NRSG258 Supplemental Assessment

NRSG258 Supplemental Assessment
Marita Müller is a fit, healthy 22-year-old German woman, with no past medical history and nil known allergies. Marita is currently working on a cattle farm in outback central Australia. Two days ago, she was thrown from her horse and fell into a barbed wire fence. At the time of the fall Marita was wearing only shorts, a tee-shirt, sturdy work boots, riding gloves, and a helmet. Marita sustained the following injuries in the fall:
NRSG258 Supplemental Assessment

* Two deep lacerations to her right leg
* Grazes to the right side of her face, shoulder, arm, leg, and torso
* Severe injury to her right wrist and upper right arm
*She had no altered conscious at the time of the accident. Marita denied any neck pain and denied any altered sensation in her limbs.

Marita was taken to Alice Springs hospital via air ambulance. Where she had multiple Xrays that showed:

Fractured Right humerus,
Fractured Right radius
Fractured Right 3^rd& 4^th ribs.
There were no other injuries
Head CT showed no signs of bleeding or trauma to her brain.

Surgery
Marita required surgery under general anaesthesia to clean and suture her multiple wound lacerations and reduce her fractures. A plaster cast was applied to her right arm. She has sutures in her right thigh wound and a Jackson Pratt drain to her thigh, and sutures to her calf laceration.

The operation was mostly uneventful apart from approximately 300ml of blood loss from her lacerations. She was given 1 unit of packed red cells, and 1 litre of Hartmann’s solution intra-op.

NRSG258 Supplemental Assessment

Marita was transferred to the orthopaedic ward from theatre last night at 10:30pm. It is now the following morning and you are assigned to care for Marita. You assess Marita at 08:00 hours and your assessment findings are:

Marita is awake and alert. She is orientated to time, place & person.
Her right eye is bruised and almost shut due to an extensive haematoma. She is quite teary & asks if she is going to be ugly due to the facial grazes and her other scars.She’s extremely worried she’ll never get full use of her right arm back. She is also very concerned that she won’t be able pay for this as she’s not covered by Medicare.
There is blood staining the dressings on her leg. The right leg drain has about 70ml of frank blood in it. Her right arm is swollen and bruised. The fingers on her right hand are also swollen. She has good movement and normal sensation in the fingers of her right hand. The skin is the same colour as her left hand apart from some bruising. The fingers to her right hand are cool to touch, and the capillary refill time is 3 seconds. Marita is complaining that the cast feels tight.
Her vital signs are: Temperature: 37.6C, Pulse: 115 & regular, Blood Pressure 92/58 mmHg, Respirations: 20 & shallow, Oxygen Saturation: 95% on 3LNP. She says it hurts to breath.
Marita is complaining of a dry mouth and being thirsty. There is no record of her passing urine since her return from surgery. Marita can’t remember when she last used the toilet.
She did not eat much of her breakfast but drank some of the orange juice and half a cup of coffee. She said it hurt her face to eat and the coffee was cold and not real coffee.
She has a PCA in place and says her pain is bearable at the moment if she doesn’t move too much or try to breathe deeply or cough. Her PCA and IVT are connected to the cannula in her left arm. She has a litre of Normal Saline running at 40mls/hr.

NRSG258 Supplemental Assessment

Complete the 3 tables below to address the following questions:

1.Using the case study information above, identify and justify three (3) important health issues that you need to address for Marita during your shift. Identify and explain the significance of the clinical cues you have used to prioritise your selection.

2. Provide an explanation of the action you will take to manage each health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.

[hint: There are 3 tables/care plans because you need to identify 3 health issues.][hint: your care plans may end up more than 1 page each.]

Question 1: Using the case study information above, identify and justify your firstimportant health issues that you need to address for Marita during your shift
Health Issue	Evidence – Clinical Cues and literature to support
1.
Provide a Nursing SMART Goal for this issue
1.
Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.

NRSG258 Supplemental Assessment

Question 1: Using the case study information above, identify and justify your Secondimportant health issues that you need to address for Marita during your shift
Health Issue	Evidence – Clinical Cues and literature to support
2.
Provide a Nursing SMART Goal for this issue
2.
Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.

Question 1: Using the case study information above, identify and justify your thirdimportant health issues that you need to address for Marita during your shift
Health Issue	Evidence – Clinical Cues and literature to support
3.
Provide a Nursing SMART Goal for this issue
3.
Question 2: Provide an explanation of the action you will take to manage this health issue. Please ensure that your nursing interventions are supported by current evidence-based literature.