Student Name
Chamberlain University
NR-341 Complex Adult Health
Prof. Name:
Date
This article discusses the case of Loius, a 67-year-old Caucasian male who was admitted to the neuro ICU after a motor vehicle accident. Loius sustained several injuries, including rib, mandible, and nasal bone fractures, as well as lacerations to his tongue, head, and torso. The article focuses on Loius’s nursing diagnosis, interventions, collaborative management, therapeutic modalities, and reflections on the role of nursing in his care.
Loius’s medical history revealed significant risk factors, including smoking, daily alcohol consumption, and a diagnosis of hepatitis C. A prominent scar on his back indicated previous back surgery. Upon his arrival at the emergency room, Loius presented with rib, mandibular, and nasal fractures, alongside multiple lacerations resulting from being ejected during the crash. Despite relatively stable vital signs, he exhibited confusion, likely due to head trauma, as well as significant pain, nasal swelling, and active bleeding.
The nursing diagnoses for Loius included imbalanced nutrition, ineffective breathing pattern, and risk for infection. The goals were to enhance oral intake, maintain a patent airway, prevent infection, and improve his overall health. Nursing interventions to achieve these goals included pain management, support during meals, deep breathing exercises, wound care, and monitoring for signs of infection.
Pain management was addressed using a Patient-Controlled Analgesia (PCA) pump, allowing Loius to self-administer morphine for better pain control. Enteral nutrition was provided to support his recovery and ensure adequate nutrition for healing. Despite initial reluctance to eat, nursing staff assisted with mealtime support to reduce anxiety and pain, fostering a more comfortable eating experience.
Nursing Diagnosis | Nursing Interventions | Desired Outcomes |
---|---|---|
Imbalanced Nutrition | Enteral nutrition, meal assistance | Improved oral intake |
Ineffective Breathing Pattern | Deep breathing exercises | Maintenance of a patent airway |
Risk for Infection | Wound care, infection monitoring | Prevention of infection, improved healing |
Loius’s care involved a multidisciplinary team. Occupational therapy provided assistive devices for eating and drinking, while physical therapy focused on mobility and pain management. Wound care specialists, surgical teams, and nutritional consultations were critical to his recovery, helping to ensure optimal healing.
Therapeutic care included interventions to reduce nasal swelling from his fractures and promote healing of his tongue wound. The use of Peridex solution, an antimicrobial oral rinse, helped protect the open wound in his tongue and alleviate pain. These treatments were crucial for enhancing comfort and aiding the healing process.
Therapeutic Modality | Purpose |
---|---|
Swishing with Peridex solution | Protects open tongue wound, provides pain relief |
Patient-Controlled Analgesia (PCA) pump | Better pain management |
Throughout Loius’s care, various communication styles, including passive, aggressive, passive-aggressive, and assertive communication, were observed. Assertive communication was found to be the most effective in promoting open dialogue, fostering teamwork, and improving patient outcomes. The case also highlighted the challenges of caring for patients with significant trauma, underscoring the importance of empathy and compassionate care.
Teamwork among nursing staff played a crucial role in delivering high-quality care. Collaboration between senior nurses, healthcare professionals, and support staff was key to ensuring effective patient care. A recommendation for improving safety on the unit includes increasing the availability of lifts to assist in patient transportation.
Reflection Area | Observations and Recommendations |
---|---|
Communication Styles | Assertive communication improved patient outcomes |
Teamwork | Collaboration between staff enhanced care quality |
Safety Recommendation | Increasing availability of lifts to improve patient transport safety |
Loius’s case highlights the importance of comprehensive nursing care, collaboration, and communication in achieving positive patient outcomes. The nursing diagnoses, interventions, collaborative management, and therapeutic approaches outlined in this case offer valuable insights for future nursing practice. By emphasizing assertive communication, teamwork, and patient-centered care, nurses can significantly improve patient outcomes.
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