Catherine Owens

Elevated level: High hemoglobin levels occurs when the body requires a high supply of oxygen beyond the normal body activities.

Low level: Lower levels of hemoglobin has no impact on the normal body functioning.

Date: ____________ Client Initials: _SR_____ Student Name: Everlyne Oyaro_______________________________________________ 

Medical Diagnosis(s): (found in paper chart)

Admitting/Primary: Motor Vehicle Accident

Medical History (includes medical and surgical)

Date: ____________ Client Initials: _SR_____ Student Name: Everlyne Oyaro______________________________________________ 

PRN Medication List (found in paper chart) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

Medication Data Sheet

(Scheduled medications to be given to your client during your clinical shift) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

Pathophysiology

PATHOPHYSIOLOGY: For each diagnosis below, provide a 3-5 sentence explanation of the pathophysiology of the problem.

1. Primary Diagnosis: Open displaced fracture of the pelvis

Open displaced fracture of the pelvis refers to a breakage of the bone around the pelvis due to different factors and especially accidents.

Treatment: Treatment of Open displaced fracture of pelvis depends on the extent of the injury. Minor injuries are generally treated under bed rest, anti-inflammatory medication or sometimes using a painkiller. Significant injuries are treated using primary therapies and the use of crutches. Surgery might be recommended on rare occasions.

Potential complication: Potential complications of Open displaced fracture of the pelvis include profuse bleeding as a result of injury in the blood vessels — toning of the lower rectum. Damage to the reproductive organs is a potential complication.

Potential Nursing diagnosis: Diagnosis can be undertaken through genitourinary examination because most of the fractures are associated with this. Diagnosis can also be made through Gastrointestinal, which is the evaluation of the Intra-abdominal injuries that can occur in amid pelvic fractures (Tannast et al., 2019).

Potential Nursing intervention: Immediate assessment of patients following a pelvic fracture. Immediate identification of deterioration in the health condition of the patient.

2. Diagnosis: Alcohol dependence with withdrawal

This is a condition that occurs when an individual engages in alcoholism for a long time and is at the point of being mentally or physically affected upon quitting the drugs.

Treatment: Provision of a supportive environment that will allow the patient to get out of the situation in case the condition is not severe. Having limited contact with people can treat the conditions of taking a healthy meal with lots of fruits in the diet (Agabio et al., 2018).

Potential Complication: Hallucination for not less than 12 hours in a day. High blood pressure is another complication. Confusion is also common within the patients

Possible Nursing Diagnosis: As Patients regarding their drinking history can assist. Discussing the symptoms and allowing the patient to decide if he/she has ever undergone them.

Potential Nursing Intervention: Treating possible alcohol abuse is a firm intervention because patients will not reach withdrawal point. Prior advice from the doctor to patients could assist (Agabio et al., 2018).

3. Diagnosis: Closed fracture of multiple ribs of the left side

Closed fracture of multiple ribs occurs when the ribs break without penetrating the skin.

Treatment: Treatment of closed fracture depends on the break or crack severity. Minor cracks can be treated by taking in pain killers. Severe fractures are addressed through open reduction and internal fixation with plates.

Potential Complication: Potential complications include pulmonary confusion, which results from the disorganization of fractures. Pneumothorax, which is a typical abnormal air space between the lungs is a potential complication (Panigrahi et al., 2018). Pneumonia, which is an inflammatory condition is a possible complication since small air sacs could be affected by the fractures.

Potential Nursing Diagnosis: the disease is diagnosed using a medical imaging technique. This refers to the method used in generating a visual representation of inner parts of the body, allowing clinical analysis.

Potential Nursing Intervention: Use of APAP medication will allow containing the situation. Use of opioids is essential because they act on receptors, producing effects similar to morphine ones (Panigrahi et al., 2018).

4. Diagnosis: Closed fracture of the transverse process of lumbar vertebra

This condition mostly occurs when an individual encounters an accident which leads to breakage of the lumbar vertebra without penetrating through the skin.

Treatment: This condition can be treated at home using by resting. It can also be treated by taking painkillers to reduce pain and swelling. Can be managed through limiting motion within the fracture site.

Potential Complication: Severe pain resulting from contraction of the pulling off a chip of pain. The fracture can lead to spinal cord injury (Zhao et al., 2018).

Potential Nursing Diagnosis: Evaluation of the injuries related to the back fractures helps diagnose this condition. Skeletal anomalies lying in the region could also be used in diagnosing this condition (Zhao et al., 2018).

Potential Nursing Intervention: Back brace and Traction are the two primary intervention employed by nurses. Back brace involves treating minor fractures while Traction consists in treating major fractures’

5. Diagnosis: Acute blood loss anaemia

This condition refers to acute loss of blood which leads to blood deficiency within human body.

Treatment: This condition can be treated by Stopping bleeding and utilizing iron supplements. Stopping bleeding is being used during rapid blood loss. Iron supplements are used when blood loss is not quick.

Potential Complication: Dizziness that can result from excessive loss of blood. Tiredness is another complication when blood loss is rapid (Loftus et al., 2018). Too much failure of blood could result in death.

Potential Nursing Diagnosis: Diagnosis is carried out through two significant ways. These are blood tests and endoscopy. Endoscopy is utilized in determining the source of bleeding. A blood test is used in detecting anaemia after patients list symptoms.

Potential Nursing Intervention: Testing for anaemia on time after the patient has listed the symptoms. Determination of the amount of blood loss and how rapid it is lost.

6. Diagnosis: Respiratory failure

Respiratory failure is the condition resulting from insufficient gaseous exchange within the breathing system in such a way that the gases are not maintained in the normal levels.

Treatment: Treatment may be among the following, depending on the type of diagnosis. Oxygen therapy, use of noninvasive mask respirator or even the use of antibiotics or steroids. “Noninvasive positive-pressure ventilation” can also be used.

Potential Complication: Complications of Respiratory failure include pulmonary emboli, pneumonia or fibrosis. The Mortality rate of thrombocytopenia is also another possible complication. Some patients might undergo renal failures

Potential Nursing Diagnosis: The conditions are diagnosed through the performance of physical examinations. Ordering of chest X-rays also helps in determining the existing abnormalities (Barrington, Finer & Pennaforte, 2017).

Potential Nursing Intervention: Ensuring that a person has enough oxygen to prevent any further failure. This could be administered by a mask to force it to pass into the lungs of the patients.

7. Diagnosis: Acute pain due to trauma

This condition refers to pain that an individual experience after encountering a traumatic moment. Such pain lasts for a period less than three months.

Treatment: Acute pain due to injury can be treated through resting the affected body part. Applying heat or ice can handle such conditions. Physical therapy and exercises could be used in treating the disease.

Potential Complication: Potential complications include illness, which is subject to the deficiency of platelets. Other complications include renal insufficiency and acute ulceration. These two conditions tend to remain conjoined.

Potential Nursing Diagnosis: Acute pain has typically specific causes, making it easier to diagnose. Tissue damage and inflammation are the typical aspects used in diagnosing this condition (Scholten et al., 2015).

Potential Nursing Intervention: Nursing interventions include acknowledgement of pain reports. This is because the perception of people might end up being distorted while under pain. Foreseeing the need for pain relief is an essential intervention of the conditions.

8. Diagnosis: Transection of the urethra

Transection of the urethra occurs when the part is cut transversely as a result of accidents such as when a kid forcefully straddles a bike.

Treatment: The treatment of these conditions depends on the severity of the injury. These injuries are fixed through surgery. Minor injuries of the terms could be mended through the catheter.

Potential Complication: Complications of these conditions can be either long term or short term. Long term complication includes Impotence and stricture. Incontinence is another possible complication

Likely Nursing Diagnosis: The conditions could be categorized by the use of the mechanism of injury (LaPallo et al., 2017). This is blunt versus penetrating trauma. They can be diagnosed by location. Also, that is posterior and anterior.

Potential Nursing Intervention: Nursing intervention for this condition include Endoscopic urethrotomy. This involves the insertion of optical devices into the urethra to vaporize them with water.

References

Agabio, R., Pani, P. P., Preti, A., Gessa, G. L., & Franconi, F. (2016). Efficacy of medications approved for the treatment of alcohol dependence and alcohol withdrawal syndrome in female patients: a descriptive review. European addiction research, 22(1), 1-16.

Barrington, K. J., Finer, N., & Pennaforte, T. (2017). Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane database of systematic reviews, (1).

LaPallo, B. K., Wolpaw, J. R., Yang Chen, X., & Carp, J. S. (2017). Spinal transection alters external urethral sphincter activity during spontaneous voiding in freely moving rats. Journal of neurotrauma, 34(21), 3012-3026.

Loftus, T. J., Brakenridge, S. C., Murphy, T. W., Nguyen, L. L., Moore, F. A., Efron, P. A., & Mohr, A. M. (2018). Anaemia and blood transfusion in elderly trauma patients. Journal of surgical research, 229, 288-293.

Panigrahi, S. K., Mishra, A., Khuntia, P. K., & Kanungo, A. (2018). A stress ulcer duodenal perforation is complicating diaphragmatic rupture with multiple bone fracture in a polytrauma patient due to fall from a tree. International Surgery Journal, 5(5), 1952-1955.

Scholten, A. C., Berben, S. A. A., Westmaas, A. H., van Grunsven, P. M., de Vaal, E. T., Rood, P. P., ... & Emergency Pain Study Group. (2015). Pain management in trauma patients in (pre) hospital-based emergency care: current practice versus new guideline. Injury, 46(5), 798-806.

Tannast, M., Keel, M. J., Siebenrock, K. A., & Bastian, J. D. (2019). Open Reduction and Internal Fixation of Acetabular Fractures Using the Modified Stoppa Approach. JBJS essential surgical techniques, 9(1).

Zhao, C., Zhang, B., Shi, J., Li, Y., & Pang, L. (2017). Spontaneous Reduction of Fractured Thoracolumbar Spine With Complete Dislocation. Orthopaedic Nursing, 36(5), 350-355.