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Identification Of Actual Health Problems

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Identification Of Actual Health Problems Question: How Do Identification of Actual Health Problems?   Answer: Introducation: In the subsequent report, the case study relevant to a 38-year-old patient, named Ben Casey who had been brought to the UTS emergency following injuries because of occurrence of motor vehicular accident (MVA) will be discussed. The report will aim to prepare an evidence based complete plan of care utilizing literatures from a variety of sources after identification of two prioritized patient problems. References will be incorporated for the underlying pathophysiology in order to further rationalize the care to be implemented. Proper nursing interventions that will cater to the identified problems will be developed in conjunction with providing explanation of the intended patient outcomes and the ways in which the effectiveness of the nursing interventions may be evaluated. The entire report will be done by means of relating to Mr. Casey’s situation. As per the description provided in the case study, acute pain and pressure sore have been identified as the actual and potential health problems respectively for Mr. Casey. Mr. Casey has been experiencing acute pain that may be attributed to both the causation of accident as well as due to the surgery that he has underwent. Therefore, it is imperative to assess his pain on regular intervals to account for proper interventions. The patient has been found to be in a state of semi consciousness, however his facial expressions suggested that he has been living with grimacing pain that may be suggested as non-verbal indication of pain. Uneasiness and pain localized in the tibia and femur region is further due to the undertaking of the surgery evident through his facial expression, stiffness and voiced pain (Macintyre and Schug 2014). The imposition of abnormal stresses in case of the joints and soft tissues might lead to impaired functioning of the muscles and musculature that in turn culminates in the onset of pain in both before and after surgery situations. Nerve root impingement, referred pain due to cervical injury in addition to placement of abnormal stress on shoulders because of improper positioning in bed may be speculated as possible sources of pain during the early post injury phase (Pergolizzi, Raffa and Taylor 2014). Post operational pain might cause restlessness and alteration in the vital signs in the patient. Pressure ulcer may be recognized as the potential problem in case of Mr. Casey, because of the dual reasons that he had underwent surgery and had to stay on bed for long time. This complication is likely to occur in patients with spinal cord injury due to synergistic effects of both motor as well as sensory impairments under the impact of prolonged unrelieved pressure and external negative forces (Qaseem et al. 2015). Higher risk for Mr. Casey is noted as he is in spinal precaution that has restricted his mobility and repositioning in bed significantly. ORIF surgery in left tibia and left femur also pose threat for him to give rise to physical impairment. In post surgery  condition, pain, swelling and motor functioning impairments are commonly reported complications that further necessitates the urgency to attend to the bodily functions along with participation and abilities to carry out activities of daily living for patients undergoing ORIF surgery (Hudson et al. 2015). Nursing Interventions Pain management is considered as a fundamental feature pertaining to nursing care whereby effective pain reliving measures encompassing both pharmacological and non-pharmacological interventions are suggested for the purpose of rendering holistic outcomes for the patient. Pain in post operative condition is evident in case of Mr. Casey. where patient controlled analgesia (PCA) may be applied for harboring optimum benefits in a safe and effective manner (Gatchel et al. 2014). Enhanced pain relief coupled with greater patient satisfaction, decreased sedation and lesser post operative complications are some of the common advantages of resorting to PCA. Compliance with the right dose of medication in the follow up post-operative period is necessary to ensure quicker recovery. Therefore, the nurses need to watch out for depression and respiratory troubles that are common side effects in PCA. Nurses must also provide proper nursing guidance and review of symptoms with respect to acting in sync with the PCA. The situation may be extrapolated in case of Mr. Casey where PCA will be quite effective. Teaching is the most suitable option for making the patient as well as his family aware about his condition and further to prevent the possibility of causation of pressure sore. Mr. Casey is more vulnerable to develop pressure sore as he is lying on supine position and has to rely on the healthcare professionals to turn around. Hence, pressure ulcer management in a comprehensive way is the only resolution to ameliorate the problem and further abating the possibility of development o pressure ulcer in future. Interventions in this regard must address the management of tissue loads, cleansing and dressing of wounds, bacterial colonization and infection prevention, wound healing promotional adjunctive therapies in addition to optimization of patient’s health and nutritional status. Restoration of muscle mass and wound healing is promoted by means of recommending appropriate diets that meet the energy and protein requirement in such conditions (Lewis et al. 2015). Hence, knowledge about the equipment related techniques as well as awareness regarding paraphernalia following pressure sore is crucial to generate positive outcomes through seedy recovery.   Evaluation Assessment of the patient situation will be fostered to determine the efficacy of the implemented interventions. The pain management fruitfulness will be evaluated by means of Numerical Rating Scale that further highlight on the outcomes following application of analgesics and measurement of the current pain status for the affected individual. The relative frequency and dose of analgesics administered to the patient need to be carefully monitored and if needed the attending physician must be consulted for determining the regime for PCA (McNicol, Ferguson and Hudcova 2015). Necessary and prudent amendments may only be used when directives are received from the concerned authorized medical practitioner. The pressure sore or ay swelling or inflammation in skin must be looked out for understanding the extent to which the PCA education and knowledge has been applied. The post-operative care after surgery for Mr. Casey needs to be crucially evaluated for measuring the efficacy of interventions (Boykin and Schoenhofer 2015). On completion of the report, succinct and pertinent information related to post operative surgery for complex medical or surgery needs have been retrieved.  Moreover, detailed knowledge and understanding through critical thinking about comprehensive patient assessment data and their implications in planning care as part of competent nursing practice is procured from completing the report.   References Boykin, A. and Schoenhofer, S.O., 2015. Theory of nursing as caring. Nursing theories and nursing practice, pp.341-356. Gatchel, R.J., McGeary, D.D., McGeary, C.A. and Lippe, B., 2014. Interdisciplinary chronic pain management: past, present, and future. American Psychologist, 69(2), p.119. Hudson, D.A., Adams, K.G., Van Huyssteen, A., Martin, R. and Huddleston, E.M., 2015. Simplified negative pressure wound therapy: clinical evaluation of an ultraportable, no?canister system. International wound journal, 12(2), pp.195-201. Lewis, S.L., Maltas, J., Dirksen, S.R. and Bucher, L., 2015. Study guide for medical-surgical nursing: Assessment and management of clinical problems. Elsevier Health Sciences. Macintyre, P.E. and Schug, S.A., 2014. Acute pain management: a practical guide. CRC Press. McNicol, E.D., Ferguson, M.C. and Hudcova, J., 2015. Patient controlled opioid analgesia versus non?patient controlled opioid analgesia for postoperative pain. The Cochrane Library. Pergolizzi, J.V., Raffa, R.B. and Taylor, R., 2014. Treating acute pain in light of the chronification of pain. Pain Management Nursing, 15(1), pp.380-390. Qaseem, A., Humphrey, L.L., Forciea, M.A., Starkey, M. and Denberg, T.D., 2015. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 162(5), pp.370-379.

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