Comprehensive Nursing Assessment and Care for a Trauma Patient on a Surgical Ward

QUESTION

Jane Wilson is a 30-year-old female who presents to the regional Emergency Department (ED) by herself. She is hobbling up to triage whilst holding her left leg. Jane reports she had fallen off her horse and has suffered a deep and dirty penetrating laceration to her left thigh. Jane appears alert and orientated. Jane can recall all history of events and answer questions appropriately. Jane has wrapped her thigh with a towel to stop the bleeding. In the ED the towel is removed, and the wound is irrigated with normal saline before being redressed with a pressure bandage. It is not possible to insert a peripheral intravenous (IV) canula, so a decision to obtain access through a Central Venous Access Device (CVAD). The CVAD has been performed on Janes L) Jugular vein under sterile technique. The CVAD is patent and secured with sutures and a transparent IV 3000 dressing. Triage Observation Airway: Patent, own, RR: 16 Sp02: 92% on Room Air (RA) BP: 105/52 HR: 118, regular T: 35.5 Pain 6/10 GCS 15 BGL: 5.5 Medical History Nil allergies Denies any alcohol intake or illicit drug use Independent and active Investigations Hb: 89g/L (Cross match report: AB+) X-ray: No bony fractures or abnormalities visible. CT: Deep laceration to left medial thigh. No associated vascular injury present. In the ED, one unit of Packed Red Blood Cells (PRBCs) is administered through the CVAD. After the first unit of blood, Jane is admitted to the surgical ward to wait for surgery as the ED is now becoming overcrowded. 1g Paracetamol and a Stat dose of Ceftriaxone has been administered by ED staff. School of Nursing, Paramedicine and Health Science NRS283_202360 Assessment item 1: Case Analysis. 3 You are working as a Registered Nurse on the Surgical Ward and when you assume care of Jane and when you introduce yourself to Jane it is 1430. Jane appears anxious and remains in pain. Jane can recite her full name, date of birth and can tell you the time and place. It is obvious Jane is worried and tries to call her wife, Emily, but is unable to get in contact. Initial admission observations to the ward Airway: Patent, own, RR: 16 Sp02: 93% on RA BP: 107/60 HR: 105, regular T: 34.9 Pain 6/10 GCS 14 (Eyes open to voice, orientated and obeying commands) BGL: 5.4

ANSWER

Comprehensive Nursing Assessment and Care for a Trauma Patient on a Surgical Ward

Introduction

In the context of nursing care, this essay focuses on the case of Jane Wilson, a 30-year-old female who suffered a deep and dirty penetrating laceration to her left thigh after falling off her horse. After initial assessment and treatment in the Emergency Department (ED), Jane is admitted to the surgical ward for further care. This essay will discuss the nursing assessment, interventions, and care priorities for Jane, considering her presenting condition and history.

Initial Nursing Assessment

Upon assuming care of Jane, the initial nursing assessment is paramount to ensure her safety, manage her pain, and address her anxieties. Jane’s vital signs are stable but exhibit mild hypoxia (SpO2: 93%) and tachycardia (HR: 105). Her pain level remains at 6/10 despite receiving analgesics. Her GCS is 14, indicating appropriate responsiveness. These observations reflect the need for immediate interventions to address her pain, anxiety, and oxygenation status.

Pain Management

Effective pain management is essential to ensure Jane’s comfort and cooperation. The patient’s reported pain level and anxiety suggest that a comprehensive pain assessment is necessary. Implementing a multimodal pain management approach, including non-pharmacological techniques (positioning, relaxation), appropriate analgesics, and continuous pain assessment, can help alleviate Jane’s discomfort and promote her overall well-being.

Anxiety and Communication

Jane’s evident anxiety, along with her attempts to contact her wife Emily, signifies the importance of addressing her emotional well-being. Establishing effective communication, offering emotional support, and facilitating contact with her loved ones can alleviate her distress. Providing clear explanations of her condition, the planned interventions, and the surgical process can help reduce her anxiety.

Oxygenation and Respiratory Care

Jane’s mild hypoxia (SpO2: 93%) indicates the need for ongoing oxygenation monitoring. Ensuring proper oxygen therapy administration and addressing potential causes of hypoxia (e.g., pain, anxiety) can improve her oxygen saturation levels and overall respiratory status. If necessary, further interventions such as adjusting her positioning or providing supplemental oxygen should be considered.

Collaborative Care and Interdisciplinary Communication

As a registered nurse on the surgical ward, collaborating with the healthcare team, including physicians, respiratory therapists, and pain management specialists, is crucial. Regular interdisciplinary communication ensures that Jane’s care is holistic and well-coordinated. Updates on her vital signs, pain management, emotional state, and any interventions implemented should be shared effectively among team members.

Conclusion

The case of Jane Wilson highlights the significance of a comprehensive nursing assessment and patient-centered care for trauma patients admitted to the surgical ward. Addressing pain, anxiety, oxygenation, and emotional well-being are integral to ensuring a positive patient experience and optimizing outcomes. Effective interdisciplinary collaboration and communication further enhance the quality of care provided. By integrating these strategies, the nursing team can contribute to Jane’s comfort, emotional support, and overall recovery during her stay in the surgical ward.