Assessment Instructions
Mike Miller is a 24-year old male who fell off his motorbike whilst riding in the bush. A riding mate witnessed the fall and called an ambulance to transport Mike to ED. On arrival to ED, Mike complained of pain in his lower left leg, which had an obvious deformity, significant swelling and a 5cm lacerated wound.
Mike’s ED admission observations were: T-36.4oC, HR-90bpm, RR-22pm, BP-136/72mmHg, O2-95% RA, and pain score 10/10 on movement. Mike is allergic to latex (causing pruritus and welts), is not on any medications, and has no other medical problems noted.
Mike was given opioid analgesia in ED for his pain, and the ED x-ray confirmed the diagnosis of an open fracture of the left tibia and fibula. After review by the orthopaedic team, it was arranged for Mike to undergo surgery for open reduction and internal fixation (ORIF) of the fracture. You are a student nurse looking after Mike since he returned to the surgical ward post-operatively at 10:50hrs.
The surgeon’s post-op orders are for routine observations, wound dressing to stay intact for 72hrs, bung IVT when current bag completed, neurovascular observations two-hourly for first 48-hours, and may ambulate non-weight bearing with crutches. He is drowsy and responsive to voice; and has a dressing on his lower left leg, with minimal sanguineous ooze evident. Mike’s observations on return toward are: T-35.9oC, HR-66bpm, RR16pm, BP-109/71mmHg, O2-97% via HM at 6LPM, and pain score 2/10. Mike was given prophylacticCefoxitin 2g IVduring surgery. The anaesthetist has prescribed Paracetamol 1g IV/PO 6 hourly, Ibuprofen 200-400mg PO TDS, Tramadol SR 100mg PO BD prn, and Cefoxitin 2g IV/ IM 6 hourlyfor 2 further doses. IV Compound Sodium Lactate 1L is running at a six-hourly rate into Mike’s left arm.
. Students should format their essay management section with headings as:
• Assessments;
• Nursing Diagnosis Priority 1: (name of nursing diagnosis) -with subheadings for Planning/GOAL, Implementation, Evaluation; and
• Nursing Diagnosis Priority 2: (name of nursing diagnosis) - with subheadings for Planning, Implementation, Evaluation.
• The assignment must flow smoothly and read logically for the reader.
Introduction (approx 100 words)
•An outline of the paper
Background (approx 200 words)
•This should be given as an iSoBAR handover (with iSoBAR subheadings).
•From the information given in the scenario, students should provide an iSoBAR handover as though you are updating the nursing team they are working with, after having completed the first set of post-op observations as is given in the scenario.
•For the iSoBAR handover, students may use first person to introduce themselves and their patient, however all other information in the essay and background must be in third person academic writing style.
•Any nursing terminology that requires a definition
Management (approx 1200 words)
•Using the nursing process, outline the nursing management for this patient post-surgery, discussing all care in general, but focussing on two (2) priority nursing diagnosis/ problems.
•Ensure that each part of the nursing process is discussed within the essay, showing depth, critical thinking and coverage of each section.
•Assessment-Students should demonstrate that they have looked at all of the assessment data
•Subjective data using the SAMPLE acromion
•Objective data: normal and or abnormal (if any findings are abnormal then students should identify this and give a rational)
•Body system applicable to the patient
.12 ADL’s (Describe the 12 ADL's
But only discuss the ADL's applicable to the patient)
•Any appropriate assessment tools applicable (e.g. Fall risk, Braden scale or Pain Assessment)
•This section will require references
•No information should be assumed (i.e. only use information within the case study)
•Nursing diagnosis- Students should discuss their two (2) prioritised nursing diagnoses in-depth( focus should be on post-operative care). After analysing all of the assessment data and patient’s responses, students should consider the actual and potential nursing problems/ issues, and demonstrate why they have prioritised these diagnoses (eg. use of primary survey, use of first-aid DRSABCD, actual v potential, etc) – this should demonstrate the student’s ability to prioritise, not just choosing two that they wish to discuss.
•Planning/Goals-
•Students should demonstrate their three (3) GOALS for each nursing diagnosis.
•These should all utilise SMART goals (specific, measurable, achievable, realistic, and with timeframe).
•Implementations–
•Students should demonstrate one nursing intervention for each GOAL. Each intervention should include the rationale why this intervention is required, and be supported with references
•Evaluation
•Students need to describe how they would know whether planned outcomes had been met?
•what is the evidence that goals have been met?
•what tools were used?
•where this is documented (usually documentation as evidence).
Potential complications and post-operative education (approx 200 words)
•Outline the potential complications that the nurse and patient should be aware of.
•Outline the post-operative education would need to be provided to your patient, in order to promote a successful recovery.
•Referencing required for potential complications and post-op education
Involvement of the interdisciplinary team (approx 150 words)
•Highlight the members of the interdisciplinary team, and which particular members that would be involved in your patient’s management of care, including what service that they will provide.
•References required
Conclusion (approx 150 words)
•Provides an overview of the assignment
•No new material introduced
Referencing
•In-text and end text referencing
- APA style.
•Minimum of 10 current and credible academic references, using a variety of sources (including a minimum of 4 journal articles and minimum of 2 quality websites).
•All sources are up to 5 years old.
•Recent and quality sources used - Wikipedia and Dictionary.com will not be accepted as a reference sourc