Primary Nursing is a concept that emphasises on patient centred care. This model of care delivery will help Mr Grant to take control of and be responsible for his health. It also provides continuity of care by having only one nurse providing complete care for Mr Grant. Effective coordination between members of the health care team such as physiotherapy, social worker and the primary nurse will help towards achieving a rapid recovery for Mr Grant. The primary nurse is able to see the progression of Mr Grant health compared to other nurses who occasionally care for him. Primary nursing empowers the primary nurse who knows Mr Grant better to decide how to provide care and educate Mr Grant on the steps to recovery. However the nurse may also lack skills to provide holistic care for a patient with complex needs. Tingle (1992) claims that some nurses can find it hard to develop a close relationship with patients. Another major problem associated with practising primary nursing is psychological distress; the nurse may feel isolated particularly when their patient is dying. The nurse also sometimes might push themselves too hard causing them to be overstressed and fatigue increasing the risk of negligence (Melchoir et al.1999, p.89-90).
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Client Assessment
Discuss the importance of performing and documenting a thorough nursing assessment at the commencement of your care of John. (150-200 words)
A thorough nursing assessment at the commencement of care enables the nurse to identify actual and potential problems of Mr Grant (Fawcett & Rhynas 2012). Nursing assessment provides a baseline so that the nurse can identify changes in Mr Grant’s condition and alerts the nurse to deviation from normal expected values (Fawcett & Rhynas 2012). According to Funnell, Koutoukidis and Lawrence (2009), the information gathered during the nursing assessment will help the nurse to guide a plan of care for Mr Grant and address the patient’s specific needs. Mr Grant has a slightly high blood pressure, high respiratory rate and shortness of breath which are signs and symptoms of respiratory distress and hypoxia therefore he should be monitored closely to avoid deterioration of his health status (Funnell, Koutoukidis & Lawrence 2009). Due to his restless behaviour and confused state, Mr Grant is at risk of a potential fall as he is trying to get out of bed. Moreover, Mr Grant has an indwelling catheter and a chest tube drainage which could be possibly dislodged when trying to get out of bed.
Complex Nursing Care
John has an arterial line insitu. Discuss the reasons for insertion, nursing management of the device and potential problems a client may experience. (150-200 words)
According to Kaur (2006), an arterial line insitu will monitor Mr Grant’s blood pressure directly, continuously, and accurately. Mr Grant’s oxygenation and ventilation can be assessed by measuring arterial blood gas through the arterial line insitu (Perry& Potter, 2010). Measurement of the arterial blood gas provides valuable information in assessing and managing Mr Grant’s respiratory and metabolic disturbances (Perry& Potter, 2010). Automatic blood pressure monitoring can cause severe bruising for patient taking anticoagulant, arterial monitoring can be used to monitor Mr Grant’s blood pressure (Kaur 2006). At the beginning of each shift, the nurse has to check the patient’s BP, from the opposite arm to avoid interrupting the arterial pressure readings, using a sphygmomanometer for comparison (Kaur 2006). Aseptic technique should be maintained when handling the arterial line. The nurse has to check that all the connections are tight and that the pressure bag is at 300 mm Hg at all times to keep the system patent (Kaur 2006). Only flushing solution should be injected or infused in the arterial line, if there is an air bubble in the line the air bubble should be withdrawn with a syringe before flushing to prevent air embolism as explained by Perry and Potter (2010) . The insertion site should be monitored for bleeding and signs and symptoms of infection, including erythema, warmth, tenderness, oedema, and purulent discharge (Kaur 2006). Arterial line insitu is invasive, this type of BP monitoring raises Mr Grant’s risk of a bloodstream infection and haemorrhage, which can occur very quickly if the line becomes disconnected (Kaur 2006). An arterial line also limits the patient’s mobility. Monitoring the patient closely could avoid potential problems such as haemorrhage from accidental catheter disconnection or loose connections, thrombus formation, air embolism, local obstruction with resultant ischemia, and infection (Kaur 2006).
At night, John becomes tired. He is treated with CPAP while he sleeps. Discuss this mode of ventilation. In your answer, you must include the reasons for use on a fatigued patient, how it works at cellular level, and the nursing management of a patient on CPAP ventilation.(150-200 words)
Continuous positive airway pressure is a self ventilating form of positive and expiratory pressure (Woodrow P, 2012). The continuous positive airway pressure (CPAP) keeps the terminal airways, alveoli, partially inflated, reducing the risk for actelectasis (Perry& Potter, 2010). During exhalation, the continuous positive airway pressure machine continues to blow air to keep the airway open and also pushes the exhale air and carbon dioxide out through holes in the mask (Perry& Potter, 2010). The application of a continuous flow of gas to the airway creates a positive pressure which makes it easier for Mr Grant to breathe in. The positive pressure maintained at the end of expiration by the positive end expiratory pressure valve prevents alveolar collapse and improves lung compliance (Perry& Potter, 2010). The patient does require as much effort is to inflate the alveoli. Hence reduces respiratory effort or work of breathing, and oxygen consumption and helps to reduce work of breathing in respiratory fatigued patients (Marshall & Pittard 1998). The nurse needs to continuously assess the patient as there is always the potential for their condition to deteriorate. CPAP has the potential to cause gastric distension by forcing air down the oesophagus which may lead to vomiting and puts the patient at significant risk for aspiration. According to Marshall & Pittard (1998) continuous monitoring of the patient’s respiratory status and arterial blood gases is important for the early detection of worsening respiratory failure. Respiratory assessment should include monitoring the patient’s rate, depth, quality and pattern of respiration as well as inspection, palpation, percussion and auscultation of the chest (Marshall & Pittard 1998). Regular assessment of blood pressure, heart rate, peripheral perfusion and urine output will provide the nurse with important information about the adequacy of circulation and assessment of patient’s haemodynamic status (National Heart Lung and Blood Institute 2011). The nurse should provide full explanation of the circuit and constant reassurance; this can significantly reduce anxiety and improve patient compliance with the therapy. Patient education is fundamental to the success of CPAP (National Heart Lung and Blood Institute 2011)
John has an intercostal catheter insitu. What is the purpose of an inter-costal catheter and why is it on underwater seal drainage? Discuss the nursing assessment and management of this device during client treatment. (150-200 words)
Mr Grant has sustained severe trauma to the chest in the MCA, which could have caused a collection of air in the pleural space and an accumulation of blood and fluid in the pleural cavity. Intercostal Catheter Insitu is used for chest trauma to remove air and fluid (Perry& Potter, 2010). Perry& Potter (2010) explains that the underwater seal drainage device acts as a one-way drainage device allowing drainage out of the pleural space, but preventing air from entering or re-entering the pleural space when the patient breathes in. An underwater seal drainage bottle can give some visual clues about the progress of a pneumothorax which indicates decrease of bubbling and swinging in the underwater seal drainage bottle (Briggs 2010). The nurse should monitor the appearance of the drainage and document this at least once a shift. The chest tube drainage appearance and output may need to be documented more frequently than once a shift in cases where the patient has a large amount of drainage or if the nurse suspects that Mr Grant is having an unexpected amount of drainage (Sullivan 2008). Briggs (2010) outlines that all chest tubes should be routinely monitored for the presence of an air leak should be documented in the patient record and reported during hand over. Regular pain assessments are required to maintain adequate analgesic relief from the discomfort and pain caused by chest drains (Crisp & Taylor 2009). The chest drain should always he kept blow the level of the patient’s chest to prevent back flow of fluid in to the pleural space. If the drain needs to be raised above the patients’ chest, when moving the patient in bed, the tube can be kinked to prevent back flow (Sullivan 2008). Chest dressings should be assessed every day for oozing and signs of inflammation and changed if oozing is present. Inflammation should be monitored and if worsening a swab should be sent for analysis as stated by Sullivan (2008). The drain tubing should never be secured to the patient’s bedding or clothing, as sudden movements by the patient could cause the drain to become dislodged, allowing air to enter the pleural cavity (Crisp & Taylor 2009). It is also important to encourage the patient to mobilise; this can be in the form of deep breathing for bed-bound patients, or short walks and raising arms in the more active patient (Perry& Potter, 2010). The movement will help with fluid and air drainage.
Evidence based practice
When administering S/C heparin, some nurses swab the area with an alcohol swab before injecting and some nurses do not. What Evidence of Best Practice (EBP) can you find that supports or does not support swabbing skin with alcohol preparation before a subcutaneous injection. In your answer, you must include journal references. (150-200 words)
According to Cocoman and Murray (2007), swabbing the injection site with a saturated 70% alcohol swab for 30 seconds and allowing to dry for 30 seconds is essential in order to reduce the number of pathogens. However, recent evidence demonstrated that in instances where the skin was not disinfected before injection, no single case of local or systemic infection was observed. Research supports that skin preparation before injection should be administered when giving injections to particular patients as stated by Gittens and Bunnell (2009). These include older patients, those who are ill, or those who are immunocompromised, as it has been shown that certain groups in society are at greater risk of developing infection (Gittens & Bunnell 2009). Certain bacteria on the skin have a low potential to cause infection if the immunity of the patient is not impaired or compromised as researched by Gittens & Bunnell (2009). In conclusion, my research on evidence based practice on swabbing the skin shows that the use of alcohol swabs is not necessary before a subcutaneous injection. However to ensure the site is not contaminated, it is extremely important to adhere to thorough hand hygiene. If using an alcohol preparation, it is important to wait thirty seconds to reduce the incidence of stinging and inoculation of bacteria at the site.
Critical Thinking
John has been prescribed six medications. Discuss the reasons he may have been prescribed these medications based on his presenting complaint. Should John be prescribed a sedation for his restless behaviour? Why/why not? (150-200 words)
Metoclopramide
According to Tiziani (2010, p.208-209), Mr Grant was prescribed metoclopramide control nausea and vomiting. To reduce the side effects of nausea and vomiting as most of the medications that have been prescribed for him will cause this adverse reaction. Metoclopramide will also help with aspiration due to the CPAP.
Ceftriaxone
Mr Grant is coughing up green sputum which indicates an infection in the lungs. Ceftriaxone is used as a broad spectrum antibiotic to treat respiratory tract infection which Mr Grant might have (Tiziani 2010, p. 100)
Paracetamol
Mr Grant has sustained two fractures to the right ankle and right clavicle which will cause severe pain. Hence paracetamol has been prescribed for pain relief (Tiziani 2010, p. 11). This medication will also help to reduce the high temperature of Mr Grant.
Phenytoin
Mr Grant incurred a head injury in the motor vehicle accident. Phenytoin is used after severe head trauma and prevents the spread of seizure activity across the motor cortex (Tiziani, p. 222).
Irbersartan
Tiziani (2010, p. 265) states that this medication is prescribed for patients with mild to moderate blood pressure. In this scenario, Irbersartan is used to treat Mr Grant’s high blood pressure of 159/90 and he also had an unstable blood pressure in ICU.
Clexane
This medication will help to dissolve clots formed as a result of damage to the head, chest and abdomen in the impact of the motor vehicle accident. Since he is having a lot of respiratory problem it could also indicate a possibility of pulmonary embolism and this is why clexane has been prescribed.
Yes, John should be prescribed a sedation to help him settle down. CPAP is very invasive and therefore this will help him to have a restless sleep. A sedation will help to decrease his respiratory rate.
Reflective Thinking
John’s path to recovery will be a process of physical and emotional challenges. Discuss the physical and emotional needs that John may need when being discharged from hospital. (150-200 words)
When discharged from hospital, Mr Grant recovery will be challenged by physical and emotional needs. Mr Grant lost his wife in the car accident and he was under the influence of alcohol. This might severely impact his self esteem as he might hold himself responsible for the car accident. Moreover, grief might have a potential impact on Mr Grant’s physical social, cognitive, emotional behavioural and spiritual aspects of his everyday life. Mr Grant has sustained multiple injuries and this will severely impact on his ability to do run his everyday life. This can cause emotional and psychological distress as he was an active person. The primary nurse has to work in collaboration with the social worker, occupational therapist, physiotherapist and psychiatrist to develop a discharge plan which will address the physical and emotional needs of Mr Grant. Mr Grant was driving under the influence of alcohol when he had the motor vehicle accident, referring Mr Grant to clinicians with specialists’ skills in alcohol and follow up monitoring and care coordination will be help towards his recovery. Involve the church community to support him with his spiritual needs and also include the family in the discharge planning.
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Mission/ Value Statements
Healthcare facilities define their mission statement/values/philosophy. This statement underpins their code of practice. Select a statement/mission/philosophy of one Australian hospital and discuss how their code of practice may be reflective of John and his family’s personal and social belief system. (150-200 words)
As Mr Grant was actively involved in the Local Catholic church and regularly attended mass. I chose St Vincent Private values and care statement as it is a catholic hospital and it will be beneficial for Mr Grant due to his religious faith. St Vincent Private (2012) values are Compassion, Justice, Integrity and excellence. Compassion is a vital aspect of good nursing care. It involves the nurse developing a rapport with Mr Grant and providing holistic care. St Vincent values that, nurses showing compassion plays a major role in providing dignified care to patients. Compassionate care will enable Mr Grant to remain independent and retain his dignity. St Vincent hospital aim to make sure that nurses are available to render care and that Mr Grant is aware that quality care is available to them. Care will be given according to Mr Grant’s needs. Integrity is about being truthful to the patient and about the care he is receiving. It is also about providing the right care according to Mr Grant’s personal and social belief. Excellence is dedicated to provide outstanding care and customer service to Mr Grant and his family. St Vincent embodies the drive to perfect their competencies and enhance the quality, timeliness, and cost-effectiveness of their care. Being in a catholic hospital Mr Grant will be able to receive pastoral care and attend mass regularly depending on his health condition. Mr Grant lost his wife in the car accident and confession can help him to deal with grief.
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