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Introduction - Nur251 Medical Surgical Assessments
1. Stage 2
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Primary survey assessment
The primary survey includes an assessment of the head injury by the activation trauma team. The nursing assessment included catastrophic haemorrhage, Airway (and C-spine control, Breathing, Circulation, Disability and Exposure (Mitchel et al. 2021). A pre-arrival checkup is necessary to determine the physiopathological condition of the patient. Using this survey, patient assessment and complaints can be determined, which reflects a complete assessment of the airways. If not surveyed, the patient's critical condition is unable to examine (Babu, 2021). Mental status and exposure to the environment related document use for assisting record of assessment include radiology report, circulation by checking pulse rate, breathing rate and evidence for a head injury. Linking to the case scenario, the patient has experienced a traumatic head injury with requires analysis of the fractures. Hence, this survey enables us to acknowledge the prevailing condition of the patient.
Secondary survey assessment
Nursing assessment in trauma head injury requires nursing care and assessment for planning for diagnosis. A secondary survey assessment is the identification of life threats to a patient's stability. Monitoring mental status with saturation of oxygen, blood pressure, heart rate and airways is used to determine unexpected changes for reassessment (Kumar et al. 2021). The pathophysiology condition of the stress and trauma suffered by the patient needs to be determined. Assessment of the patient involves the head and face to determine internal and external bleeding, depression, blood clotting and the battle sign behind the head. Assessment of eye movement and inspection involve the neck for the observation of distension in the neck region. Assessment of c-spine in cerebral vertebrate and assessment based on back and chest can be done. This analysis is required to the determination of the life-threatening activity that might be associated with traumatic head injury condition (Lowe et al. 2021). If not assessed, the condition of the patient might turn out worst. Documents for recording include observation of check, signs and symptoms of neck bruising, and record of heart rate. As per the case scenario, the patient has developed a medical condition of neuro, analgesic prophylaxis which is critically evaluated for analyzing the condition of the patient. Hence, this nursing assessment enables us to plan for the next diagnosis for the patient.
Tertiary survey for nursing assessment
The tertiary assessment for the trauma head injury patient is to determine the additional damage and undiagnosed issue. Pathophysiology of the patient includes relaxation in the headache, though neurological observation has been done for prominent neuro and inability to respire (Safetyandquality, 2022). Assessment involves reexamination for the next 24 hours to determine the stable condition of the patient. Physical examination includes regular and routinely observation of heat rate, any observation of the bleeding sign, observation of CT scan and complementary test to determine the underpinned undiagnosed site. Assessment based on tertiary survey is significant for its effective diagnosis plan (nursingmidwiferyboard, 2021). If not assessed, the patient's condition might become worst and can be life-threatening to the patient. Documentation records need to maintain for consistent stability. This includes cardiac records, CT scans and levels of blood pressure, and heartbeat. Linking with the case scenario, the patient has experienced trauma head injury and has a complaint of headache. However, headache diagnosis through other test methods needs to determine for identifying the reason for the headache.
2. Stage 6
The clinical reasoning cycle in the healthcare industry is significant as its defines the step by step0 movement of nursing care in order to get an accurate assessment of the patient medical status. This cycle has 8 phases that continue to draft the right step to be followed.
The Nursing action plan
Clinical reasoning cycle
Identification of the patient current status and accurate problem promotes the effective development of the action plan. Hence, linking with the case scenarios, the patient's condition seems to be normal though, the headache complaint has raised a question about the issue (Long, 2020). Therefore, primary action needs to be done on the same day to develop the next diagnosis plan and for achieving the goal of patient care.
Diagnosis is primarily based on the assessment which tends to develop a systematic outcome for further planning. Linking with the case scenario includes a diagnosis for the trauma head injury patient for the primary survey for the continued headache that needs to be diagnosed with the effective medication of Panadeine Forte. The patient has complaints of neurological issues which need to be assessed to determine undetected damages and signs of internal damage. The secondary survey develops a diagnosis plan for the CT scan, assessment of the airway and the diagnosis of the complaint of difficulty faced by locomotion. Tertiary survey assessment develops a diagnosis plan for unresolved pain and unresponsive behaviour. Recommendation for the other test to determine the full body checkup for the issue (Barr et al. 2018).
Seems the patient finds difficulty for walking. The intervention has shifted the patient must be done from the hostile care centre to a neurological specialist hospital. Head injury traumatize patient has consistent pain and is being added to analgesic medication. Identification of the damaged site remains undiagnosed. This reflects the diagnosis pp and needs to be made for the patient as she is suffering from a neurological issue (Lowe et al. 2021)
Table 1: Nursing action plan
The parameter is chosen in the nursing action plan
Nursing diagnosis parameters include assessment of the primary survey which includes physical observation and examination of the heart rate, and blood pressure, analysis of the CT scan, and analysis of the airways (Nursingmidwiferyboard, 2022). The action plan needs to be reported to the heart surgeon for effective analysis. Duality record observation of physical observation needs to be reported to the allocated specific or the patient who is under the doctor. Secondary surveys include further examination and routine examination of the chest, neck, back and spinal injuries detection (Kumar et al. 2021). This needs to be reported to the specialist to examine the undiagnosed on-minute detailing. Linking to the case scenario, the patient had a movement issue that remains unsolved, hence, a neurologist must be reported and a complementary test needs to be established.
Critical analysis of the pain and medication management in the patient treatment,
Including associated risk management
Gibbs reflective cycle
The medicine that has been recommended to the patient for pain relief is 60mg of panadeine forte. A recommended dosage of panadeine forte is 1 to two tables for adults in case of severe pain (Roulin & Ramelet, 2012). However, the patient had been administered only 1 tablet in 24 hours which might have been the reason behind observing no improvement in her pain. Panadeine forte is effective for a maximum extent of 4 hours and after which re-administering is required, but this has not been observable here. Besides, 10 gm of oxycodone had been administered to the patient, which is a mild opioid prescribed in cases of mild pain. Oxycodone administration is also supposed to be provided every 6 hours, but in this case, it has been provided once. Also, the pain triggered due to head injury is massive, for which professionals prefer strong medications like acetaminophen (Dahm & Ponsford, 2015).
Feelings: However, in this case, these mild drugs had been administered to the patient, and hence the pain might not have been relieved.
Evaluation: The primary consideration for a patient who has experienced blunt trauma in the head is to clear the airways. The nurse allocated to such a patient requires clearing the mouth of the patient and inserting an oral airway for them. There might be assistance required with intubation of the patient and oxygen therapy when required (Rosenfeld et al. 2013). However, there have been negligible breathing issues in Vanessa, and the minor issues she might have had have been confused with her prevailing asthma. Analysis: Due to this, limited attention has been provided to the airway clearance of Vanessa since her oxygen concentration has also been normal. Monitoring the vital signs of the patient at every step is also necessary, which has been effectively performed in the case of the given patient. Conclusion: The risk management of such a patient would include proper supervision such that they do not experience accidental falls and worsen the injury (Nichol et al. 2015). Besides, it is required to keep track of the pulse rate and oxygen concentration of the patient.
Strategies for promoting health and wellness
Action plan: Promotion of health includes a set of actions that foster both physical and emotional well-being. Providing suggestions to people regarding ways they could improve their health is included in these sets of actions. The primary strategy I would initiate is to try and build a supportive environment for the concerned people. Ass strategy is required to be culturally safe such that the patient is not made to feel targeted because of their background (Safetyandquality. 2022). In the given context, a patient who has experienced severe head trauma should be made to stay with other people who have had experience in the area. The ideas shared by the other patients regarding their injury would work as a support for the concerned patient who would be motivated to improve their conditions. Physical and mental well-being is interlinked, for which it is to be ensured that the patient is out in a state of mental peace (Nichol et al. 2015). Keeping a vulnerable patient alone would trigger their fear, and that would worsen their condition.
Another strategy that I would recommend for promoting health and wellness would be the reorientation of health services. As said by Chauny et al. (2016), reorienting health services implies developing the capacity of health programs for achieving improved health. This reorientation also applies in the area of existing healthcare plans, and the requirement is pointed out in the given case study. The medications provided to Vanessa had been on the basis of the guidelines that had been created a long ago. The first NMBA standard of nursing mentions that a nurse requires having the ability of critical thinking besides strict adherence to the nursing guidelines (James et al. 2019). However, in this case, there have been no improvements made in the care plan despite negative improvements in the headache of the patient. Therefore, a reorientation of health standards is necessary after regular intervals, which I consider would be helpful for the patients as well as the hospital facility.
Legal and ethical frameworks in the management of patient care in an acute care setting
The non-maleficence principle of using ethics mentions that the safety of the patients is to be ensured. This can be done by preventing the injury of the patients or further damage by having them under proper supervision (Nursingmidwiferyboard. 2022). As a nurse myself, I had to combine my clinical expertise with the skills I possess in moral judgment. A nurse has a unique relationship with a patient in which every discomfort is conveyed to them. I had to practice collaboratively with the physicians to identify the ethical dilemmas in the hospital. In the case of the given patient, I had to compete between my self-values and the existing guidelines, and I had to go adhere to the rules.
I participated formally in the decision-making process of the ethical committee, including the policy development and case consultation. Accountability comes under the code of ethics in nursing, and the scope of practice describes each action taken by a nurse in the workplace (Jones et al. 2015). I have tried to maintain competency in my working area to increase my trust with my other colleagues. This was important for me since I am under-qualified and younger than most of the nurses in the facility. A nurse who is allocated a critical patient is because of their years of experience and educational qualification (Grinspun & Bajnok, 2018). I have tried to learn the basics of nursing from the aged nurses without allowing them to impose their ideas on me. However, when it has come to the practical application, I have tried not to indulge myself in the care plans I am not supposed to participate in. However, I have strictly adhered to the guidelines of nursing such that my clinical abilities are not questioned.
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