A Clinical RTA Case Study
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This is a paper whose intention is to analyze a clinical case study of Janice Kingsley who has been admitted to the hospital after sustaining injuries from motor vehicle accident. This paper will provide a critical review of the case study. It will be divided into two parts namely part 1 and part 2. Part 1 analyzes the previous admission history including a medication chart for the previous admission, previous ECG chart, and current paramedic handover notes and finally the initial assessment of Janice Kingsley together with nursing priority nursing intervention in her individualized case. Part two focuses on an individualized discharge plan for the patient that focuses on the determinants of health such as sociocultural factors, environmental factors, biological factors and politico-economic factors.
Critical Review of Paramedic Handover Notes, Medication chart and ECG Chart
a) Paramedic Handover Notes
Janice Kingsley is a female patient 71 years old whereby levels of estrogen have decreased due to menopause. Considering her age, she is past menopause with an obvious reduction of estrogen necessary for the maintenance of bone densities. Janice is at a glance is at risk of osteoporosis due to old age. The mechanism of injury is MV-lateral. The lateral impact may cause injury to the knee, thorax, cervical spine and extremities. Paint complains of pain at right leg. On a Likert scale of 0-10, Janice’s pain level is 10/10 which indicated extreme pain. Morphine 5mg via IV route administered pre-hospital. Initial vital signs are as follows: Bp100/60mmHg, HR is 90b/m; Respiration is 24b/m, SPO2 of 94%, GCS of 14/15 with the presence of confusion and BLS of 7.4 and temperature of 35.9oC. Using these baseline vital signs, the normal systolic pressure is 100-140mmHg while normal ranges of diastolic pressure are 60-90 dependent of the age and BMI of a patient. Janice’s pressure of 100/60mmHg is on the borderline, any indication that if no intervention is done, hypotension is imminent. Respiratory rate of 24 is tachypnea (Normal 14-18 b/m), HR of 90b/m is within normal range (Normal 60-100b/m) SPO2 of 94% is low (Normal: 95-100%). A GCS of 14/15 indicates mild loss of consciousness but should be monitored for any deterioration (Chad, 2014 pp.978-1007). The temperature of 35.9o c indicates hypothermia (Normal ranges 36.5-37), BSL of 7.4 (Normal 4.9-7.8). Socioeconomic history: driver and a widower.
b) Drug Chart
The patient was on Warfarin due to a diagnosis of atrial fibrillation. This is a blood thinner which indicates the presence of coagulopathy. She had a history of hypertension and was on metoprolol 25mg. She was also taking alendronate, a drug used to prevent osteoporosis (Chad, 2014 pp.978-1007). From this drug chart, it can be deduced that the patient is a known hypertensive, had atrial fibrillation which resulted in her past admission. She is also a high risk for falls due to osteoporosis.
c) ECG chart
QRS complex is narrow
It is reverted in some readings
Heart rate is 132b/m
This is atrial fibrillation with tachycardia
Initial Assessment of Janice Kingsley at emergency department
i. Airway (Ac )
‘A’ stands for airway and subscript c for cervical spine protection. Assessment of airway is a priority here. First I will secure the cervical column a cervical collar to protect it from any further injury considering the fact that the patient had a lateral impact while in a motor vehicle. The cervical spine is at risk of injury here unless proven otherwise. On the assessment of the airway, there is a stridor on expiration indicating an obstruction of the airway (Roger, Samuel, and Thomas, 2012 pp. 1741-1757). Chin lift without a simultaneous jaw thrust is done to clear the airway while protecting the cervical spine. Jaw thrust interferes with the cervical column hence can increase the severity of injury if used to clear the airway. Chin lift alone cleared the airway hence there was no need for intubation. On examination of the airway, there is no visible blood, froths or tooth debris in the mouth to be cleared or suction. Chin lift alone opens the airways hence there is no need for intubation.
ii. Breathing (B)
On examination of the respiratory system by look, listen and feel, the Janice is breathing at a high rate of 24b/m. The chest rise is asymmetrical, and there is a tracheal shift to the left side. Jacinta has a high respiratory rate of 24b/m which is high and is known as tachypnea(Johansson, Ostrowski, 2010 pp564-567). . SP02 is 94% which is on a lower value from the normal value of 95-100%. I immediately put Jacinta on oxygen 100% at a rate of 6L/m (Roger, Samuel, and Thomas, 2012 pp. 1741-1757). Oxygen is administered until oxygen levels remained steady at 98-100%. This will be monitored using an Oximeter. Inspection refills unequal chest rise, tracheal shift and severe chest pain on the left side as verbalized by the patient indicate a possibility of a tension pneumothorax(Chad, 2014 pp.978-1007). Since this is an emergency, I will do needle aspiration release off positive air pressure (Wipa and Praneed, 2012 pp.93-99). The patient has osteoporosis which impairs born density hence Jacinta is at risk of cervical fracture from MVI on a lateral mechanism.
Circulation compromise may lead to adverse effects if not controlled. Janice has a rate of 90b/m while the normal is 60-100b/m. Her blood pressure is 100/60 mmHg which is at the borderline of lower blood pressure. Extremities are cold, clammy skin. The patient also verbalizes that she feels dizzy. Capillary refill time is 5 seconds indicating that the patient has poor perfusion. All of these findings indicate that circulation is compromised and if immediate intervention is not done, then it will lead to hypovolemic shock. The body is carrying out compensatory mechanisms in order to maintain vital functions. This has been achieved by cutting down blood supply to non-vital organs such as the skin and extremities hence they feel cold and clammy on touch (Johansson, Ostrowski, 2010 pp564-567). On examination, the patient had a weak jugular pressure indicating hypotension, capillary refill time was 5 seconds which indicates a circulatory compromise, and extremities were cold: an indicator of imminent hypotension. I inserted two gauges 24 branula, one for blood administration and another for fluid administration (Wipa and Praneed, 2012 pp.93-99). The patient has a right leg shortening, an obvious leg deformity, and a swollen mid-thigh. Considering the fact that the patient was on an anti-coagulopathy drug known as coumadin, there is a high risk of increased internal bleeding (Roger, Samuel, and Thomas, 2012 pp. 1741-1757) caused by the lyzing effect of this drug. I immediately started running ringers lactate for the control of blood pressure at a full rate of 20 drops per minute. All fluids were kept warm to prevent hypothermia. I avoid to use normal saline since the patient is a known hypertensive considering previous hospitalization treatment which indicated that she was using an antihypertensive drug known as metoprolol 25mgs (Johansson, Ostrowski, 2010 pp564-567).
iv. Disability assessment (D)
On disability assessment, the patient had a baseline assessment of GCS of 14/15. The patient had confusion at the time of injury which may an impact to the head. This impact is the one that resulted in the mild loss of consciousness pre-hospital. On hospital examination the patient had GCS of 14/15 which was a decrease from the pre-hospital leadings GCS of Janice is as follows:
Motor response- Patient obeys command (value of 6 which is the best motor response)
Verbal response- Patient confused (value of 4, a drop by 1 from the best verbal response)
Eye-opening- Patient opened eye spontaneously (a value of 4 which is the best attainable)
The total score was 6+4+4=14 out of the possible 15. This value is an indicator that if there is an internal injury to the head, then it should be a mild head injury. However, head injuries do deteriorate very fast easy close monitoring of a score less than 15 is necessary at all cost. Therefore I will monitor Janice until the GCS stabilizes at 15.
I used the AVPU to as her disability state (Roger, Samuel, and Thomas, 2012 pp. 1741-1757).
A-alert: the patient is confused
V-Responds to verbal stimuli: There is a clear logical communication
P-Responds to painful stimuli: the patient is responsive to pain stimuli
U-Unresponsive to pain: The patient is responsive to pain
From the above AVPU, the patient is at level 3 out of the possible 4
The patient body temperature is low 35.9o C as documented in the handover notes by the paramedic. However, the area of impact of MVI is swollen and warm. This is due to inflammation caused by infiltration of the inflammatory biomarker. Exposure of the patient is done by cutting patients clothes with scissors to ensure minimal movement and avoid further injuries. Exposure is necessary so that other parts of the body can be assessed fully from head to toe examination as follows.
Discharge Planning of Janice Kingsley
A patient is not meant to stay in a hospital forever hence there is a need for discharge as soon as the patient is stable. Taking care of a patient in an environment that is usual improves patient outcomes. Janice Kingsley has complex needs that require a well-organized discharge plan (Angela, Anna, Synneve, 2017 pp.57-63). In order to ensure that the patient is given a holistic care, this plan of care discusses the determinants of health as follows: biological, sociocultural, environmental and politico-economical determinants of the health status of an individual.
Janice is 71 years old had been diagnosed with osteoporosis as indicated in the previous admission. Biological factors that affect health include age and sex. In this clinical case study, the age of Jacinta has played has predisposed her to osteoporosis. Compounded with the diagnosis of fracture head of the femur, this will delay the bone healing process. The discharge plan should focus on patient education on how to minimize re-fracture and promote bone healing. The patient will be educated on the following issues related to biological factors before discharge: the importance of taking prescribed Alendronate for management osteoporosis which increases the risk of re-fracture, the importance of maintaining the site of incision clean to avoid colonization of microorganism which will cause infection to the site and complicate wound healing process. Age also contributes to the development of hypertension (Mohamed, 2014 pp.68-80). At 75 years, Janice’s blood vessels start to constrict due to old age and this contributes to increase in blood pressure.
The history of Janice indicates that she is a widower and stays alone. She is also a Christian and has a personal car which she uses to drive to the job. Being a widow affects her as a biopsychosocial being (Angela, Anna, Synneve, 2017 pp.57-63). Plans should be underway to discuss with Jacinta on she can get somebody to stay with for emotional support and other supports that she is unable to do unaided. Culturally, most people do not have raised toilets and from the history given by Janice, she is not exceptional. Plans should be made for teaching her to use raised toilet to prevent another fracture from hip flexion. She will take some time out before she is able to do her job which involves bending at some particular situation. Considering the fact that she is hypertensive and taking metoprolol, she should be educated on the best coping mechanism for stress as it can lead to shooting up a controlled pressure at a normal range. Stress coping mechanisms are necessary for the control of pressure (Michael, Jessica, 2014. pp. 202-210).
Environmental factors play a key role in determining the health status of an individual. Fracture healing depends largely on immobilization of the fracture site after reduction to allow the bone healing process to take effect. One of the environmental factors that should be considered in the discharge plan is the lighting system in the house. A good lighting system in her house is necessary for this patient to falls. The floors of the house should not be slippery to avoid falls. The patient is also hypertensive therefore the importance of emphasizing on taking antihypertensive drugs as prescribed key in the management of the condition. A randomized clinical trial indicates that too much intake of table salts worsens hypertension hence the patient should be advised to reduce the amount of salt intake (Wilkinson, Marmot, 2010).
Considering the age of Janice, it can be noted that she is at an unproductive age past retirement from a government job. She drives home and to her own business based in the city. The fracture has caused a disability that will affect her productivity hence this will decrease her source of income which will, in turn, affect her health-seeking behaviour. Travelling also requires sitting which can dislocate the repaired fracture.
Patient care is a continuation from hospital to home and therefore for a better outcome, care must be transfer from hospital to home (Lin, Wen, 2013). To ensure that there is no breakdown in care of Janice, the following disciplinary team will be included in the planning of the patient’s discharge:
a) Nutrition specialist
Janice has a BSL 7.4g/L. The normal BSL ranges from 4.0 to 6.0. This patient is at the pre-diabetic stage and an intervention on nutrition is highly recommended before it escalates to the diabetic stage. The patient can also benefit a lot about nutrition and pressure.
b) Medical consultant
The patient should be attached to a consultant so that in case there will be a need for help, the patient can easily contact a consultant who has an upper hand history about her case. The patient is also using warfarin which can cause excessive bleeding hence having a place to consult from is necessary.
c) Family members
Family plays a major role in the patient’s care after discharge hence they should be actively involved in patient discharge. They not only offer financial support but also spiritual, psychological support and emotional support.
d) Critical care specialist
The patient had been recently diagnosed with atrial fibrillation has been taking warfarin has a preventive measure for future attacks. In addition to that, the patient had undergone a recent hip surgery to reduce the fracture of head of the femur. The drug can increase the risk of bleed but again hip surgery is a risk for thrombosis (Lin, Wen, 2013) hence advice of a critical care specialist is important before discharge.
Discharge of a patient may be a complex process or simple process depending on what primary diagnosis and other secondary diagnoses the patient. Assessment of a patient to uncover their need is important to ensure a smooth transition from hospital-based care and to home-based care. Care at home should be holistic hence sociocultural, biological, environmental and political economic factors should always be factored in when discharging a patient. Janice’s case is a complex case requiring a multidisciplinary approach to meet patient’s needs. A holistic care plan will improve Janice’s care plan and prevent unnecessary readmission for the same problem.
Angela, B. Anna, D. Synneve, D. (2017)Collaboration in discharge planning in relation to an implicit framework. Applied Nursing Research 36(2017)57-62. Retrieved from https://doi.org/10.1016/j.apnr.2017.05.010
Chad, T. 2014, Initial Assessment and Management of the Trauma Patient. Journal of Research Gate. 4(1)978-1007. DOI: 10.1007/978-1-4939-0909-4_1
Johansson, P.I. Ostrowski, S.R.2010 Acute coagulopathy of trauma: balancing progressive catecholamine-induced endothelial activation and damage by fluid phase anticoagulation. Med Hypotheses. 75: 564-567. 10.1016/j.mehy.2010.07.031
Lin, S. Wen, C. (2013)The Past, Present, and Future of Discharge Planning in Taiwan. International Journal of Gerontology, 7(2)65-69. Retrieved from https://doi.org/10.1016/j.ijge.2013.01.011
Michael, M. Jessica, J. (2014).Social Determinants of Health Equity. AJPH Publication, 26(3) 202-210). Retrieved from http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.302200
Mohamed, A. (2014). Nursing intervention in discharge planning for elderly patients with hip fractures. International Journal of Orthopedic and Trauma Nursing. V18(2)68-80. Retrieved from http://www.sciencedirect.com/science/article/pii/S187812411300066X#!
Roger, F. Samuel, M. Thomas, E. 2012. Critical care considerations in the management of the trauma patient following initial resuscitation. Australian Journal of Trauma, Resuscitation and Emergency Medicine. 20(68)1741-1757.
Wilkinson R, Marmot M, eds.(2010) Social determinants of health: The solid facts [Internet]. 2nd ed. Copenhagen: World Health Organization; 2003 [cited 2010 May 26]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
Wipa, S. Praneed, S .(2012)The development of clinical nursing practice guideline for initial assessment in multiple injury patients admitted to the trauma ward. Australasian Emergency Nursing Journal. 15(2)93-99. https://doi.org/10.1016/j.aenj.2012.02.003