Case study

Case study. By: Morgan Miller NUR 213 Capstone Project 11/13/2021.

Day 1. Anna Smith, 77 year old, Caucasian female begin brought into the emergency by EMS. EMS reports t he patient was in motor vehicle accident. She was hit head on by another car who ran a red light. Patient was partially ejected out of the front window due to not being properly restrained. Patient is unresponsive with a GCS of 9. Patient is noted to have lacerations to head and deformity to the right flank. Weak radial pulses. C- collar is in place. Vitals as followed: HR- 136, BP 86/40, R- 14, Sp02 86 room air Temp: 98.7 F BGL- 150.

Initial Assessment. General Appearance: Cool, pale skin Neuro: Patient is unresponsive. GSC 9. Respiratory: Patient has shallow breathing and lung sounds present bilateral. Low 02 on pulse oximetry. Cardiac: Tachycardia, hypotensive, weak radial pulses. Genitourinary: No urine output Abdomen: Soft, non-distended Skin: Cool. Pale skin to touch..

What’s abnormal in the assessment?. Neuro : Patient is unresponsive. GSC 9 .- (Possible head trauma) Respiratory: Patient has shallow breathing. Low 02 on pulse oximetry .(need more data, monitor) Cardiac: Tachycardia, hypotensive, weak radial pulses . (Heart is working to compensate) Genitourinary: No urine output (Need more data) Skin : Cool. Pale skin to touch . ( monitor ).

What do you anticipate the Doctor to order?. Doctor should order CT, MRI, chest x-ray. To assess head trauma, lungs, broken bones, possible spinal cord injury. Provider should order complete labs. Prescribe PRN pain medication, 2-3L NC as needed. C-collar to remain in place until spinal cord injury is ruled out..

Nursing care Treatments. Assess pt. for further trauma, LOC, Establish peripheral IV access Monitor vital signs Give PRN pain med.

Diagnostic testing. MRI X-ray Chest x-ray.

Results. Patients CT and MRI results come back. The patients MRI shows complete T11 spinal injury. CT- normal. X- ray displays closed fracture to left arm. What interventions are expected for the patients results?.

Interventions. Patient c-collar can be removed. No cervical damage. T11 is thoracic and affects lower extremities of hips and legs. The fractures to the spinal can be stabilized with rods and screws to prevent further damage. The fracture to the left wrist is placed in a case to immobilize the wrist..

Labs. WBC- high Potassium- low Calcium-low UA: WDL BUN & Cr- WDL Albumin-low BGL - high.

Day 2 Shift report. You have been off for the last two days. You come back to work and get shift report from night nurse. Patient is now A&O x3. Supine in the bed. Patient was diagnosed with paraplegia based on MRI results, complains of pain in upper extremities, has a cast to left wrist, normal saline with potassium running at 125 mL/ hr , pt. is incontinent of bowel and bladder, has regular diet ordered, but doesn’t seem to have an appetite to eat, will be seen by PT, OT, and dietician sometime today. BP- 122/86, resp - 18, HR- 92, Pain- 7/10, Temp: 99.2, Sp02- 97% RA After report, you check the patients chart. You notice a skin assessment hasn’t been done. You decide to go do your shift assessment and do a skin assessment..

Assessment. Appearance: patient is crying in bed. Neuro: A&O x3. Patient knows her condition. Respiratory: Lungs clear, non-labored Cardiac: tachycardia, heart sound regular, radial pulse palpable Abdomen: Soft, non-distended, hypoactive bowel sounds Skin: warm, dry to touch. You complete the daily Braden scale for risk of pressure ulcers..

What would you as a nurse do for the crying pt.?.

You perform a skin assessment using the Braden scale. Your findings include:.

You turn Pt over to assess skin integrity. Right heel.

What stages would identify wounds?. Stage 1 pressure ulcer on heels- non- blanchable intact skin. Appears to be light pigmentation in color. Continue to monitor Stage 2 pressure ulcer on sacrum-partial thickness, skin is intact, but appears to look like an open blister..

What to do you do next?. Prevention of further skin breakdown: You ask NA to assist you in turning patient to get them off the sacrum with pillows. Request new air-fluidized bed to help turn patient. Get wound dressing such as Aqua cell to apply to sacrum and heels. Inform NA to turn patient every 2 hours and use clock rotations to keep track on what side to rotate next . Lift pt when turning and not pulling due to friction. Gather absorbent pads to keep moisture off pt. body You notify provider to request orders for wound evaluation , medications..

Pt is now resting in bed on left side with pillows behind her back, pillows between legs, and heels are elevated off the bed. Aqua cell applied to sacrum. IV fluids infusing. Pt denies no discomfort or pain at this time. You give handoff report to oncoming nurse..

Day 3: I nitial assessment. General appearance: Agitated, confused, laying supine in bed Resp : Breath sounds clear with equal bilaterally, non-labored Cardiac: Warm and dry, heart sound regular- S1 S2 noted, equal palpations at radial/brachial landmarks Neuro: Alert and oriented x2- is consistently oriented to date and place GI: Abdomen soft/ nondistended , bowel sounds audible in all four quadrants. Musculoskeletal- moderate grasp on hands bilaterally, no strength in lower extremities ..

Vitals. BP- 126/92 Res- 18 HR-86 Temp- 100.4 Pain- 4 on scale 0-10 Sp02- 98 % RA.

Labs. WBC- High Potassium- WDL Calcium-WDL UA: cloudy, (+) for bacteria BUN & Cr- WDL Albumin-low.

Any concerns regarding assessment findings?. Neuro- agitated and confused, change in LOC from previous day. Temp- 100.4 a little elevated Labs: WBC- high (possible sign of infection) UA- cloudy, (+) for bacteria, (+) for protein, ( sign of infection) Albumin-low (slow healing and sign of possible infection).

Based on Lab findings, What do you think is going on with pt ?.

Orders. Nurse notified doctor of UA lab results and elevated temp. Pt is diagnosis with UTI. Doctor orders Trimethoprim/sulfamethoxazole 20 mg IV q 6-12hr and Ibuprofen 200 mg PO every 4 to 6 hr ..

Nursing Interventions. Pt is started on IV antibiotic. Pt is given PO ibuprofen for temp PT and OT have seen pt. Pt has a trapeze bar at bedside to help strengthen right arm. Nutritionist has instructed pt. on diet needs. Nutrition education provided to pt. with increased protein in diet to promote wound healing and overall body function to get well..

Why is the nutritionist so important for the pt right now?.

Day 4. Pt is A&O x4. Patient is able to verbalize understanding of medical condition. Pt consumed 100% of protein rich breakfast and lunch. Patient has improved upper body strength to right arm using trapeze bar. Left arm cast is stil l in place . Pt states pain at 3/10. Aqua cell is still in place and intact. Pt bilateral heels stage 1 ulcer is healing. Pt antibiotic infusing. Waiting am lab results. Waiting orders from provider.

Am labs. WBC- WDL CBC-WDL UA- WDL Potassium-WDL Sodium- WDL GFR- WDL BUN and Cr- WDL Albumin- WDL.

What team collaboration should the nurse anticipate for discharge?.

What orders will the nurse anticipate?. Pt has improved with antibiotic therapy for UTI. Discharge orders to Village Green house is anticipated. Pt has been seen by PT, OT, and nutrition. PT needs rehab therapy to help improve upper body strength..

Discharge orders. Pt is cleared for transfer. Pt will continue PO antibiotics at nursing facility. Pt will receive wound care from wound care nurse at facility once daily. Apply topical ointment daily per dressing change. Continue PRN pain medications as needed. Continue PRN ibuprofen as needed for temp above 100.4 F. Adequate hydration of 2,500 mL/day High Protein and calorie diet.

Discharge Instructions. Change your position every 2 hours if you are in a bed all day. Set an alarm to help remind you when it is time to turn. Keep a written turning schedule to help you remember to turn. Clean and cover your injury. You may need to keep a bandage over your injury to protect the skin from more damage. You need to clean it with saline. Keep your skin clean, dry, and moisturized. Use mild soap and warm water to clean your skin. Do not rub or scrub when you wash. Gently pat your skin dry. Apply the medication supplied on your skin every dressing change. Protect the skin over bony areas. Use pillows to keep bony areas from touching, and to relieve pressure. Place a pillow under you to keep your hip raised when you lie on your side. Avoid resting directly on your hipbone. Put a pillow under your legs from calf to ankle when you lie on your back. A pillow should raise your heels, so that they are not touching the bed. Take medications as prescribed Keep follow-up appointments Increase protein in diet to improve healing Signs and symptoms to recognize when to notify provider..

Why is discharge teaching so important?. Even if a pt is going to a nursing facility, it is important to educate pt on disease process and how care is maintained. A pt should be educated on signs and symptoms to alert provider that there have been changes. Pt education on preventing further complications can impact the pt outcome and satisfaction. Pt is to verbalize understanding and if pt doesn’t understand, more teaching should be provided until pt feels comfortable with the ability to take care of themselves with or without assistance..

Pt verbalized understanding of discharge instructions. Wound care education demonstration performed and pt. verbalized understanding. Pt is transferred to Village Green facility with supplies and medications..

Reference. Henry et al (2016). Pressure ulcers . Fundamentals for nursing Edition 9.0. Content Mastery series ,review module, pp. 332-334. ATI Nursing. Division of Assessment Technologies Institute. LLC. Pearson. (2019). Pressure injuries . In Nursing: A concept-based approach to learning 3 rd edition, Vol. 1: pp.1619-1631. Waniga , H. (2016, Nov 7). The impact of revised discharged instructions on patient satisfaction . Vol. 3 issue 3 pg 64-68. Doi:10.1177 Available from https:// journals.sagepub.com / doi /full/10.1177/2374373516666972.