Male patient aged 24 admitted for elective surgery “right knee arthroscopy” and removal of metal work
Average weight 172 lbs Height 6ft 2
Pre- admission observations
BP 120/68
Respirations 17 per minute
Pulse 68
Temp 36.7
Abby Pain score 2
observations one hour Post – operative
BP 110/50
Respirations 14
Pulse 75
Temp 36.1
Abby pain score 8
observations two hour Post – operative
BP 135/75
Respirations 18
Pulse 75
Temp 37.2
Abby pain score 11
observations three hour Post – operative
BP 110/50
Respirations 14
Pulse 80
Temp 37.8
Abby pain score 7
Procedure undertaken as planed however was more involved than originally anticipated due to the location of the metal work to be removed.
First Nursing problem and concern to be addressed
Pain not controlled
Post operative pain
Pain relief administered one post operative
Paracetamol 1g codeine phosphate 30 mg and oramorph 10mg
Second nursing problem to be addressed
Mobility – full knee brace prescribed and applied.
Non weight bearing for 6 weeks per orthopaedic surgeon directive
HOWEVER patient very anxious about needing to return to work as self-employed tradesperson – keen to self-discharge prior to being seen by physiotherapist although in patient physio review was made and attended by patient prior to discharge.
LEARNING OUTCOMES
Discuss the role of the adult nurse in assessment and planning of care during illness, differentiating between the nurse’s role and that of other health professionals.
Explain how clinical decisions and interventions are influenced by assessment showing appreciation that needs during illness are at times uncertain and will change requiring the need to evaluate and re-assess.
Compare and contrast the different types of knowledge utilised when making clinical decisions and planning care.
Discuss commonly encountered physical, mental, cognitive, behavioural health conditions and the nursing interventions to manage such conditions in adult nursing practice.
Essay will be addressing learning outcomes 1-4 of the module (review the learning outcomes) . It is an academic essay and will need to be written objectively using supporting evidence throughout from nursing literature, policies and clinical guidelines relevant for your field of practice and also relevant to the care of your patient. You will also need to show an ability to discuss appropriately the evidence in the essay.
The content of the essay will need to analyse the role of the nurse for your field of practice.
Adult Nursing. For this essay it must link to the role of the nurse in the clinical environment where assessment and planning of care for your chosen patient took place with supporting evidence from the literature to discuss the role.
The essay will need to address clinical decision making in relation to the assessment and planning of care for your patient. Using supporting evidence form the literature analyse how these clinical decisions were made for the patient to plan the care; the different types of knowledge that informed the clinical decisions such as empirical, personal, aesthetic, ethical, cultural knowledge. These must relate to the two main nursing problems in the care plan formulated and used for the patient in your episode of care.
The essay will then need to analyse the nursing care focussing on the nursing interventions using supporting literature to analyse the evidence base for the care that has been prescribed. The outcome of the interventions must also be analysed to show appreciation of how the needs of your chosen patient changed for e.g. did they improve or did the deteriorate and why utilising supporting evidence.