Viva Voce Analysis of a Patient - Case Study Example

Case study Analysis Introduction The focus on this paper is on a viva voce analysis of a patient known as XX who was under my care during my placement. Mrs. XX was born on 10th/June/1950. The patient’s identity has been concealed to ensure her privacy and uphold confidentiality. Nurses are obligated to protect the privacy and confidentiality of their patient’s personal information (Erickson & Millar, 2005, p. 1). The case will be written and discussed using a clinical handover tool namely, ISBAR. ISBAR tool organizes communication into the vital aspects during the transfer of information from one source to another and studies show that ISBAR is effective in transferring information in clinical as well as non-clinical situations (Hunter New England Health, 2009, p. 2).This case involves a patient who was admitted to the surgical after right distal fracture post-surgery. Accordingly, I will explore the background of the patient’s condition, pathophysiology and nursing care provided to the patient. In addition, I will explore the patient’s risk due to deterioration of her diagnosis as well as dehydration secondary to the diagnosis. The patient also has increased risk to DVT due to reduced mobility as well as increased risk to infection due to the surgery and hospitalization. Patients undergoing surgery are at risk of developing DVT due to lack of ambulatory movement (Galson, 2008, p, 421). In addition, according to Cimiotti et al (2012, p. 487), a high number of hospitalized patients acquire infections during treatment of other conditions. Al-Mulhim et al (2014, p. 267) support this and explains that surgical site infections are common in patients after orthopedic surgery. I will also carry out an analysis of the patient’s emotional disturbances due to depression and anxiety associated with the current surgery, hospitalization as well as increased sleep depression due to hospital environment. Finally, I will also perform a reflective analysis on the feedback that was provided during my placement. Identification The patient’s identity has been concealed due to confidentiality and in order to respect her privacy. Healthcare providers have the ethical and legal responsibility to safeguard patient’s privacy and confidentiality by safekeeping and protecting patients’ personal information (Erickson & Millar, 2005, p. 1).The patient is a female and her date of birth is xx. She is a social worker and a single mother. She lives with her 18 year old son in her own housing unit. The significance of knowing the patient’s type of house is that it will help in planning and knowing the needs of the patient when she goes home after being discharged (Rich et al, 2012, p. 2). The patient was in a restaurant having dinner with her friends and fell down in front of the door when she was about to leave the restaurant. After the fall, the patient suffered right distal fracture. Situation Analysis Patient xx was admitted on xx July 2016 to the surgical ward zero-day post open reduction, internal fixation of right distal fracture under local anesthesia. The fracture occurred after the fall onto an outstretched hand which led to disruption of distal radioulnar joints. Due to the fracture, this caused pain and swelling (Kakarala, G, 2015, p. 1). The patient is independent which can independently perform activities of daily living. Being independent will inform healthcare providers of her needs and make the care plan and recommendations in accordance with her needs (Gamatese et al, 2013, p. 340). The patient had acute pain which was due to tissue trauma allied to current surgery as depicted by the surgical incision and breaks in skin integrity. The pain score was used in assessing the pain and the post-surgery Pain score 3/10 without moving her right hand and 8/10 while moving her hand. Pain score is used in measuring different aspects of an individual’s pain (Galer, 2008, p. 2). The patient was administered with oxycodone PRN 5mg to 20 mg and Panadol 1g every 6 hours. These medications are analgesics that were used to relieve the pain that the pain was experiencing (Gola S, 2011, p. 1). The analgesics should be administered as directed by the physician because adhering to the appropriate analgesic treatment will help in reducing and controlling the pain (Cavalieri, 2007, p. 4). Swelling was assessed using head to toe nursing assessment and compared with the other hand. Comparison helps in assessing the injured hand with the normal hand to identify abnormality in the injured hand (Eddy, 2012, p. 203). The swelling is as a result of soft tissue swelling and distortion of osseous landmarks. When fracture happens, there is massive disruption of channels that supply blood to the bones as well as bleeding from the fracture fragments and this is what causes swelling (Eddy, 2012, p. 202). The swelling can be reduced by applying ice and elevating the patient’s arm (Ocansey, 2013, p. 12). Tenderness on the affected arm was also assessed using head to toe nursing assessment and compared with the other hand; tenderness to touch is common in distal fractures. Assessment also indicated that the patient had increased numbness in her right post-surgery complication. This was assessed using neurological assessment. Neurovascular assessment was important to assess circulation, sensation and movement. Regular neurovascular assessments were done to demonstrate return of function after surgery and also to ensure that no nerves were injured during the surgery (Akhtar, 2013, p. 320). The patient had nausea and vomiting. She started complaining immediately and she could not tolerate soft diet oral intake post-surgery and this indicated a post-surgery complication. The patient was administered with ondansetron 4mg IV. Ondansetron is effective in preventing late postoperative vomiting (McCracken, 2008, p. 605). Post-operative nausea and vomiting can prolong recovery for the patient and also result to electrolyte disturbances due to loss of fluids. While vomiting, wound dehiscence can occur on the patient as well as aspiration of gastric contents (Mandal, 2014, p. 53). The patient was drowsy after the surgery and this could have been due to post-anesthesia complications. Anesthesia is known to cause sedation effect and the effects may linger long after the surgery (Akhtar, et al, p. 320). Assessment of the vital signs (Blood pressure, pulse, respiratory rate and sedation score) and also maintained fluid balance chart to compare input and output was done. Fluid challenge was started because in order to have effective fluid management to maintain adequate tissue perfusion and ensure that there was reduced risks of complications due to dehydration (Kayilioglu, 2015, p. 200). In addition, the patient had tachycardia post-surgery and this was as a result of hypovolemic shock and was assessed using vital signs. The patient was treated using IVT fluid to treat hypovolemia and tachycardia by replacing the fluid volume that the patient lost when vomiting (Kayilioglu, 2015, p. 200). IV Cetirizine was prescribed for the patient due to itching. Cetirizine in an antihistamine used in treating pruritis (itching) as well as allergies (Church & Church, 2013, p. 220). Background of the Patient The patient’s medical history indicated that she had vitamin D deficiency. Vitamin D is vital in maintaining bone health and affects bones through controlling calcium levels in the body (Sunyecz, 2008, p. 827). Vitamin D is therefore essential for healthy bones (Sunyecz, 2008, p. 827). Therefore, vitamin D deficiency in patient xx contributed to her fracture since her bones were weak and fragile and hence more susceptible to fractures (Sunyecz, 2008, p. 827). In addition, the patient is a female and women have a higher likelihood of have low levels of vitamin D (American Orthopaedic Foot & Ankle Society, 2015, p. 2). The patient was also allergic to medications as indicated by itchiness although there is no specific medication that can be linked to the allergy. The patient has Epipen which indicated that she has a past history of allergies and hence her allergic reactions towards the medications can be linked to this past allergy reactions. Epipen is a life saving device used in treatment of anaphylaxis (Ackaoui A, 2011, p. 273). It was necessary for the patient to carry Epipen because anaphylaxis can progress to death and hence fast treatment of symptoms through intramuscular injections of epinephrine is important to save life (Ackaoui A, 2011, p. 273). XX underwent appendectomy when she was 20 years old. Appendectomy was done to remove the appendix as a result of appendicitis which is normally caused by obstruction of the lumen of the appendix (Livingstone et al, 2007, p. 3). In addition, her son has asthma and eczema which are all allergy reactions. Assessment In nursing, subjective data is the information that the patient provides according to his/her perspective, for instance the pain level, feelings and perceptions. On the other hand, objective data is the measurable aspects of a patient’s condition that is collected using diagnostic tests and examinations. Data collection from the patient forms the basis of all care provision for the patient because all aspects of nursing care flow from the patient’s data. In addition, both subjective and objective data determine the required (Phaneuf, 2006, p. 1). Central nervous system assessment of the patient was performed and the results indicated that the patient was alert and oriented to time and place. GCS was 15/15. The GCS is a scoring system used in gauging a patient’s consciousness level. The patient’s score was 15/15 which indicates that he was fully conscious after the surgery. The CNS assessment was important because evidence indicates that neurological complications are common cause of death during the immediate postoperative period after surgery. Therefore, it is important to quickly identify any neurological complication in order to treat and manage them promptly and on time before they deteriorate and this is achieved through effective assessment of the central nervous system (Pérez-Vela et al, 2005, p. 1). Cardio vascular system was also performed on the patient. Her blood pressure was between 110/69mmHG to 115/75.However, evidence for having hypovolemia was found when she became hypotensive 90/60 after vomiting. Vomiting could have resulted to loss of high amount of fluids and cause hypovolemia (Yavuz et al, 2014, p. 2). Doctor was informed and he ordered 250mls normal saline as bolos then start her on 1000mls normal saline over 6 hours. BP went up to 112/68 after the IV fluid. Pulse rate between 70 to 82 but she became tachycardia 112 due to hypovolemia and then went back normal after giving her IV normal saline. Hypovolemia occurred as a result of decrease in fluid volume due to loss of fluids through vomiting (Furlong, 2016, p. 2). Therefore, IVF was administered to replace the fluids and return homeostatic mechanisms to normal (BP and pulse rate) (Furlong, 2016, p. 8). The significance of performing cardiovascular assessment is that cardiovascular complications are common in post-operative patients. Generally, maintaining a patient’s heart rate and blood pressure within normal limits results in suitable post-operative outcomes (Akhtar, et al, p. 320). Respiratory system assessment indicated that the Sat was 98% and the patient was on 2L via nasal mask. Generally, a range between 94% to 98% is considered normal (Driscoll et al, 2008, p. 3). The patient was put on nasal mask to ensure that the normal respiratory rate was maintained in order to keep sat within the target saturation range (Driscoll et al, 2008, p. 2). Her respiratory rate was between 16 to 19 breath/minute but increased to 23 due to hypovolemia and then went to normal 16 after administering IV fluid. An “abnormal” respiratory rate for adults ranges from above 14 to over 36 breaths/minute (Cretikos et al, 2008, p. 657). IVF was administered to replace the lost fluids and return homeostatic mechanisms to normal (Furlong, 2016, p. 8). The significance of monitoring the respiratory rates for the patient was effectively observe respiratory function and indentify any post-operative respiratory complication (Akhtar, et al, p. 321). GIT assessment was also carried out to assess her bowel function. Her abdomen was soft and lax without distension. Bowel sounds were present but hypoactive because she was fasting since midnight before surgery. The rationale for hypoactive bowel sounds is that bowel motility takes time before returning after anesthesia administration (Levitt et al, 2011, p. 170). Assessment of the renal system was also done to ensure normal renal function. Patients who undergo orthopedic surgeries are at high risk for renal failure because of likely electrolyte disturbance, peri-operative infections and high blood loss (Kateros et al, 2012, p. 2). She was continent and voided in toilet. Skin integrity assessment was performed to identify any skin abnormalities. Skin integrity assessment can help in identifying any skin breakdowns or pressure ulcers for the patient (Gardiner et al, 2008, p. 2). Braden pressure injury risk assessment was done and the score was 20 out of 23 which indicate no risk to pressure injuries. Braden risk assessment scale is a tool used in assessing the risk of patient developing a pressure ulcer (BSPNSWC, 2014, p. 1). Her skin mustered and intact with normal colour and right operated hand with cast and elevated by 2 pillows. She had small scar in her right lower quarter due to her previous appendectomy. IV cannula in the left cephalic arm day zero and was secured with no sign of infection or bleeding. Assessing the IV cannula is important because IV sites are common infection sites and this could result to infections and also delay the healing (Al-Mulhim et al, 2014, p. 267). The patient’s metabolism was also assessed and she was afebrial between 36.5C to 36. This was important to ensure that the patient was febrile. The laboratory test results indicated that her limit were within normal ranges. The laboratory tests were important to establish if any abnormality on the parameters occurred during the surgery (Kumar & Uma, 2011, p. 174). Haematology results were: Haemoglobin 150g/l; Haematocrit 45; Red blood cell count 5.2; White blood cell count 4.6 and Platelet count 345. Biochemistry results were: Sodium 140; Potassium 3.5; Calcium 2.20; Bicarbonate 25; Creatinine 51 and Urea 3.2. Vitamin D assessment was done and her range wasc41 nmol/L. This is because she has a history of vitamin D deficiency. Vitam D is important in maintaining healthy bones and hence vitamin D deficiency contributed to the fracture the patient sustained due to weak bones (Sunyecz, 2008, p. 827). As aforementioned, women have lower levels of vitamin D and hence more susceptible to fractures (American Orthopaedic Foot & Ankle Society, 2015, p. 2). Radiology (X-ray) was done pre and post-surgery as a diagnostic to detect the bone fracture as well as establish if the surgery was a success and detect any other abnormality in the bones (Macura M, 2014, p. 1). Diet/Nutrition assessment was done as the patient is on low risk of malnutrition (wt 56kg and ht 163cm). Nutrition assessment was important to detect any malnutrition in the patient and come up with a plan for a healthy diet that will aid the patient in her recovery (Wells & Dumbrell, 2006, p. 68). A soft diet was prescribed and if she was tolerant she could gradually proceed to normal diet. However, the patient started vomiting after taking tea and soup. The vomiting indicates a post-surgery complication that can also be due to the effect of anaesthesia and other pain medications that the patient was administered with before and after surgery (Akhtar, et al, p. 320). The doctor was informed and IVT restarted with NSS 1L/6h then Hartmans 1L/6h. Fluid balance chart stool chart was maintained in order to identify any pre-existing fluid deficits, and to replace unusual losses (Akhtar, et al, p. 319). Comfort and Pain Post-surgery Pain score 3/10 without moving her right hand and 8/10 while moving her hand. The patient was administered with oxycodone orally in order to relieve the pain. The patient was also on panadol. Oxycodone and panadol were used because they can effectively relive the pain with minimal side effects (Akhtar, et al, p. 319). Hourly assessment of (pulse, respiratory rate, sedation score and pain score) was done in order to detect any clinical deterioration and also for allowing evaluation of the patient’s response to treatment (Akhtar, et al, p. 316). Falls risk Patient’s risk to fall was assessed because the patient has a high risk to fall due to anesthesia that the patient was administered before the surgery and also post-surgery anxiety (Lam et al, 2016, p. 3). The patient was assessed by a physiotherapist to evaluate her needs in order to maintain patient safety while doing activities of daily life (Lam et al, 2016, p. 1). The patient was wearing TED in order to avoid DVT. A deep vein thrombosis (DVT) refers to a blood clot in a vein and wearing a TED prevents the likelihood of the patient developing blood clot (John, 2012, p. 1). Recommendation and discharge plan Planning for Ongoing Care Intervention Observation 4 hourly Rationale To allow collection of routine data in order to detect any clinical deterioration: and assess if the patient is responding to treatment (Akhtar, et al, p. 316). Intervention Neurovascular assessment hourly for 24 hours then 4 hourly for 48 hours Rationale To evaluate return of neurovascular function (Pérez-Vela et al, 2005, p. 1) Intervention Deep breathing Rationale To ensure the patient’s lungs are well-inflated and are healthy while she heals (Restrepo et al, 2011, p. 1601). Intervention Mobilise the patient Rationale To reduce the patient’s risk of developing DVT and prevent her from developing pressure injuries (BSPNSWC, 2014, p. 1 & John, 2012, p. 1) Intervention Elevate the arm Rationale To reduce the swelling of the arm (Ocansey, 2013, p. 12) Intervention Rotate in the bed Rationale To prevent the pressure injury (BSPNSWC, 2014, p. 1) Intervention Do fall risk assessment Rationale The patient has a high risk to fall due to anesthesia that the patient was administered before the surgery and also post-surgery anxiety (Lam et al, 2016, p. 3) Discharge Plan The patient to return after 2 weeks for wound check The patient to return after 6 weeks for orthopaedic clinic appointment to assess the healing trend of the fracture 6 weeks no driving to give the affected hand ample time to heal. Also the medications may cause drowsy effects (Benyamin, 2008, p. 109) Educate the patient on importance of physiotherapy exercises to ensure quick recovery and refer her to the appropriate physiotherapist Dieticians will advise the patient on the appropriate diet for her recovery. For instance, it is important for patient to take foods high in calcium and ensure adequate vitamin D in order to strengthen her bones. Pharmacist will educate the patient about each medication for instance side effect of cetirizine. The patient should be careful while driving or while doing anything that requires her to be awake and alert. The patient should also avoid alcohol since it has interactive effect with the medications (Jalbert, Quilliam & Lapane, 2008, p. 1319) Refer the patient to a social worker. The social worker will assist the patient in activities such as cooking and other things which she might not be able to handle while recovering.The social worker will also offer some counselling to the patient to assist her in regaining her confidence (Gamatese et al, 2013, p. 346) If the patient will not be able to cook, make a meal on wheels referral Help the patient to get a medical certificate because she is a social worker and might be required to do home visits and write reports Write a discharge letter to GP to update him about the patient Give the patient her belongings following the discharge ( money, clothes, credit cards, own medications) Arrange for transportation of the patient from hospital to home because she will not be able to drive and her son will be in the school Reflection on Feedback In this reflection I will focus on the feedback I received following my presentation on the surgical patient. The feedback was from my clinical facilitator who assessed my presentation regarding my clinical practice and wrote the feedback. The feedback indicated that I had a good understanding of nursing care that I provided (post-surgical care). In addition, the feedback indicate that I was competent in performing other aspects of nursing care such as discharge planning and a good understanding on medications. My facilitator played a big role in mentoring me during my placement. Throughout my placement, the facilitator would always supervise and monitor me whenever I was performing the clinical skills. For instance, there was a time I was confused during medication administration and the facilitator quickly advised me and this boosted my confidence in medication administration because actually I was hesitant on a medication I was correct. I also learnt about the significance of collaboration with other healthcare providers. Whenever I was unsure about a certain skill, I would consult other nurses or my facilitator and they would promptly guide me on what to do. I would also carry out research during my free time regarding different clinical skills in order to enhance my knowledge and update myself regarding the most recent evidence. The feedback played a big role in during my clinical practice and will also impact my future practice positively. This is because the feedback was positive and indicated that I was competent in my clinical skills that I performed during my placement and this provided me with more confidence to perform clinical skills during my practice as a nurse even in future. In future I plan to practice in accordance with the national competency standards set up by the Nursing and Midwifery Board of Australia. I will endeavor improve my nursing skills by collaborating with other healthcare providers, applying critical thinking, analyzing most recent research evidence and by continually conducting self-assessment on my professional nursing skills (NMBA 2010, p. 1). References Akhtar,A, 2013, Pre-Operative Assessment and Post-Operative Care in Elective Shoulder Surgery, Open Orthop J, vol. 7, no. 3, pp. 316–322. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3788190/ American Orthopaedic Foot & Ankle Society, 2015,How Vitamin D Affects Bone Health, Rosemont, IL, Orthopedic Foot & Ankle Foundation. Ackaoui A, 2011, Treatment of anaphylaxis: EpiPen, Twinject, or another autoinjector? Can Fam Physician, vol. 57, no. 3, pp. 273. < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056667/> Benyamin, R, Trescot A, Datta S, Scott E, Buenaventura R & Sehgal N, 2008, Opioid Complications and Side Effects, Pain Physician, Pain Opioid Special Issue: 11:S105-S120. 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Yavuz et al, 2014, Investigation of the Effects of Preoperative Hydration on the Postoperative Nausea and Vomiting, BioMed Research International, Vol.2014 (2014), p. 1-4. Read More