Nursing Assignment

Question: Write an intervention report for patient Mr John Harding, an undergraduate student, and age 21 years who met with a road accident when driving back home with his friends. Answer: Introduction and overview of the patient The assignment involves an assessment and intervention report for patient Mr John Harding, an undergraduate student, and age 21 years who met with a road accident when driving back home with his friends. He got his car hit a tree leading to major injury on the forehead. Mr Harding was treated in the emergency department with a following next week appointment but was soon brought back to ED by his mother Mrs Harding, complaining about other issues. The assignment involves a clear identification of patients subjective and objective data followed by the details of previous assessment performed in ED as well as required additional assessments. Lastly, the study describes two major nursing concerns as per the identified problems client is facing as nursing care plan interventions. Assessment Data Subjective Data Objective Data Mr Harding is complaining about a regular headache and neck pain. There is 7 cm laceration on patient forehead Client complaining about a regular vomiting Mr Harding is feeling very sleepy and tired Client mentioned substance abuse performed by him on accident night Temperature: 36.6 C Pulse rate: 58 beats/min Respiration rate: 20/min Blood pressure: 150/60 mmHg Positive alcohol intoxication Positive posttraumatic headache and neck pain Assessment Done The initial physical assessment involved blood pressure test, respiratory rate, pulse rate, and temperature identification in the form of vital signs assessment. Pupil Examination A pen torch was used to examine the size and working of pupils for identifying the state of patient consciousness (Wright Leahey, 2012). Self-reporting - an array of questioning was involves identifying the patient clinical as well as other details. Additional assessment with rationale Additional assessment Rationale Fluid Balance Chart This assessment will help to determine the fluid loss occurred due to vomiting to determine the rate of dehydration. As patient complained about regular vomiting it is important to determine the rate of dehydration (Gerrish Lacey, 2010). PQRST assessment This is a self-reporting subjective assessment tool used by nurses to determine the severity of patient pain and document the patients pain. The tool involves an array of questions for determining the P=palliation, Q=quality, R=region, S=severity and T=timing of pain (Giger, 2014). This tool will help to understand the exact location, time and severity of neck pain reported by the patient. Pain Assessment The Copenhagen Neck Functional Disability Scale can be used to determine the severity of pain occurring in the neck region of the patient. This scale involves a questionnaire related to sleeping ability, headache and daily activities that are answered in self-reporting form by patient (Gerrish Lacey, 2010). Leeds Dependence Questionnaire This assessment tool can be used to determine the severity of drugs and alcohol dependence in the patient as he is identified of getting indulges in regular substance abuse. SOWS (Subjective Opiate Withdrawal Scale) This assessment is a 16 symptom-based questionnaire that helps to determine the severity of drug abuse done by the patient on the basis of self-reporting from 0-4 for each symptom question on the scale indicating no use to extreme use. As the patient is identified to be indulging in drug activities this test will help to determine the severity of substance abuse (Giger, 2014). AUDIT (Alcohol Disorders Identification test) This test is a set of ten questionnaires that involves general questions related to alcohol usage, activities and effects on the patient health. The AUDIT scoring system that ranges from 0 to 20 indicating a lower risk (0-7) to severe risk (16-19). This test will be helpful to determine the alcohol intoxication performed by the patient (Dossey et al. 2012). Nursing care plan Client Goals Nursing interventions/ Nursing actions Rationale Evaluation To minimise the acute head and neck pain within 2 hours of nursing interventions Encourage bed rest as much as possible Adjust resting position to comfortable mode Teach deep breathing technique Perform movement exercises (Lowe et al. 2012) Perform Simple Relaxation Therapy Use pain killer, anti-inflammatory medications or acetaminophen Application of ice or heat on pain region (Fairman et al. 2011) This will help to reduce the pain intensity Letting patient sleep in right position will help to reduce muscular tension in head and neck region Deep breathing will reduce stress increasing comfortability Movement exercises help to release nerve stress The relaxation techniques and treatment atmosphere along with relaxation scripts or audiovisual aids help patient to eliminate pain The medication will help to minimise severe pain in short duration of time Reveals muscular stress The patient reporting minimization of pain as per pain assessment tools and scales. To minimise the number of vomiting episodes and maintain fluid balance within 6 hours in the body Monitor the input and output urine concentration Provide little fluid very often Provide rest in Semi Fowlers position (Lowe et al. 2012) Provide intravenous cytotoxic drugs Remove noxious odours and sights from treatment zone (Rosted et al. 2012). Encourage deep breathing and slow positional movements Allow small and frequent fluid intake as well as meals (Riesenberg et al. 2010) Encourage non-pharmacologic treatments like relxation, acupressure, music therapy, biofeedback (Marcum et al. 2010) This will help to determine the severity of dehydration in case of decreased urine output concentration This intervention will minimise the fluid loss This comfortable positioning will help to minimise the number of vomiting episodes and provide rest to body These medications help to minimise the vomitting centre stimulation The noxious elements cause vomiting stimulation and there removal will help to provide relaxation to the patient Fast breathing and movements accelerate the chemoreceptor zone stimulation leading to excitation of vomiting zone. This will help in proper digenstion and movement of food in the body. The non-pharmacologic interventions are specilized and specific technique to control vomiting without medication side-effects on the digestion and body. A perfect outcome of fluid-balance chart and control over regular episodes of vomiting. Conclusion The above study on the overview of performed assessment, additional assessment and nursing interventions required for provided patient case indicates a clear understanding of the nursing practice required to manage emergency situations. The interventions developed to control specific conditions on the basis of specifically determined goals are developed with keen analysis and study. These interventions are considered as most working actions to control the specific condition. References Books Dossey, B. M., Certificate, C. D. I. N. C., Keegan, L., Co-Director International Nurse Coach Association. (2012).Holistic nursing. Jones Bartlett Publishers. Gerrish, K., Lacey, A. (2010).The research process in nursing. John Wiley Sons. Giger, J. 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