Question:

Peter Bowman, a thirty-eight (38) years old plumber, has just been brought by ambulance to the Emergency Department following a fall from a roof.

An Xray showed a fractured right femur along with fractures to his left third and fourth ribs.

Other injuries are not significant.

He did not strike his head and was conscious at the time.

The following data are available for assessment:Primary SurveyA – patent

B – RR 24 and shallow, bilateral, chest expansion, equal Air Entry

C – pale, not diaphoretic. Left foot cool, pale and pale

D – alert and orientated towards time, place and person.

Pain 7/10 left limb and 8/10 left side.

E – swelling and bruising of left leg, grazes towards back, left elbow or forehead.

Peter’s initial assessment was completed by an emergency register, who issued the following orders.

For this assessment task, you will have to submit a paper in which you discuss Peter’s assessment findings and your nursing management.

You should add the following sections to your paper.

Pathophysiology underpinning

Registered nurses must be aware of the disruptions in normal physiology which can lead to abnormal assessment findings.

There are many abnormal assessment findings that can be found in this scenario.

This section asks you to:

Discuss the underlying pathophysiology for Peter’s injuries (fractured hip and fractured spine) by explaining how the disturbances to normal physiology have led to abnormal assessment findings in this case study.

Nursing Interventions

There are many nursing interventions and orders that make up the clinical scenario.

To ensure the safety of patients and to achieve the best clinical outcomes, it is essential that these interventions be prioritized.

Registered nurses should also be able understand how the interventions that we provide link to the patient’s underlying disease.

This section of the report asks you to:

Prioritize the orders according to clinical urgency

Explain the rationale behind each intervention you have listed in your case study.

Each rationale should contain an explanation for why you have chosen the intervention in this order, and a description about how the intervention will improve Peter’s situation based upon the underlying pathophysiology.

The discussion must be supported in both sections by a minimum of 10 recent (less 6 years) and credible sources.

Credible sources include:

Ppeer reviewed journal articles are high quality sources.

Text books

Evidence summaries

Guidelines for the bestGovernment documents

Guidelines, protocols and policies/procedures for healthcare facilitiesWebsites containing content aimed at health professionals.

This paper should adhere to academic writing standards.

Sub-headings should be accepted, but not point form or tables.

Answer to Question: HLT54115 Diploma Of Nursing

Introduction

This is the clinical discussion report for the case Peter Bowman.

The report covers the patient’s pathophysiology, nursing interventions, and the reasoning behind them.

The report can be used to interpret abnormal observation, findings, subjective and objective assessment of patient conditions.

Peter Bowman is a 38-year-old male.

His profession is plumbing.

After falling from his roof and being injured, he was brought to an ambulance by the Emergency Department.

Initial Xrays revealed a fracture in his left femur. He also had fractures to the left second, and fourth ribs.

He denied having lost consciousness at the injury site and also said that he hit his head.

Pathophysiology

Pathophysiology describes any impairment in function or organ structure caused by illness, trauma, or disease.

It is a combination physiology, pathology.

Pathology describes the medical conditions that lead to an illness. Physiology refers specifically to the biology of the organism. (McGurk (2012)

After falling from a roof, the patient presented to Emergency Department suffering fractured ribs.

Patient presented in this manner because he fell stressing primarily from his left side. Due to direct and unexpected force, the patient’s left ribs as well as his femur bone were fractured.

There were also grazes to his forehead, forehead and left elbow. This is a result of the patient falling to the ground.

There was skin discoloration on the patient’s body that did not show any signs of injury, which could indicate some internal tissue damage.

Bone fractures are caused by excessive stress, or from a physical injury.

Reasons behind the patient’s symptoms

The patient presented the following symptoms: pain in his left side, swelling and bruising.

In this instance, the patient’s left leg swelling caused by inflammation of the cells.

Edema in adjacent tissues and muscle spasms are signs of an altered physiology in the femur tissue and muscles.

The rib fractures caused him to have shallow breathing and high respiration rates.

Femoral Fracture

The femur has been called the longest, strongest, and most important bone in the human body. It is also crucial for proper ambulatory movements.

There are three types of femur fractures: transverse, open and spiral/transverse.

The femoralbone is a tubular type that extends from the lower trochanter through the flexure and femur condyles.

The femur experiences various forces during ambulation, such as bending and torsional forces.

These tissues may cause abduction malformations in the proximal femoral shaft, and subtrochanteric vertebral fractures.

The iliopsoas is connected to the lower trochanter and causes flexion deformity.

The medial end of the big-adductor muscle attaches to the medial, causing deformity at the apex.

The vascular supply tissues in the Femur are responsible for regulating the supply of nutrients to the body through the profunda Femoral Artery.

The healing of fractures is important due to the importance of the periosteal flow.

The case study patient described left leg pain intensity 7/10. This was due to a deformity of the femur’s structure.

Because the patient’s leg appears shorter than his other limb, he is unable to lift weights.

Another reason is bruising. Bony pieces are pushing up into the skin and causing pain, discomfort, and ambulatory problems. (Fawthrop. 2015).

The fracture of the patient’s left femur resulted in a disruption of normal blood and nutrients flow mechanisms, which led to further complications during healing.

Fracture in the femur suggests that there is a possibility of blood leakage into the thigh.

The symptoms mentioned above caused pain while ambulating and decreased the strength of his hip bone.

Patient’s leg swelling was due to inflammation at the site of the injury.

Fractured ribs: The ribs protect and support the organs and structures below.

The bony structure and forelimb of the forelimb protect the top three ribs.

The barrier to rib injury is provided by the muscles bonding in the scapula (clavicle), scapula (humerus), and scapula (scapula).

Fracture of the scapula and sternum, or the first or second rib, indicates that there is a significant risk for vessels in the neck, spinal cord, head, and lungs.

These fractures result from a blow or direct force. (Sobak (2014)

Rib fractures, which are the most common type of injury following blunt chest physical injury (Sobak, 2014), account for the majority thoracic injuries resulting from non-penetrating injuries.

The first and second fractures indicate high index vessel injury (Brown and Walters, 2012).

It can cause pain during motion and reduce oxygenation, ventilation and effective coughing.

The injury to his internal organs from second and forth rib fractures resulted in left side chest discomfort.

His average loss of blood per bone was i.e. 100-150 ml.

100 to 150 milliliters.

Paradoxical motion refers to when the normal movements within the chest are reversed. It causes an increase in pain and work during breathing.

Peter complains that he feels pain in his left side (Le, 2015).

Lower O2 stats, i.e.

Hypoventilation causes hypoventilation which reduces oxygen intake.

The broken rib could compromise ventilation by various mechanisms. Atelectasis and respiratory surgery can be caused by pain from rib injuries.

Multiple rib injuries, also known by flail chest, disrupt the normal diaphragmatic muscle excursion. This can cause inadequate ventilation.

Pneumothorax (or hemothorax) can be caused by trauma. For example, a fall causes air to enter the pleural cavities from the outside.

On the injury side, tension pneumothorax causes difficulty breathing or labored breath (shallow). It is also responsible for elevated pressure in the Jugular Venous and muffled heart sounds.

It can also cause a decrease in oxygen saturation.

Tension pneumothorax results from a puncture to the lung as a result of fractured ribs.

Secondary to rib fracture and shift of mediastinum and tracta towards unaffected sides due to elevated air pressure, respiratory symptoms are shallow and weak.

To maintain normal volume, the patient has a rapid respiration rate.

The patient’s rapid respiration rate (RR of 12-20 minutes per minute) may also be due to blood clots, anxiety attacks secondary and rib fractures, and decreased tidal volume.

Peter’s average heart rate was between 60 and 100 beats per minute. Peter’s pace was 120. This is because Peter had hypertension, imbalanced vasoconstriction/vasodilation and circulation of markers inflammation. (Berry, & Miller, 2008).

The left foot feels cool and non-diaphoretic. It is pale from disruption in the blood vessels.

Prioritizing Nursing Interventions

Nursing intervention can be described as the care and treatment provided to the patient to recover from his medical illness.

The patient was taken immediately to the ED so that treatment could be given at the right time. Delaying treatment can lead to more complications.

Initial chest X-rays were taken to rule any possible intrathoracic injuries.

Nursing care plans or follow the symptoms and problems described by the patient.

Patients care starts with the assessment of vital signs like blood pressure.

They establish the treatment protocols and make life-saving decisions.

It helps to limit the scope of treatment (“vital measurements”) 2016,

This primary survey is designed to help trauma patients. (Duch, Moller (2015)

These are the treatments that the doctor orders after primary surveys: The patient was given morphine (7.5 mg IV STAT) for pain management.

The patient received Oxygen therapy to increase O2 saturation until normal.

In 30 minutes, the patient received 0.9% Sodium Chloride ILIV.

The patient was then fitted with indwelling bladder catheters (IDC), to record hourly urine samples.

Finally, the patient was moved to a new sitting called High Fowler’s for early mobilization.

Pain Management: In order to provide adequate ventilation for the patient, it is important that pain be managed.

For the relief of pain, the patient was administered 7.5mg IV morphine.

It is also known to be opioid (narcotics-analgesics).

It works by changing how the brain responds to pain receptors. Wight, King, 2014.

Oxygen therapy is the provision of oxygen therapy to maintain Oxygen stats between 96% and 99 percent.

Lower O2 stats mean that body cells will function less well.

For proper cell functioning, extra oxygen is supplied to the patient. This is followed by periodic assessment of vital signs at set intervals.

Electrolyte Balance: Next, the patient was given an IV fluids litter which was used to treat their sodium depletion (extracellular) or isotonic hypohydration.

Interiano (2012). Intravenous fluids allow for the fastest restoration of electrolytes. They are directly administered to the veins.

Insertion a IDC (Indwelling bladder catheter): This device is used for evaluating the urological conditions, including the level of urine output and any abnormalities that may be caused by ongoing injury or fluids (Lim & Sirichai 2016, 2016).

Sitting in the high fowlers’ position: Fowlers are those positions where the patient’s head is elevated at 30 degrees, 45 degrees, 90 degrees, or 90 degrees. There are four types of fowlers’ positions.

This would mean that the patient should sit in a high fowler position where the body lies at between 60 and 90 degrees angles.

You can either bend your legs or keep them straight when you do this.

This device is used when the patient needs to be fed, groomed, or when they have breathing problems.

The intervention’s purpose is to maintain circulation, avoid nerve damage and constriction, and prevent pressure on the chest cavity.

It allows the patient to have proper chest expansion and oxygenation. (Ellis (2013)

Linking Nursing Interventions & Pathophysiology

Proper recovery and proper treatment requires the linking of pathophysiology and interventions.

It is also useful in determining the cause of unknown injuries.

Regular vital signs evaluation is necessary to watch for disappearance patient symptoms (Lim & Sirichai 2016, 2016).

O2 therapy was prescribed to the patient. It would aid in the healing of the fractured bone and raise the oxygen saturation up to 96%.

The patient was unable take proper oxygen due pain in his chest. O2 therapy could be used to help the body recover oxygen levels.

It is vital to be seated in the high fowlers position in order to eliminate the problems of shallow breathing and high respiration rates in the patient who has suffered from second and forth rib fractures.

It will assist in the healing of the vessel damage and intrathoracic damage.

The patient can be treated for pneumothorax and hemothorax that result from the penetration of broken rib pieces.

To ease his pain in his left leg and chest, the patient received IV morphine of 7.5 mg to help. The medication altered the brain cells’ pain receptor responses.

The femur being the most strong bone in the body, it supports the body while moving around and helps overcome anxiety (Shah 2015.

After multiple injuries and falls, the patient suffered from internal vascular injury. He was treated with 0.9% sodium chloride IV fluids.

The electrolytic balance is caused by the breaking down of blood vessels and capillaries.

In order to support healthy blood and nutrient metabolism, restoring electrolytic balance is essential.

To aid in diagnosing urological abnormalities like incontinence, or other, an Indwelling Catheter was inserted into the patient.

It is used to diagnose any urinary malfunction that may be caused by femur fractures, and the associated injuries. (Ellis (2013)

Conclusion

This discussion report about clinical representation was useful in learning the guidelines of clinical nursing to be followed when treating trauma patients (ED fractures).

Peter Bowman, a patient who suffered left femur and second and third rib fractures as a result of a fall, is assisted by nurse in this report.

This report shows how critical it is for nurses to be able to recognize the cause of injury or fractures and prepare a nursing care plan that will help the patient recover quickly.

The nurse must know the order or priorities of the care that is given to the patient in ED. They should also be aware of the role or importance of abnormal assessment.

The report outlined the importance of the nurse understanding the reasoning and linking the patient’s care to their symptoms.

It provides guidance on how to treat multiple fractured patients and outlines the best nursing practices.

Reference

Age-friendly nursing interventions for the management of older adults in emergency departments. (2012).

Nursing & Health Sciences. 14(2). 272-274.Berry, S., & Miller, R. (2008).

Falls: Epidemiology of fractures, pathophysiology, & relationship to them.

Current Osteoporosis Reports 6, 149-154.Brown, S., & Walters, M. (2012).

Patients with Rib Fractures. Journal Of Trauma Nursing, 19(2), 89-91.Duch, P., & Moller, M. (2015).

An systematic review of randomised controlled trials evaluating epidural pain relief in traumatized rib fracture patients. Acta Anaesthesiologica Scandinavica, 59(6), 698-709.Ellis, G. (2013). Essential Nursing SkillsEssential Nursing Skills.

Nursing Management, 20(1). 9-9.Fawthrop, P. (2015).

Essential Pathophysiology and Nursing Students Richards Ann Edwards Sharon and Nursing Students Essential Pathophysiology489pp PS19.99 McGraw Hill Education.

Nursing Standard, 30 (11), 28-28.Interiano, A. (2012).

Use of elastomeric pumps to relieve pain from traumatic fractures. Nursing, 42 (2), 65-67.Le, L. (2015).

2091535 Ultrasound in Revelation Chest Xray Film.

Ultrasound In Medicine and Biology, 41(4). S164.Lim, L., & Sirichai, P. (2016).

Assessment and management of bone injuries. Australian Dental Journal, 61, 74-81.Liu, Y. (2015).

Analysis on Post-Operative Dementia and Tissue Injuries in Patients with Lower Limb Fracturing in Mining Area.

Journal Of Nursing 4(3), 10.McGurk, S. (2012).

Understanding Pathophysiology Fifth editionUnderstanding Pathophysiology Fifth edition

Nursing Standard, 26 (49), 30-30.Shah, M. (2015).

To intubate and not to intubate: Management of multiple broken ribs. Trauma, 17(4), 299-302.Sobak, S. (2014).

Nursing process of health-care for patients with broken ribs. Sestrinski Glasnik/Nursing Journal, 19(1), 48-52.

Vital measurements. (2016). Electronics Letters, 52(19), 1577-1577.Wight, J., & King, S. (2014).

The intravenous catheter that was damaged has been repaired. Anaesthesia, 69(10), 1180-1181.Yazkan, R. (2012).

Traumatic First rib Fractures.

Journal Of Academic Emergency Medicine. 11(1), 27-30.