Patient with a Sustained Unwitnessed Fall Mr. D, 90-year-old man with a recent fall and unstable T10-T11 fracture requiring a thoracic lumbar sacral orthosis (TLSO brace) complicated by a pressure injury to mid-back.
The patient was transferred from one of the acute hospitals in the GTA. The patient had undergone neurosurgery for the spinal fracture with prolong hospital stay. Upon arrival to the neurology unit, the patient was very confused, not engaged and has poor pain management. Past Medical History includes endocarditis, heart failure, TAVI (Transcatheter aortic valve implantation), mitral stenosis, mitral regurgitation, osteoarthritis, osteoporosis, retinal detachment, right inguinal hernia repair, left diaphragmatic hernia, pulmonary embolism. Pt also admitted with kyphosis. Medications:
• Tylenol 2 tabs PO Q 4-6 hours for pain
• Hydromorphone 0.5 mg IV for pain PRN
• Digoxin 0.625 mg PO / NG tube daily
• Atenolol 50 mg PO / NG tube daily
• Dalteparin (Fragmin) 10 IU SC daily
• Risedronate 35 mg once a week PO/NG tube
• Mirtazapine 7.5 mg PO/NG tube QHS PRN Vital Signs: T = 36.7 OC then 38.6OC 3 weeks after admission P = 113 to 125 beats / min R = 26 to 30 / min BP = fluctuating from 120/70 mmHg to 90/60 mmHg. Highest BP 140/90 mmHg Lab: CBC, lytes, CR; blood culture x 1 Orders:
• Activity as tolerated requiring TLSO brace use for HOB above 45 degrees.
• Enterostomal nurse (ETN) consulted early when skin break down was first noted – orders for wound care entered for stage 2 pressure injury.
• NG feeds for supplemental feeding – Resource 2.0 at 5ml/hr until reached maximum rate of 75/hr. Pressure Injury: Skin assessment findings on patient’s back close to spine from brace use o Day 1 of the assessment: skin tear – 1.2cm x 2cm o Day 3 – skin tear- 0.01cm x 0.01 cm 2 o Day 6 – stage 2 pressure ulcer – no measurements, no staging of the wound. Wound dressing changed every 2-3 days and PRN (with each bowel movement). Staging of the wound / measurements remains incomplete. By 4 weeks of hospital stay, Mr. D. developed an unstageable wound with 60% necrosis. Wound care team ordered for VAC therapy initiated. PICO therapy initiated to further manage the wound. 2 nd Pressure Injury: The feeding formula caused abdominal bloating and diarrhea resulting to further skin breakdown on the coccyx area. Consults:
• Consult to orthopedics completed and recommended discontinuation of the brace due to contributing ongoing pressure to the wound.
• Consult to plastic surgery with recommendation for the transferring hospital to suggest wound management and use of the TLSO. Team consults with the neurosurgery team and order was to continue to use the brace due to complications of spinal compression.
• Consult to infectious disease – soft tissue infection treated with Cefazolin 1 GM Q 6 hours via PIV. During the hospital stay, the patient has a very poor appetite. Despite maintaining an oral caloric intake, the patient was not eating all his meals. He has been at risk for malnutrition.
The decision from family was to insert an NG tube for supplemental feeding. Due to ongoing concern with the pressure injury, the neurosurgeon team decided to remove the TLSO brace as it was ill-fitting. The patient also developed spinal cord compression with loss of sensation to his lower extremities bilaterally. CT scan results indicated the spinal fracture has become unstable resulting to the spinal cord compression. Family refused the team to gradually transfer the patient from chair to with as per care plan. The spouse had requested for the patient to sit in the chair over 2 hours / day. Mr. D. has an elderly wife and a daughter who is very knowledgeable of the health care system. The family did not want the care team to administer analgesics to the patient for pain management. The concern was that the patient will be very confused with a risk of respiratory depression. Patient was to remain on Tylenol 2 tabs every 4-6 hours via NG tube with very poor pain management. Mr. D continues to be restless, moaning during repositioning/turning and transferring. He does not want to be touched by nursing staff and has become aggressive. Geriatrician consult was completed to work with the family on pain management approaches. The spouse had agreed to try Hydromorphone 0.5 mg IV BID with minimal effect. The case study you are assigned is listed on Blackboard under the Assignment folder.
CARE PLAN ASSIGNMENTS: Outline and Grading Rubric Use the nursing process (ADPIE) to identify the following from the information provided in the case study.
• Assessment: Assessment Data for the patient ○ Complete the Patient Demographic Form ○ Actual and potential problems: Review the assessment data collected. From this information identify and create a list of areas of concern/symptoms for your client. (Actual and Potential problems) ○ Clustering and prioritizing your data: From the list you created – group similar data that pertain to the identified areas of concern/symptoms. These groupings will help you to identify the actual and potential health problems for your client. Keep in mind class content. ○ List of priorities: Prioritize the grouping of data collected from the highest to the lowest order of priority.
• Diagnosis & Analysis: What is the priority problem being experienced by the patient? This is your diagnosis.
• Planning: How and When does this need to be fixed? What are the priorities?
• Intervention: What nursing interventions both pharmacological and non-pharmacological can you use to support this patient’s care needs that DIRECTLY will impact the priority problem? How do you know this is an important intervention? Provide your rationale with APA reference.
• Evaluation: This is your outcome! What do you expect will happen after the intervention is implemented? What is the timeline that it should be completed within? Your care plan must include: (Refer to NCP Template to complete)
1. Diagnosis – choose ONE that pertains to the client
2. Two (2) goals related to the above diagnosis –
SMART format 3. For EACH goal you are required to have 5 interventions with 5 rationales: one related to social determinants of health the other anatomical/physiological. a. Goal #1 – must have 5 interventions with rationale b. Goal #2 – must have 5 interventions with rationale
4. Each intervention needs an outcome statement please ensure you include a TIMELINE. 5. Each rationale must be supported by current scholarly resources within the last 5 years.
You MUST have a reference page and title page with your care plan. All citation MUST follow APA format including a reference page/section. Refer to templates provided. provided. (Adapted from Canadian Neighbourhood)
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