Scholarly Assignment Part B
NURS252
My Tran 810 040 279
Monday, March 16th, 2015
This case study presents a thirteen year-old female with no past medical history.
The chief complaint was a fracture on the left femur caused by a motor vehicle accident.
The patient is eight hours post-operative of insertion of intramedullary rod in the left
femur. The patient’s vital signs are stated as: temperature thirty-five point six, ten breaths
per minute, sixty-six beats per minute, the systolic pressure is one hundred over sixty
diastolic, oxygen saturation is ninety-six percent on two liters on nasal prongs. The
patient presents with adequate pedal pulses distal to surgical site with extremity warm to
touch. The patient denies paresthesia. Patient is currently very drowsy and has difficulty
answering questions to pain.
The most important physiological need in this case according to Maslow’s
Hierarchy of Needs is airway and breathing (Potter & Perry, 2010). Pre-operative and
post-operative initial assessment is respiratory functioning. Assessing respiratory
function has a significant importance to an individual’s physiological need to intake
oxygen and expel carbon dioxide, which will promote homeostasis and prevent
complications from developing. As the patient is presented in a post-operative scenario,
respiratory depression could potentially be due to an overdose of an opioid resulting in
sedation.
The client exhibits ten breaths per minute, which causes concern, as it is less than
the expected average respiratory rate for her age group of sixteen to twenty breaths per
minute (Jarvis, 2009). Postoperative surgeries prioritize airway, breathing, circulation,
and vital signs, thus, it is important to complete a full assessment of the respiratory rate,
the movement of the thoracic wall for symmetry, use of respiratory muscles, and percuss
the chest for unilateral dullness or resonance (Thim et al., 2012).
Nevertheless, it is important to assess pain and behavioural cues of pain such as
wrinkling the face or brow, a clenched fist, moaning, diaphoresis and increasing pulse
rate (Jarvis, 2009). According to Lewis (2014), during the first forty-eight hours of
postoperative surgery, analgesic medication is required to relieve moderate to severe
pain. In the early postoperative period, pain assessment may be difficult to complete. It is
important to assess the effectiveness of all pain control management. All patients must be
assessed using a pain scale. Effective pain management will reduce harmful
complications and promote optimal healing, prevent complications, and allow patients to
participate in activities of daily living.
The priority of this case study will be the risk for impaired respiratory function as
evidenced by ten breaths per minute. If the patient is in a supine position, airway patency
will be assessed. The most common cause of blockage of the airway after surgery is the
tongue (Lewis, 2014). The base of the tongue can fall back and occlude the pharynx.
Once the airway is assessed and cleared from blockage of the tongue or retained
secretions, the head of the bed will be raised to semi-fowlers or high-fowlers position for
optimal diaphragm excursion.
Interventions will include assessment of rapid, shallow, or slow respirations for
dyspnea. Assessment of use of accessory muscles when breathing, adventitious breath
sounds, diminished or absent breath sounds, and asymmetrical chest excursion and the
airway for patency is important to determine if there is a change in function of the cardiac
or neurological state. With this in mind, it is important to consider the patient’s
respiratory rate could be a side effect of an underlying issue. A depressed respiratory rate
could indicate adverse effects of analgesics and opioids and ineffective pain management
that can place a patient at increased risk for potential complications.
Assess changes in mental status and levels of consciousness. The patient’s
neurological functioning should be assessed. Orientation to person, place and time, ability
to follow commands, and size, reactivity, and equality of pupils should be determined.
Sensory and motor status should also be recorded. It is important to maintain patient
safety and to advocate for the patient until the patient is awake and able to communicate
(Lewis, 2014). Increasing lethargy, confusion, or irritability can be early signs of cerebral
hypoxia (Jarvis, 2009). Further, close monitor of vital signs and maintaining oxygen
administration device as ordered. If signs and symptoms of impaired respiratory function
persist or worsen, consultation of a respiratory therapist, physician and health care team
would be required.
Above all, these interventions have highest priority and significant importance to
this individual’s physiological need to promote health, and to prevent complications from
developing. According to Lewis (2014), it is important to continually monitor the
respiratory functioning especially if the patient is receiving oxygen therapy.
Complications such as tachypnea, and dyspnea would be significant findings to this
patient’s overall health as she is susceptible to deep venous thrombosis that may lead to
pulmonary embolism. This patient is at higher risk for inactivity, pressure and
immobilization of her left leg, which may lead to venous stasis and decreased perfusion.
All in all, the most important physiological need in this case according to Maslow’s
Hierarchy of Needs is airway and breathing (Potter & Perry, 2010).
References
Jarvis, C. (2009). Physical examination and health assessment (1st Canadian ed.).
Philadelphia: Saunders.
Lewis, Sharon L. Medical-Surgical Nursing in Canada, 3rd Edition. Mosby Canada,
2014. VitalBook file.
Potter, P. & Perry, G. (2010). Canadian fundamentals of nursing (revised 4th ed.). (J.C.
Ross-Kerr & M.J. Wood, Canadian Editors). Toronto, ON: Mosby.
Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial
assessment and treatment with the Airway, Breathing, Circulation, Disability,
Exposure (ABCDE) approach. International Journal of General Medicine, 5,
117–121. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3273374/
Whiteing, N. L. (2008). Fractures: Pathophysiology, treatment and nursing care. Nursing
Standard, 23(2), 49-57; quiz 58, 60. Retrieved from
http://search.proquest.com/docview/219871581?accountid=11530