2803NRS Acute Nursing Practice


Consider the Following Client Scenario

John Grant, aged 63, has been diagnosed bilateral knee osteoarthritis.

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John had Endone 5 mg prn added by his GP. John then began to feel worse in his right knee. John was referred for a right to total knee replacement. After he has fully recovered from the first surgery, he will be able to have the left leg done.

He is prone to angina, hypertension and hyperlipidemia.

John is a widower and runs a cafe along with his eldest son.

He used to work six days a weeks, but his knee pain has forced him to reduce his work hours to office work and light duties. He now worries about the workload of his daughter.

John lives alone with six steps to the front of his house. He is capable of doing all his activities of daily living (ADLs) as well as household chores independently.

His family frequently visits and, recently, his son-in law and daughter-inlaw have helped with the housework as well as cooking.

John has been discharged from the hospital and is now in your care.

Pick one of the two topics below: Post-op breathing infection or Post-op deep venous thrombosis (DVT).

Answer to Question: 2803NRS Acute Nursing Practice

John Grant is the case discussed in this essay.

He is experiencing bilateral knee osteoarthritis. Therefore, he is at increased risk for developing deep veinthrombosis.

He is also experiencing other complications such as metabolic, cardiovascular, psychological and other disorders.

John’s current condition will be discussed, along with his medical history and family.

Also discussed is the pathophysiology for deep veinthrombosis.

John should be tested to assess the problem and then interventions for those problems are planned.

John care can also include different professionals.

Overview of Client

John Grant is 63 years old and has bilateral knee osteoarthritis.

Endone 5 mg is prescribed for him and he is advised to have both knees replaced.

He may also be suffering from other complications, such as angina, hypertension and hyperlipidaemia.

Due to knee pain, he has reduced his work load from 6 days per week down to 2 days per.

His daily activities are being performed by him alone, but he has a few family members who assist him.

Reduction in blood flow could cause deep vein embolism.

Venous stasis can be caused by reduced blood flow and dilated veins.

This can lead to injury to the blood vessels’ intimal walls, which is the site of thrombus production.

Phlebitis is an inflammation of the vein walls that occurs immediately following thrombus production.

Venous hemorhages are caused by the accumulation of platelets on vein walls.

Venous thrombi look like tails and are made up of fibrin as well as white blood cells, red blood cell, and fibrin.

The natural or artificial fragmentation of the thrombus could occur due to an increase in venous pressure.

The reestablishment or the restoration of the lumen of vein is possible following an episode of deep-vein thrombosis (Houshmand et. al. 2015; Nisio. 2016).Comprehensive Assessment:

John should be evaluated for the musculoskeletal systems as he suffers from osteoarthritis.

Functional assessment should be conducted to evaluate John’s strength and balance as well as his joint range for motion in the daily activities.

The movement, body posture, and symmetry must be examined.

This assessment can be made by observation.

Tenderness and contour of the spine should also be assessed.

This assessment can easily be done visually by looking at the spine from both sides.

This assessment allows for the examination of John’s spinal configuration and range.

John should be evaluated for balance and gait.

John should be asked to take 5 to 6 steps around the room to measure his gait.

To assess John’s gait, nurse should ask John to move in different ways. John could walk heel-to-toe and on his tiptoes.

Romberg testing (Almoallim und Gelidan (2012); Maricar et. al. (2016)) should be used to balance test John.

To assess John’s diabetes, a nurse should examine John for weight changes, sweating patterns and weakness.

John should also have polydipsia, Polyphagia, or polyuria assessed by the nurse.

John should be assessed for cardiovascular conditions like blood pressure, heart beat and blood pressure.

John should be examined for vision impairment with ophthalmoscopy.

Neuropathy should also be assessed for ankle and leg reflexes using tendon hammer.

John should conduct a glucose level test as well as a HbA1C test to determine if he has diabetes.

John should have his glucose level measured by glucose oxidase and HbA1C using an ELISA kit.

His family members should regularly visit him and take him to hospital to assess his health.

John should be assessed by a clinical laboratory scientist as well as a dietician (Pagana-Pagana, 2014; Selph. et. al., 2015.).

John could be more at risk due to osteoarthritis or his age.

The information needed to assess fall risk is the number of falls and the frequency of fall over the last six-months.

Information about fall-prone activities and jobs should also be collected.

Fall risk should be assessed using frequency of bowel movements and urine elimination. This is because the majority of elder patients use the bathrooms.

You can evaluate fall risk using gait and hearing impairment.

The assessment of cognition is a way to evaluate fall risk.

It is possible to use cognition to gain knowledge about the environment and obstacles around you (Suman and al., 2013, Suman et.al.

Surgery has a higher risk of infection.

The risk of infection can also be evaluated by checking for purulent drainage at the surgical site and examining any tissue or fluid.

A patient can also be evaluated for infection by observing signs such as redness, pain, swelling and reddening (Cheng and colleagues, 2015).

You can plan nursing care based on the assessment of your client:

John should receive intervention in order to improve mobilization. In osteoarthritis, mobilization can be reduced.

Use warm compresses or warm blankets to help reduce joint stiffness and ease muscle tension.

It can be beneficial to massage the legs gently, as it helps with fluid movement into the lymphatic system. Fluid also moves from the extremities to the central compartment.

This could help increase mobilization.

Active range of motion and stretching should be used to improve the function of the affected joints.

This would be helpful for pain-free movement, strength, and limb usage (Musumeci und al., 2014).

John, a patient with type 2 diabetes mellitus, should be treated with gliclazide (and acarbose)

These medications are very useful in managing type 2 Diabetes Mellitus.

Gliclazide is an inhibitory agent on the sulfonylurea receptacles (SUR-1) on the pancreatic Beta-cells.

Acarbose is inhibitory to enzymes like alphaglucosidase small intestine, and alpha amylase pancreas.

It facilitates carbohydrate digestion while lowering HbA1C (Singla and Singh, 2016; Singhand Singh (2016)).

Nurse interventions should be made to increase blood flow to the leg in deep vein embolism.

By changing the position and using compression therapy, blood flow can be increased to the leg.

John’s legs should not be lower than the knees and should be kept slightly bent at the knees.

Use warm and moist compresses for the legs.

Gradually applying compression stockings to the legs can reduce the caliber of superficial veins in the legs and increase blood flow.

External compression devices, wraps in a 50 percent spiral wrap, should be applied starting at the toes and ending at the knees.

These are short stretch elastic wraps.

John’s intermittent pneumatic compression device could be useful in increasing blood speed.

Research has shown that these devices are effective in preventing the formation of bloodclots.

These devices are better than medications to prevent blood from clotting because there is less chance of bleeding.

The chances of blood clotting with the consumption of medication are much lower than those using compression devices (Blann and 2015).

Evaluation of Care

Nurse should administer and maintain optimal perfusion to John upon consultation with the physician.

It would be beneficial in the prevention of clot formation for John.

John should be informed about the medications by the nurse.

John should be educated by the nurse, pharmacist, and clinical pharmacologist.

John should learn how to properly dose anticoagulant and when to drink it.

John should be instructed by his nurse to have a clinical laboratory specialist perform blood tests regularly to adjust medications or change the dose.

John’s family members should help the nurse to stop John from drinking alcohol as alcohol can affect anticoagulant effectiveness.

Nurse should get help from a physical trainer to learn about the movements of the legs and how to increase blood flow.

John has metabolic and cardiovascular issues. John should be seen by a dietician so that he can plan the right diet.

The role of diet is crucial in this disease.

John, who is depressed, should be managed by a psychologist.

John would benefit from the counsel of a psychologist (Blann, 2015).

John’s current health and his medical history informed how I described John’s situation.

I understand that John is suffering from a complicated medical condition.

John has multiple complications, including those of his cardiovascular system, nervous system, and musculoskeletal system.

To help understand John’s main problem, I assessed his condition.

After the assessment, it was clear that immobilization caused by osteoarthritis or high glucose due diabetics are the main problems.

John required nursing intervention. I was able to mobilize John and decrease blood glucose levels. (Papathanasiou.Conclusion:

John has bilateral knee osteoarthritis. This is very serious and should be treated with knee replacement surgery.

Deep veinthrombosis is one of the major risks for knee replacement surgery.

John should be assessed for the musculoskeletal, and endocrine functions.

John should receive nursing intervention in order to increase mobilization or decrease glucose level.

John should receive nursing intervention for deep-vein thrombosis. This should include the participation of other professionals like a pharmacist, psychologist and clinical laboratory scientist.

John would benefit from a thorough assessment and targeted intervention.References:

Almoallim Hani. & Gelidan A. (2012). Musculoskeletal Examination Skills: Are We Still Interested?

International Journal of Clinical Medicine. 3, 335–340.Blann, A. (2015).

Deep Vein Thrombosis & Pulmonary Elolism: A guideline for practitioners

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Cheng K. Jiawei L. Qingfang K. Changxian W. Nanyuan Y. Guohua X. (2015).

One prospective study of 1138 patients.

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Molecular imaging and deep vein thrombosis: The role of molecular image in diagnosis

American Journal of Nuclear Medicine and Molecular Imaging. 4, pp. 406-425.

Maricar. N., Callaghan. M.J. Parkes. M.J. Felson. D.T. O’Neill. (2016).

Clinical assessment of effusions in knee osteoarthritis: A systematic review.

Seminars on Arthritis or Rheumatism. 45(5): 556-63.

Musumeci G. Mobasheri A. Trovato F.M. Szychlinska M.A. Szychlinska M.A. Imbesi R. Castrogiovanni P. (2014)

Post-operative rehabilitation, nutrition in osteoarthritis. https://dx.doi.org/ 10.12688/f1000research.4178.3.

M. D. Nisio (2016), van Es N. and Buller H.R (2016).

Deep vein thrombosis (DVT) and pulmonary embolism. Lancet, 388(10063), 3060-3073.

Paganam T.J. (2014). Blood studies. In: Pagana KD, Pagana TJ, eds.

Mosby’s Manual of Diagnostic and Laboratory Tests. 5th ed. St Louis, MO: Elsevier Mosby; 2014:chap 2.Papathanasiou, I. V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., &Kourkouta, L. (2014).

Critical thinking: The essential skill of nursing students. ActaInformaticaMedica, 22, 283. https://dx.doi.org/10.5455/aim.2014.22.283-286

Singla R.K. Singh R., Dubey A.K. (2016).

Acarbose is an important post-prandial antidiabetic drug.

Current Topics of Medicinal Chemistry (16(23), 2625–33.Singh, A. K., & Singh, R. (2016).

Is gliclazide an sulfonylurea that is different?

A review of 2016. Expert Review of Clinical Pharmacology, 9, 839-851.https://dx.doi.org/10.1586/17512433.2016.1159512Selph, S., Dana, T., Blazina, I., Bougatsos, C., Patel, H., Chou, R. (2015).

Screening for type 2 Diabetes Mellitus: A Systematic Review for the U.S. Preventive Services Task Force.

Annals of Internal Medicine. 162(11). pp. 765-776.Suman, V.B., Khalid, P., Jeganathan, P.S., Subbalakshmi, N.K., Sheila, R. P., Shaila, M.D. (2013).

Risk factors associated Osteoporosis: A population-based study using p–Dexa technique.

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