Introduction

According to the given case scenario, John Smith is an 80-year-old woman who was admitted to the Emergency Department at 17:30 with a prior experience of an unwitnessed fall. Following the event, she was found to have severe pain and her right leg appeared to be internally rotated and shortened. In this case study of Jane Smith, the pathophysiological assessment of the clinical signs that she is experiencing will be analyzed followed by a nursing diagnosis based on the case study will be identified and immediate nursing interventions that could be applicable in this scenario will also be thoroughly discussed. The pharmacokinetics of the prescribed medication, as well as the nursing management for those, will also be summarised and the patient education needed for the regular medications that Mrs. Smith is taking will also be highlighted.

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Deviation from the normal findings and the need for further investigation

Mrs. Jane Smith had multiple bruising was there over her face and right arm and due to this event, she was administered an opioid. She was taking regular medications such as metoprolol, amiodarone, thyroxine, and apixaban. Her pre-diagnosed medical illness includes hypothyroidism, hypertension, atrial fibrillation, ischemic heart disease, and multiple falls associated with the disease. Following the fall, a fracture in the neck of the femur was identified. These are the findings that she has exhibited so far.

Her vital signs deviated to a great extent followed by these events. Her blood pressure was 157/77 mmHg which is considerably higher than the normal blood pressure (Brekke et al., 2019). She was experiencing a higher heart rate also which is 122 per minute, and irregular. She had a higher respiratory rate too- 28 per minute. Her GCS score was 13 out of 15, thus deviating moderately.

Further investigations that are required should encompass consecutive assessments for the consciousness score of the patient as falls often increase the risk for acute trauma and associated complications. Gradual loss of consciousness is very common after an acute fall event. Considering this particular event. Proper assessments of the complete body map are required to find subjective data associated with falls associated with injury. The nurse must be responsible for assessing wounds, lacerations, and short and long-bone fractures. Consecutive pain assessments are required to understand the current pain status of the patient. These investigations are considered after falls as they may increase the risk of further complications associated with falls in patients. As the patient has already been diagnosed with hypertension and atrial fibrillation, anxiety after falls may increase the risk of stroke. In the subsequent section of this study, the author is going to focus on additional information that is to be assessed.

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The additional information that the nurse must ask for

The nurse should ask about the pain the patient is experiencing. Using a pain-score assessment scale may help in the said situation (Ahmadi et al., 2016, p. 94). Apart from that, any signs of nausea and vomiting after a fall reflects clinical deterioration in patients. Therefore, the nurse must monitor if the patient is experiencing above mentioned symptoms (Singh, Yoon & Kuo, 2016, p. 100). Persistent monitoring of pulse rate, breathing rate, and blood pressure is also considered very essential as acute falls often increase the risk for anxiety and further increases adrenergic responses (Brekke et al., 2019). As the patient was already diagnosed with comorbid conditions like hypertension, atrial fibrillation, and ischemic heart disease, they had a huge risk for further clinical deterioration. Therefore, the nurse must assess for the above-mentioned symptoms or alterations and ask the patient about the physical discomfort she is experiencing. Following the said event, it also seems essential to ask the patient if she is experiencing anxiety, confusion, persistent worry, and fear as they are very common after an acute fall event and often interfere with the standard of life of patients (Payette et al., 2016). Further monitoring of alteration in diet pattern or sleep pattern needs also to be assessed to identify the patient’s discomfort due to pain and other complications associated with falls. In the subsequent section of this study, the author is to specifically focus on presenting the problem of the patient by focusing on pathophysiological issues.

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Patient’s presenting problems and pathophysiological issues

The presenting problem of the patient includes multiple bruising over her right arm and face and a 4 cm laceration to her right lower arm. Excessive pain was also there when the patient was admitted to the ED after experiencing a fall. The patient is pre-diagnosed with some conditions including hypothyroidism, hypertension, atrial fibrillation, and ischemic heart disease, and due to the said illness, she has been prescribed a drug that acts as a blood thinner. Therefore, it may further increase the risk of bruising and blood-loss-associated complications. The study by Margolis et al., 2019, p. 728), suggested that patients with hypertension commonly have a significant risk of falling. Some independent predictors enhancing the risk of falling in patients with hypertension are the utilization of the diuretics group of drugs and the co-occurrence of heart failure as well as ischemic heart disease. The patient was already diagnosed with atrial fibrillation and ischemic heart disease. Both factors are considered a very common predictor of increased risk of falls and in response falls also hurt the progression of hypertension, atrial fibrillation, and ischemic heart disease (Hung et al., 2013, p. 440). In this aspect, it can be stated that some low-output symptoms that commonly result from the cardiac inability to generate sufficient cardiac output, ultimately lead to decreased flow of blood to the brain as well as some other vital organs. These in response increase the risk of fatigue and light-headedness associated with falls. Fall again increases the stress response of a patient that is fostered by the release of the adrenergic hormone (Herman et al., 2016, p. 607). Such a compensatory mechanism further increases cardiac output, respiratory rate, and blood pressure. As the patient is already diagnosed with atrial fibrillation, sudden elevation in blood pressure and cardiac output may lead to stroke and associated complications (Cho, Yu & Rhee, 2015, p. 1752). Considering the current physiological condition in the subsequent paragraph of the study, the author is going to focus specifically on two nursing diagnoses that require urgent interventions.

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Nursing diagnosis, interventions, and nursing management

Nursing diagnoses that were done based on the current case study were physical immobility as well as pain.

Nursing Intervention for physical immobility

The patient must be put under bed rest and limbs must be well rested by providing support, support to the fractured hip must be provided in case of moving and changing sides. Timely observation of the patient would be done in case of any occurrence of edema around the fractured joint and the nursing practitioner must examine the patient for any swelling at the joints. Patient must be provided to the patient and this should be well taken care of so that any malfunction is prevented (Pereira et al., 2020, p. 263).

The nursing practitioner must intervene to assist with the degree of immobility that the patient is experiencing after the injury and must provide education to the patient based on a holistic approach considering the age and culture of the patient (Liu et al., 2019, p. 755). The patient may experience Constipation due to several pain medications that could occur, so the nursing practice in mast assists with an appropriate intervention that would help his peristalsis and bowel movement.

Patients experiencing fracture and immobilization often are victims of skin deterioration of many types.  The nursing practitioner must examine the patient head to toe to assess any occurrence of rashes, infection, etc. The nursing caregiver must provide the patient with massage from time to time which would help in better circulation at the affected areas thus helping in proper aeration, which would prevent the formation of aberrations as well as breakdown. The patient must be repositioned once in a while so that hard skin is dry and there is no infection (Meneses et al., 2020, p. 73).

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Nursing intervention for pain

The patient is experiencing excruciating pain due to his bone fracture and injury. The nursing practice must provide a pharmacological intervention that would take care of the excruciating pain immediately to help the patient during mobility. Nursing providers must examine the patient and ask for feedback from the patient to understand the patient’s experience of pain. The nursing practitioner must be able to understand the degree of pain that the patient is experiencing and never undermine or ignore the patient’s response to pain which may lead to therapeutic misunderstanding and wrong management. The nursing practitioner would be able to provide nonpharmacological interventions to relieve the patient of their excruciating pain. These are physical intervention, cognitive and behavioral therapy, and lifestyle management (Varndell, Fry & Elliott, 2017, p. 75).

Evaluation of the progress

The nursing practitioner must examine the patient from time to time to check the progress of the nursing interventions that were applied to manage the excruciating pain as well as to help the patient with immobility. The nursing practitioner can follow a survey and assessment method by taking interviews with the patient about their experience at a particular time and analyzing these data to assess the progress of the patient (Saal et al., 2018, p. 4).

Physical examination of the patient by engaging in some activities might also serve to be a good tool to understand the degree of immobility and the level of pain the patient is experiencing.

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Pharmacokinetics of the ED drugs

In this section of this study, the author is to specifically focus on the pharmacokinetics of the prescribed drugs to the patient in the Emergency Department and their interactions and indications. In the ED the patient has been prescribed drugs called morphine, diclofenac, Panadol bupivacaine, and fentanyl femoral block. Panadol is considered to be distributed evenly and rapidly throughout body fluids and most tissues and has a distribution volume of around 0.9 L/kg (Raffa et al., 2018, p. 260). As current evidence suggests, around 10 to 20% of the drug is attached to red blood cells (RBCs). The primary metabolism of the drug takes place in the liver or hepatic tissues and the resultant metabolites are glucuronide conjugates and sulfates. The drug is commonly indicated for backache, muscle pain, osteoarthritis, rheumatic pain, headache influenza, and colds (Raffa et al., 2018, p. 261). Diclofenac on the other hand is considered to bind significantly with plasma albumin. The region under the AUC of concentration-time-curve of plasma of diclofenac has a proportionality to the prescribed oral dose between 25 mg to 150 mg. As the current evidence suggests, a major concentration of the said drug is taken in synovial fluid and this site is considered the proposed action site for NSAIDs (Standing et al., 2008, p. 848). The drug is commonly indicated to treat a condition like dysmenorrhea. Anti-inflammatory action-response is considered helpful for patients with osteoarthritis who are suffering from pain. Approximately 90% of morphine administered is released from the body within 24 hours of the administration period. Excretion is mainly done from urine. The half-life of the drug is around 120 minutes and deposition of the drug in fat is very common in patients. Metabolism of the drug takes place in the kidney and brain (Mashayekhi et al., 2009, p. 100). The drug is indicated to manage moderate to severe pain in patients due to acute falls or injuries. In the subsequent section of this study, a specific focus will be given to the nursing management of prescribed medication for the patient in the ED.

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Guidelines and management for ED drugs

Side effects of morphine include nausea, constipation, urinary retention, respiratory depression, pruritus, difficulty or trouble breathing, etc. Adverse side effects are severe respiratory depression, hallucinations, disorientation, vertigo, intracranial hypertension, tremor, pylorospasm, bronchospasm, heart failure, hypothermia, etc. (Duron et al., 2020).

Side effects of Bupivacaine + fentanyl femoral block are headache, diarrhea, seizure, difficulty breathing, numbness, dizziness, chest pain, etc. (Teymourian et al., 2018).

Side effects of Diclofenac PO are Nausea, diarrhea, upset stomach, constipation, dizziness, headache, vomiting, mild rash, Tinnitus, black stool, etc. Adverse effects are severe indigestion, color change in skin or lip, severe rash on the body, black stool or blood vomiting indicating GI bleed, breathlessness that can be an indication of heart failure, and severe dehydration (Haffer et al., 2022, p. 145).

Side effects of Panadol PO include fatigue, diarrhea, dizziness, headache, blurred vision, weakness, abdominal pain, rash, vomiting, burning sensation, etc. Adverse side effects are wheezing, chest tightness, and worsening progression of rash, trouble breathing, face, lip, mouth swelling, and trouble talking.

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Patient education for regular drugs

Patient education must be provided for the introduction of the medicine and the long-term effects that regular medications

The medicine Apixaban must be taken at the same time regularly, the side effects such as red or pink-colored urine, black stools, headache, chest pain, vaginal bleeding wheezing. The use of thyroxin must be as per the doctor’s indication and it could result in weight gain or loss, appetite changes vomiting or diarrhea, etc. The medicine amiodarone must be taken with food or without taking the food, and the storage and disposal guidelines of the medicine must be provided to the patient. The medicine metoprolol is a beta blocker play which reduces the chances of death due to heart failure so the patient must be advised to not take the medicine during training for heart-related conditions without a doctor’s advice. The capsule must be taken as a whole without crushing achieving it, frequent medical tests must be done to check the progress after taking this medicine.

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Conclusion

In this case study the proper identification of the deviations that Mrs. Smith has exhibited was done. Based on the clinical manifestations of Mrs. Jane Smith nursing diagnoses that were done are hypertension and fracture. Several nursing interventions were highlighted throughout the report which are specific toward addressing these diagnoses. The side effects associated with ED drugs were also mentioned. The nursing management, and patient education for both the ED drugs and regular medicines were also summarised.

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