HLT54115-Diploma of Nursing Report Writing – Medical Science Assignment Help

Scenario – Mr George McFarlane:

I: Mr George McFarlane is a 53year old Male.

S: George has presented to hospital yesterday after he fell while getting out of his truck. The X-ray on admission showed that George has sustained a compound fracture of his right ankle, which required an open reduction and internal fixation (ORIF) to repair. Surgery was completed this morning and George has returned to the ward from the Operating theatres 2 hours ago.

B: George’s past Medical History (PMHx) include:

• Type ll Diabetes needing close management. Records BGL daily
• Osteoarthritis in L) Knee
• Allergy to Penicillin

Social History (SHx):

• Married for 5 years to Yu Yan, who is of Chinese heritage. She speaks English well.
• Has a 26 year old son from a previous marriage, who has depression and uses illicit drugs. The son visits occasionally.
• Lives with his wife and 3 year old twins from his current marriage. One twin has a developmental disorder. His 17 year old step son also lives with the family.
• Occupation: Long Haul truck driver, often isolated from family and friends as on the road and away from home due to work. Speaks to wife daily when away.
• ETOH (Alcohol) usage on a regular basis
• Smoker, averages 15 cigarettes per day
• Often consumes take away/ fast food diet as away from home regularly
• Sedentary lifestyle, often watches TV to cope with stress. Little to no exercise
• A: Mr McFarlane is 118kg and 180cm in height. Current vital signs Resp 26, O2 Sats 97% on room air (RA), BP 170/90, HR 110, Temp 37. 

R: Continue 2 hourly observations, including monitoring neurovascular observations and pain scores. Elevate right foot. Strict resting in bed until review by doctor tomorrow.   

Question 1:

Based on the information received in the case study, you need to complete a plan of care for George. Use the template below to outline the anticipated care for George for his post-operative period, considering your EN Scope of Practice.  To complete this question you need to:

• Specify four (4) nursing diagnoses or risk factors associated with the client’s current health presentations. (Consider manual handling, strict resting in bed, post-operative vital signs, pain score and management, neurovascular and wound monitoring, Type ll Diabetes requiring close monitoring, smoker, risk of post-operative complications, self-care needs. Reflect on Maslow’s hierarchy of needs)
• Record at least two (2) nursing interventions that could be applied for each diagnosis, these interventions must be in lines with current best practice standards.
• Specify at least one (1) member of the multi – disciplinary team who may be able to support your suggested interventions.
• Note at least one (1) expected outcomes that you would hope for as a result of each intervention. (Consider SMART goals when discussing outcomes)

Question 2:

George is at an increased risk for respiratory compromise due to his history of smoking and having recent surgery. Outline:

a) Two assessments you could complete on George to evaluate his respiratory systems.

b) Two nursing interventions which you, as an Enrolled nurse, can implement to decrease George’s risk of respiratory complications.

c) What other health professional (not a doctor or a nurse) could assist George. Describe how they could assist George to decrease his risk of complications.

Question 3:

Due to his medical history and post op instructions of strict resting in bed, George is at an increased risk of Venous thromboembolism (VTEs) and pressure injuries.
Outline:

a) What assessment tool would you use to assess George’s risk of pressure injuries? Describe in your own words how this assessment tool works.

b) Two (2) nursing interventions which you, as an Enrolled nurse, can implement to decrease George’s risk of pressure injuries

c) One (1) nursing intervention which you, as an Enrolled nurse, can implement to decrease George’s risk of VTE’s

Question 4:

While you are completing George’s post-operative observations, he states that he is feeling tight in the chest and a little breathless. 

a) Explain what you think might be happening to George. Provide a rationale for your response.
When you report the situation to the RN, they request that you record a 12 lead ECG on George

b) In your own words, describe the steps in completing a 12 lead ECG (remember to include in your response dignity and privacy considerations)

Question 5:

After completing the 12 lead ECG and review by the doctor, it is determined that George’s chest tightness is not cardiac related. The doctor has requested that you collect a sample of blood to determine what may be the cause of George’s symptoms.

a) In your own words, describe the steps in completing venepuncture (remember to include in your response dignity, privacy and safety considerations).

Question 6:

George is for strict rest in bed after his surgery. Outline three (3) ways you could encourage George to remain as independent as possible while attending to his activities of daily living (ADLs)

Question 7:

Other than an EN/ RN, name three (3) health care professionals found in a hospital setting that you might be able to refer George to for assistance with his current healthcare requirements and his previous comorbidities.For each professional, in 20 words, state how they could contribute to Mr. McFarlane’s care. 

Question 8:

When you go and check on George you find that he has fallen out of bed. On initial assessment he is unresponsive. 

a) Outline your immediate response to this situation.

George regains consciousness very quickly and explains to you that he was trying to get up to go to the toilet. After the doctor and RN have examined George and determine that there are no significant adverse outcomes from his fall, you assist him to return to bed. 

b) Outline your nursing interventions for George after his fall.

Question 9:

George is due for discharge from hospital tomorrow. Outline three (3) referrals and/ or community resources that you could provide to George to assist him after discharge.