This is an essay about the nursing care priorities for a case study in which the patient had serious health issues like broken ribs, chronic obstructive pulmonary disease (COPD), hypertension, and few others, using the Levitt-Jones Clinical Reasoning Cycle. This cycle is a method in which the nurse learns by collecting and processing information of the patient and evaluates outcomes with reflection.
Consideration of the patient’s current situation
A patient named Mrs. Deborah Scott who is a 65-year old woman was admitted to the Public hospital. She was found by her husband after he found her lying on her bedroom floor. It’s her third admission to the hospital with a fall in the last six months. The chest x-ray is suggestive of broken ribs and injuries to the chest wall. She has a history of type II diabetes – insulin-dependent; hypertension; osteoarthritis and chronic obstructive pulmonary disease (COPD).
Collecting cues and information
She has a history of type II diabetes – insulin-dependent; hypertension; osteoarthritis and chronic obstructive pulmonary disease (COPD). She is prescribed panadol osteo – for osteoarthritis, atenolol – for hypertension and chest pain control, telmisartan - it lowers the blood pressure and treats hypertension, spironolactone – effective for hypertension and vitamin D – as she is an old lady with osteoarthritis, therefore, she is prescribed with vitamin D. She is also prescribed with Ventolin, Novolin 70/30, and metformin. According to Laiteerapong et al. (2013), a patient with diabetes has a high blood sugar level this can affect the body organs with blood vessel complications causing increase blood pressure resulting in serious cardiovascular issues like heart strokes. Hypertension leads to complications of diabetes as well making the condition of the patient worse. Therefore, she is prescribed with Novolin and metformin, it reduces the production of glucose and increases glucose utilization and uptake by increasing insulin sensitivity. The patient with diabetes is at high risk of osteoarthritis, thus diabetes can make patients with osteoarthritis worse (Courties et al., 2019).
Processing the information
As the patient has fallen on the ground and her X-ray reports showing that she has developed broken ribs and injuries to the chest wall as well, resulting in a life-threatening emergency of pneumothorax. This shows that fracture can damage the lungs along with its outer covering and alveoli as well, making it very difficult for the patient to breathe as he/she will suffer from extreme pain in breathing and the chest. This can be diagnosed with the help of X-ray or in a few cases if the damage is a severe computerized tomography (CT), is used to get detailed information about the fractures or damage. Moreover, ultrasound imaging is also used for the diagnosis of pneumothorax. If a major part of the lungs gets damaged due to rib breakage then chest tube insertion and needle aspiration are conducted to remove the excess air so that the patient can breathe. Diabetes can be diagnosed through various methods like fasting blood sugar tests, random blood sugar tests, oral glucose tolerance tests, or glycated hemoglobin (a1c) test (American Diabetes Association (2010). Along with these tests, the doctor also tests for blood pressure and blood cholesterol levels as these are associated complications that arise in a patient with diabetes. As the patient’s blood pressure is very high that results in hypertension so to diagnose it the health professionals use a sphygmomanometer. Using a sphygmomanometer the health professionals detect whether the patient has stage I - 80 to 89 mm Hg dor diastolic and 130 to 139 mm Hg for systolic or stage II hypertension – with a diastolic pressure of 90 mm Hg or higher and systolic pressure of 140 mm Hg or higher. As hypertension can lead to various health complications as discussed so it's necessary to treat it (Word Health Organization, 2020). The patient's COPD is diagnosed by a simple test called spirometry, to detect the amount of air inhaled and exhaled by the patient (World Health Organization, 2020). According to Courties et al. (2019), a patient with chronic obstructive pulmonary disease (COPD) is at a risk to develop osteoporosis. Chronic obstructive pulmonary disease (COPD) hurt the various functional and structural domain of the lungs. Skeletal muscle dysfunction, nutritional abnormalities, and weight loss are major health complications that arise due to COPD. Thereby, making it a care priority for the health care staff to prevent the patient from facing these health complications.
The first nursing priority is to prevent the chances of the occurrence of pneumothorax. This condition majorly occurs in the collapsed lungs that are due to the broken ribs (Kim & Moore, 2020). This is the most critical complication of displaced rib fracture as it punctures the lungs and pleural sac that surrounds the lungs. The punctured lungs cause air leakage that is a potentially life-threatening condition. The chest wall injuries are also associated with the high risk of decreased oxygen component in the blood and the occurrence of pneumonia. This is the nursing priority because this will have a direct impact on the patient’s breathing ability and this chest trauma demands nursing interventions for the management of this condition (White & Eaton, 2017). Thus, the complications that may arise due to the risk of pneumothorax makes it the first nursing care priority in this case study. The patient is old and this condition of collapse lung will cause the change in pressure inside the chest.
The second nursing priority is pain management because of the broken ribs that may have a direct impact on the respiratory system and cardiovascular system of the patient. The patient is an older adult that is of age 65 years and it is very important to make the lungs inflate to their maximum capacity. The nursing care priority will be pain management because broken ribs are associated with high pain levels that cause extreme discomfort to the patient (Mathews, 2016). The first important step in pain management starts with the effective evaluation of the pain level in the patient. The pain score scale can be best used as an evaluation tool to systematically record pain intensity. The rib fracture in geriatric patients may cause pain to preclude in normal breathing and also in the secretion clearing. This is a priority because intensifies the discomfort and the evidence highlights that the breathing becomes shallower and it also represses coughing that leads to respiratory insufficiency. The patient can be administered a local anesthetic like an opioid for pain management (Brasel et al., 2017). This will assist the patient in breathing properly which would be free of discomfort in the patient.
The first SMART goal for the nurse is pain management in a day so that Mrs. Scott can breathe properly and most importantly pain-free respiration. The nurse will ensure that the pain levels are reduced so that the patient can be given a high level of comfort while she breathes normally and while she performs daily activities like eating and drinking. This goal can be evaluated for the results in the patient as the patient will be able to self- report the pain levels and its intensity. This nursing goal is thus very important to achieve to make her life comfortable and to give her a healthy lifestyle (Baiu& Spain, 2019). The second SMART goal is to prevent the occurrence of pneumothorax in the patient so that further complications can be prevented. This requires a proper assessment of the patient's condition that will lead to a better decision- making in context with the patient’s treatment plan and care plan. Patients with pneumothorax face many difficulties concerning breathing and other complications so the goal of prevention of the development of further complications will assist in improving the patient's condition (Kamali et al., 2017). The goal is to provide ventilation assistance to the patient that will help the patient in breathing properly and will also promote the blood oxygen levels. This is thus important to apply the interventions as per the goals formed for the patient so that recovery is observed in a patient.
The outcomes in the patient will assist in evaluating the interventions and goals utilized by the nurses. The goal of pain management can be evaluated if the patient self- reports the pain to medical health care professionals and the positive patient outcomes can also be evaluated by observing the healthy lifestyle of the patient. Independence in carrying out the day- to- day activities will also assist in evaluating the outcomes and the nursing goals as it will justify the interventions that are applied for the patient recovery and prevention of the development of the complicated condition of pneumothorax. The constant improvement in her physical activities and breathing capacity can also be used to evaluate outcomes in the patient.
This patient’s condition was complicated as the patient was admitted due to the fall but other comorbidities made the patient live in a painful condition. I learned that in such conditions, the nurses must use their critical thinking skills and decision- making skills to ensure patient safety. The nurses play a very important role in patient safety and also contribute to patient recovery. The vital signs of the patient were not recorded at the time of admission and later this caused a lot of issues while planning an effective treatment plan of the patient. Comprehensive skills can be best applied when the resources and full information of the patient are available. According to the Nursing and Midwifery Board of Australia (2016), standard 1 states that the nurses must always utilize their critical thinking skills and decision-making skills while taking care of the patient and must analyze their nursing practice.
American Diabetes Association (2010). Diagnosis and classification of diabetes mellitus. Diabetes care, 33 Suppl 1(Suppl 1), S62–S69. https://doi.org/10.2337/dc10-S062
Baiu, I., & Spain, D. (2019). Rib Fractures. Jama, 321(18), 1836-1836.
Bordoni, B., Marelli, F., Morabito, B., & Castagna, R. (2018). Chest pain in patients with COPD: the fascia's subtle silence. International journal of chronic obstructive pulmonary disease, 13, 1157–1165. https://doi.org/10.2147/COPD.S156729
Brasel, K. J., Moore, E. E., Albrecht, R. A., deMoya, M., Schreiber, M., Karmy-Jones, R., &Biffl, W. L. (2017). Western trauma association critical decisions in trauma: management of rib fractures. Journal of Trauma and Acute Care Surgery, 82(1), 200-203.
Courties, A., Berenbaum, F., & Sellam, J. (2019). The phenotypic approach to osteoarthritis: A look at metabolic syndrome-associated osteoarthritis. Joint Bone Spine, 86(6), 725-730.
Kamali, A., Broujerdi, G. N., & Bagheri, H. (2017). Comparing epidural block and intercostal block in patients with 3–4 broken ribs following chest cage blunt trauma. Annals of Tropical Medicine and Public Health, 10(4), 850.
Kim, M., & Moore, J. E. (2020). Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Current Anesthesiology Reports, 1-8.
Laiteerapong, N., Huang, E. S., & Chin, M. H. (2013). Prioritization of care in adults with diabetes and comorbidity. Annals of the New York Academy of Sciences, 1243, 69–87. https://doi.org/10.1111/j.1749-6632.2011.06316.x
Matthews, J. M. (2016). 16 Pain management in the trauma patient. Handbook of Acute Pain Management, 266.
Nursing and Midwifery Board of Australia. (2016). Registered nurse standards of practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
White, D., & Eaton, D. A. (2017). Pneumothorax and chest drain insertion. Surgery (Oxford), 35(5), 281-284.
World Health Organization. (2020). Diagnosis of COPD. Retrieved from: https://www.who.int/respiratory/copd/diagnosis/en/
World Health Organization. (2020). Diagnosis of hypertension. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/hypertension
Wshah, A., Guilcher, S. J., Goldstein, R., & Brooks, D. (2018). Prevalence of osteoarthritis in individuals with COPD: a systematic review. International journal of chronic obstructive pulmonary disease, 13, 1207–1216. https://doi.org/10.2147/COPD.S158614
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