering study tools and resources for students.

Nursing
assessment

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
CONCLUSION................................................................................................................................1
REFERENCES................................................................................................................................2

INTRODUCTION
Nursing is defined as the professional of health that is reliable in order to promote the
quality, prevention of illness and disease and the care of illness that is based on the disability and
dying people. With this context, the nursing diagnosis and their prevention used to play primary
role within the healthcare setting. In addition, the nurse used to play role within the healthcare
setting that include promotion of safe environment, research and participation in the shaping of
health policy and in term of patients and the health system management and the education which
is also showing the contribution (Bell and et. al., 2021). In this report, the study is usually focus
the patient George, who used to face the issue which is related with the fracture of Ulna and
Radius. In addition, the proper nursing diagnoses and treatment with intervention is provided to
George in order to reduce complication. Therefore, the major help of nurses with the case is
occur due to the George who is living alone with their two dogs and one cats. Moreover, the
proper nursing diagnoses and their pathological study is being conducted while taking the
reference of George with the heart rate, respiration rate and many more (Hidayat and Uliyah,
2018).
MAIN BODY
TASK 1: QUESTIONS
Describe and discuss the pathophysiology of Sepsis, as the EN. How would you then explain this
to George and his son?
As an Emergency nurse, the pathophysiology of Sepsis can involve when the infection
can insult triggers a localized inflammatory reactions which then spills over to cause the
systemic symptoms of the fever or hypothermia, tachypnea, tachycardia and either the
leukocytosis or the leukopenia. These such clinical symptoms are known as systemic
inflammatory response syndrome. The reactions of the infection are generally mediated by the
release of cytokines, containing the tumor necrosis factor-alpha, interleukins as well as the
prostaglandins from the neutrophils and macrophages. In addition to this, the cytokines can
activate the extrinsic coagulations cascade and can suppress fibrinolysis. As per the case study,
the vital signs of George is the blood pressure is 100/60, his heart rate is about 86 which is quite
low, his respiratory rate is 22, which is little abnormal. His SpO2 is about 94% on room air,
which must be 95% or higher(Coelho & Mead, 2018).
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Sepsis is a circulatory dysfunction that is generally caused by the immunological overactivity
when capillary is grown more permeable. Hypertension sets in and immune mediators are
released. This event can compromise of blood flow to tissue and organs. In this, intravascular
volume decreases and it is difficult to maintain tissue perfusion. This response to release of
adrenalin in to mark the vascular dilation and inadequate vascular volume that lead to cause
tachycardia. Due to lack of circulating volume leads to reduce the organ perfusion risk to organ
failure when it is not treated properly it can lead to death. In this, it can observe decrease in blood
flow and disrupting protective mechanism of mucosal barrier. Patient may get more susceptible
to G.I bleeding ulcer and bacterial movement within bloodstream from the gastrointestinal tract.
Due to severe liver infractions lead to rise in liver enzyme level. This creates sensitivity to
hypoperfusion and resultant renal failure can be observed which manifests a decrease in urine
output (Nagalingam, (2018)).
This case is needed to explain to George and his son. In this, it is necessary to avoid the
core medical term which is not easily understandable by George and his son. There is a need to
effectively elaborate the term sepsis that can help to understand the health condition and enable
them to take precaution to improve better health.
Discuss the comprehensive nursing assessment of this patient and prioritise the care, including
basic investigations and possible treatment and the rationale behind each. Present you
priorities of care in order of importance (DRSABCDE).
As per the case scenario, the nursing interventions for the patient can involve eliminating
the infection, maintaining adequate tissue perfusion or circulatory volume. The care nurses must
prevent the complications and can provide information to the patients about the illness process,
its prognosis as well as the treatment needs. The nurses must teach the patient proper hand
washing using the antibacterial soap before and after each care activities. The care nurses must
maintain the sterile techniques when changing the dressings, suctioning as well as providing site
care, like as an invasive line or a urinary catheter. Care nurses must inspect the wound as well as
the sites of invasive devices daily, paying particular attention to the parenteral nutrition lines.
The care nurses must support or provide frequent positions alterations, deep breathing and
coughing exercises (Monard, Rimmele & Ronco, 2019).
As a comprehensive health assessment, there is need to ensure about the physical state
through observation. Care Nursing staff to ensure about the measurement of sign and symptom
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which should be self-reported. In this way, there is need to the investigation of the all the vital
signs and symptoms that can enable nursing staff to ensure about possible treatment. In this,
there is a need to ensure about a Priority of care to provide better understanding about the detail
of sign and symptom of patients health (Pant et. al., (2021)). There is also need to assessing the
image quality of the patient which includes rotation and speciation, picture and penetration.
There is also need to ensure about the soft tissue and bones of George which may include ribs,
spine symmetry, fractures and their density. It also includes the soft tissues and calcification of
vessels or carotids.
It is also needed to ensure about the Airway of George to ensure about the breathing. It is
also need to ensure about the circulation through observation of blood pressure and monitoring
of diaphragm from the shape and needed to ensure about the ECG electrodes and chest tube
(Chausse et. al., (2018)).
Identify and discuss three (3) multidisciplinary healthcare professionals that the acute care nurse
would need to consult with for this patient and describe what role they may play in
George’s care.
The three multidisciplinary healthcare professionals that are effectively involved in the
acute care nurse would require to consult the health of the patient with such as the intensivist
physician, the healthcare professional, emergency care nurse and patient himself. The healthcare
professionals and emergency care nurse can effectively diagnose the injuries and illness which
George possess. Here, healthcare professional need to ensure that proper medication and
treatment is done on time. This can be effective and provide better care to patient for
improvement in George health (Jacobi, (2022)). With the help of emergency care, nurse
healthcare professional to ensure that they should provide acute care. Through effectively
following their roles and responsibility, it can enable them to provide quality care to improve
patient health more effectively. The care professionals can take the diagnosis and provide him
effective care treatment so that his conditions can be improved effectively. The care nurses must
identify whether the patient is having another illness or injury or not. They must take all the
necessary tests such as measuring heart rate, blood pressure levels, respiratory rate and many
more. The role of intensivist physician is to provide a special care for critically ill patients and
these are called as a critical care physician. The intensivist physicians generally involve the
advanced trainings as well as experience in the training this complex type of the patients
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(Pandompatam, Kashani & Vallabhajosyula, 2019). Intensivist physicians improve the quality of
care through following the evidence-based guideline. This can be effective and enable them to
deliver proper care as a multispeciality team approach. This can provide improvement to patient
outcome including survival rate. It also help to reduce the complications within patient and they
provide shorter length to stay critical. They also provide their quality care to enhance the
medication safety to provide better improvement to patient health (Reveruzzi et. al., (2020)).
You are about to talk to George, list and document how you would explain to him four (4)
potential physical and four (4) psychological impacts this acute presentation has on his
ADL’s.
The systemic response to the infection manifested by 2 or more of the following
conditions as an outcome of the infections such as temperature >38 degree Celsius or the more
than 36 degrees Celsius. The heart rates are quite abnormal that is 86 beats per minute. In
addition to this, he has a fracture on the right ulna and radius and has burns on his back as well as
the upper arm. Furthermore, the psychological impacts of the patient having Sepsis such as
developing the signs and symptoms of depression and anxiety. The patient can also be
experiencing fatigue and issues with sleep (Fathi, Markazi-Moghaddam & Ramezankhani, 2019).
Four potential physical impact may include showing difficulty in common which can lead
to create a muscular weakness or neurological damage. There is also problem in performing
difficulty in different activity on daily basis like bath or toilet independently. There can be
difficulty in bathing and toileting independently as a physical impact. There can be also George
may face inability to manage money. George may face often developing physical weakness like
neuropathy, cardiorespiratory impairment or a combination of these conditions. George may also
face impact of ability to function independently which frequently declines (Whitfield, (2019)).
There is also psychological impact on George which may impact as anxiety, depression
with high prevalence within 2-3 months. George may also face post traumatic stress disorder
symptoms within 1-6 months. George may also face somatic symptoms of depression like a
appetite change, fatty with weakness and others. George may also face a neurological damage
which may include metabolic derangement, cerebral ischemia and neuroinflammation.
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TASK 2: CARE PLAN
Nursing Diagnosis Goals Nursing Interventions
1. In this, the nursing diagnosis
for the George is state that he is
facing the issue of fracture of
ulna and radius. Therefore,
proper medication is provided
with the intravenous route with
the higher bioavailability that
help to reduce the pain.
1. The first goal is to provide
proper medication at time which is
useful in order to reduce the pain.
Intravenous injection is more
appropriate to control the
unnecessary pain that usually occur
due to the rising pain within the
site that is suggested to support
with plaster of paris (Jacobs, Zeeb
and Hoffmann, 2018).
1. In this, provide proper
massage is provided to
George as pain
management.
2. Drug such as fentanyl,
hydromorphone,
oxycodone and many
more are useful to
minimise the pain.
3. The other intervention
is performing some
exercise such as stretch,
pronation or supination
and many more support
the patient
4. Using exercise which is
appropriate to handle
pain.
2. reduce pain and provide
comfortability that generate
wellbeing and relaxation
1. In this, the pain should
be managed by using
the modern and
traditional method. It is
usually provided by
nurses. The pain
therapy which is based
on traditional method is
usually follow the
technique of
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Nursing Diagnosis Goals Nursing Interventions
acupuncture which is
productive for George
to deal with acute pain.
2. In this, the support and
care is provided to
George for their daily
activity.
3. In addition, within the
pain management the
physiological therapies
are used to provide for
George.
4. Use proper traditional
method to manage pain.
Nursing Diagnosis Goals Nursing Interventions
2 In this, they are requiring
support and care with the
assistive technology which is
helpful for the George.
1. In addition, they also use
assistive device and the
dressing, grooming aids
which is required. They
are usually follow the
aspect support for their
daily activities.
1. The assistance is being
required to George in
order to reduce the
complication that may
render the day-to-day
activities.
2. The assistive equipment
is also derived in order to
reduce the complication
which may related with
the bathing, washing and
walking and other related
care.
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Nursing Diagnosis Goals Nursing Interventions
3. Nurses are used to
support the George with
their daily activities
which including provides
proper care and support
and many more.
4. In addition, the George is
living alone and in such
cases that require proper
support for their regular
activities. The Ulna and
radius are part of arm
which is fracture and
George require proper
intervention support
regards with nurse.
2. The Nurses should assist
George with support with
proper communication
and interaction. It is
helpful in order identify
the complexities which is
faced by George and
nurse usually develop
coordination with
healthcare professional in
order to provide proper
quality of health (Morri
and et. al., 2019).
1. The proper medication
with the different
complex situation is
provide to George with
the proper consultation
with healthcare
professional.
2. In this, the assistance
towards the pain and
medical related support is
usually provided by nurse
with the aspect of their
knowledge is delivered to
the George that provide
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Nursing Diagnosis Goals Nursing Interventions
them proper relaxation.
3. The nurse has their
specific knowledge which
is related with the certain
field. Therefore, the
proper health advise is
require to George in order
to overcome from the
issue. In addition, nurses
used to focus on their
patient and they contacted
with healthcare
professional in order to
provide quality of health
outcome.
4. George is usually facing
the issue which may
related self-assist deficit
due to the condition of
loneliness and they
require proper support
and care that is usually
provided by nurses.
Nursing Diagnosis Goals Nursing Interventions
3 In addition, they require proper
support and carer to minimise the
risk of falling or inducing the
injury. In addition, t risk of injury
1. The goal is to provide
assistive device such as
wheelchair for the support
to the George. In this, the
1. Nurses used to educate
about the proper use of
assistive technology
which provide support
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Nursing Diagnosis Goals Nursing Interventions
which is related with the case
study is based on the risk of
injury due to the inappropriate
behaviour that may cause the risk
of falling also. George is living
alone and due to the fracture on
arm that do not perform their
day-to-day activities.
nurses used to take
monitoring and inspection
of the recovery
progression. Therefore,
the nurses provide proper
care with the aspect to
assistance on the daily
activities.
and care.
2. The nurses also conduct
training and used to
provide the information
which is related with the
assistive device such as
wheel chair. Therefore,
nurse provide proper
instructing that is based
on the use and their
productivity in
difficulties.
3. They take the proper
monitoring towards the
George in order to reduce
the complication which is
appropriate for the
reduction of issue which
may associated with the
fall or having injury.
4. The nurses show their
intervention by focusing
the use of assistive device
and to George in with the
aim to make the things
appropriate and reduce
the chance of harm.
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Nursing Diagnosis Goals Nursing Interventions
2. The goal is reducing the
chance of injury which is
based on the different
type of traction, extremity
or the body part which is
affected. It useful to
provide the detail
regarding the use of
traction to realign bone
ends. In this, the
immobilized is the part of
correct towards the
deformity (Sanford,
Morley and McKee,
2018).
1. The reduction of injury
with appropriate plan that
include support and care
while working any task.
2. Used to produce effective
information that is based
on the effective
communication and
integration that support
moral of George.
3. Develop sense of
knowledge to George and
reduce the
misunderstanding that
may cause the issue.
4. Avoid to lift heavy blocks
and take rest.
CONCLUSION
As per the above discussion, it is well analysed that the nursing diagnose and their
intervention play effective role within the care and support of patients. The related aspect which
is usually focus on the aspect of pathophysiology which may create the issue with the fracture. In
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