Strategic Nursing Interventions in Orthopaedic Care

Strategic Nursing Interventions in Orthopaedic Care

Care operations within the emergency department are chaotic and fragmented. Sometimes, ED nurses have to deal with patients with undifferentiated diagnoses or with conflicting health needs. This can create a pressured and challenging environment for nurses coming out of orientation. Therefore, nurses require in-depth knowledge of managing patients with unexpected health needs and planning their care for the best outcomes. In this paper, I will present my approach to managing a client scenario who had been admitted from the ED after a vehicle accident resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions and had open reduction internal fixation of the right femur, and is a smoker. I will provide the basis for each clinical judgment to guide my action.

What is the best action to perform first from the six actions identified as part of planned client care for this particular client?

As per the planned client care, my first action is to administer 2mg Morphine IV now for breakthrough pain. The top concern for the client as per their injuries is pain. Therefore, it is important to administer medications for pain management before considering other actions in the client’s care plan to achieve favorable analgesia. Providing a 2mg Morphine IV ensures analgesic efficacy is achieved, and at the same time, it helps the side effects of morphine use. Morphine is recommended as a first-line option for pain management; however, it is also recommended to reduce the associated risks and withdrawal effects after discontinuation (Chalil et al., 2021). The low dose provided on a need-to-basis is considered the goal of the treatment, not to eradicate the pain the client is experiencing but to manage it to a level that allows for the client’s functioning.

What is the best action to perform the second of the six actions identified as part of planned client care for this particular client?

The second-best action to perform as a part of the planned client care is to input consult for pain management into the electronic order system. The input of the consult for pain management is selected as the second important action to take for this client for a number of reasons. Firstly, it will provide the necessary information for my client’s patient records. Sharing this information via the electronic system not only helps provide information on all actions taken and why they were taken, but it will also help me easily have consent for the treatments I will provide to the client throughout their pain. Electronic Health Record (EHR) systems provide ready integration of departments and sharing of medical data between medical centers and specialists, improving communication between points of care and the diagnostic process (Quinn et al., 2019). Another reason is to provide a point of reference in case complications or other health issues are identified, and a history of medications administered is needed to avoid fatal drug interactions, as well as help other physicians understand what treatments were provided to the client. The records can help avoid claims by the patients in case of unexpected outcomes. The records can also provide a point of opioid surveillance in case of future problem prescription opioid use (Carrell et al., 2020).

What is the best action to perform a third of the six actions identified as part of planned client care for this particular client?

The third best action to perform as part of the client’s planned pain management care is applying anti-embolism stockings bilaterally. The client only has one anti-embolism stocking on the left leg. Applying anti-embolism stockings bilaterally can help the patient recover from the open reduction internal fixation of the right femur. The anti-embolism stockings are important in improving and encouraging normal function of both legs’ venous and lymphatic systems, especially the right leg, which has undergone a surgical operation. Based on the current evidence on the use of anti-embolism stocking, it is essential to use the stocking as they have been proven to reduce and prevent complications such as deep vein thrombosis (DVT) related to pooling of blood after surgery (Awadallah et al., 2021). Additionally, the stockings have been found to reduce and prevent skin problems on the legs, such as pressure ulcers, neurovascular problems, wrinkles and creases, and associated skin health problems (Akyüz & Tunçbilek, 2021).

What is the best action to perform fourth of the six actions identified as part of planned client care for this particular client?

The fourth best action to perform as part of the planned patient care is to decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring. However, this first requires the reevaluation of the patient’s SpO2. The 2L Nasal Cannula can provide the needed oxygen flow rate and maintain the recommended physician SpO2 of 92% or greater. The 2L per minute flow is also average and can reduce the risks associated with high SpO2. Monitoring the patient will help them identify any extra oxygen needs and respond accordingly.

What is the incorrect action?

The incorrect action during the management of the client was to call the physician to get an order for Nicotine Patch, and report decreased urinary output with amber urine. Firstly, the decreased urinary output with amber urine may be due to dehydration. Providing the client with fluids can help resolve the problem. On the other hand, ordering a nicotine patch for a patient managing pain is not the correct action to take at the moment for various reasons. Firstly, nicotine is a ganglionic cholinergic-receptor agonist that can regulate cardiovascular (CV) and heart oxygen demands as well as body temperature, leading to vasoconstriction and restricted blood flow and risk for increased heart rate, high blood pressure, and related CV problems (Deng & Jiang, 2020). Additionally, nicotine regulates pain perception. Animal models have proven the increased effects of chronic nicotine on increased pain perception during withdrawal (Zhang et al., 2020). Additionally, prolonged nicotine exposure leads to decreased α7-nAChR expression, leading to increased experiences of chronic pain (Zhang et al., 2021). This means providing the client with nicotine can limit the analgesic efficacy of administered drugs, risking overdosing and dependency.

References

Akyüz, E., & Tunçbilek, Z. (2021). Anti-embolism stocking care protocol to prevent associated skin problems: A quasi-experimental study. Journal of Tissue Viability, 30(1), 89–94. https://doi.org/10.1016/J.JTV.2020.07.001

Awadallah, M., Gurusamy, K., Easey, S., & Parker, M. (2021). SHOULD WE CONTINUE TO USE ANTI-EMBOLISM GRADUATED COMPRESSION STOCKINGS? Orthopaedic Proceedings, 103-B(SUPP_13), 56–56. https://doi.org/10.1302/1358-992X.2021.13.056

Carrell, D. S., Albertson-Junkans, L., Ramaprasan, A., Scull, G., Mackwood, M., Johnson, E., Cronkite, D. J., Baer, A., Hansen, K., Green, C. A., Hazlehurst, B. L., Janoff, S. L., Coplan, P. M., DeVeaugh-Geiss, A., Grijalva, C. G., Liang, C., Enger, C. L., Lange, J., Shortreed, S. M., & Korff, M. von. (2020). Measuring problem prescription opioid use among patients receiving long-term opioid analgesic treatment: development and evaluation of an algorithm for use in EHR and claims data. Journal of Drug Assessment, 9(1), 97–105. https://doi.org/10.1080/21556660.2020.1750419

Chalil, A., Staudt, M. D., Harland, T. A., Leimer, E. M., Bhullar, R., & Argoff, C. E. (2021). A safety review of approved intrathecal analgesics for chronic pain management. In Expert Opinion on Drug Safety (Vol. 20, Issue 4). https://doi.org/10.1080/14740338.2021.1889513

Deng, J., & Jiang, H. (2020). Role of Nicotinic Acetylcholine Receptors in Cardiovascular Physiology and Pathophysiology: Current Trends and Perspectives. Current Vascular Pharmacology, 19(4), 370–378. https://doi.org/10.2174/1386207323666200917104920

Quinn, M., Forman, J., Harrod, M., Winter, S., Fowler, K. E., Krein, S. L., Gupta, A., Saint, S., Singh, H., & Chopra, V. (2019). Electronic health records, communication, and data sharing: Challenges and opportunities for improving the diagnostic process. Diagnosis, 6(3), 241–248. https://doi.org/10.1515/DX-2018-0036/MACHINEREADABLECITATION/RIS

Zhang, Y., Sevilla, A., Weller, R., Wang, S., Gitlin, M. C., & Candiotti, K. A. (2021). The role of α7-nicotinic acetylcholine receptor in a rat model of chronic nicotine-induced mechanical hypersensitivity. Neuroscience Letters, 743, 135566. https://doi.org/10.1016/J.NEULET.2020.135566

Zhang, Y., Yang, J., Sevilla, A., Weller, R., Wu, J., Su, C., Zheng, C., Rodriguez-Blanco, Y. F., Gitlin, M., & Candiotti, K. A. (2020). The mechanism of chronic nicotine exposure and nicotine withdrawal on pain perception in an animal model. Neuroscience Letters, 715, 134627. https://doi.org/10.1016/J.NEULET.2019.134627

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Clinical judgment is a dynamic process requiring nurses to adapt to contextual factors while processing effective interventions based on perceived and real priority needs.

Competency
Determine appropriate responses when integrating situated cognition into clinical reasoning.

Scenario

One week ago, you started your dream job as an orthopedic nurse at a Level 1 Trauma Center in a metropolitan city of 3.7 million people. The hospital has been ranked the #5 Trauma Orthopedic Specialty Unit in the United States for eight years. During orientation, you can care for one stable client per 12-hour shift. Today, you start your shift with Ryan, a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room, his first statement is, “Can someone please get me a cigarette or a patch? I have not had a smoke since yesterday morning!”

Assessment Data:

The client sits in bed with thigh-high anti-embolism stockings on the left leg.
Dressings to multiple abrasions appear dry.
Urine in Foley Bag amber colored, and urinary output in the past 2 hours 40cc
Pain reported as 8 on a scale of 10 with a goal of 5

Vital signs:

BP 130/80
Heart Rate 92
O2 Sats 94% on 4L Nasal Cannula

Blood Gases:

pH 7.32
PaCO2 53 mmHg
HCO3 22mmol/L
Pao2 84mm Hg

Physician’s Orders:

Bed Rest Only
Clear Liquid Diet
Oxygen to maintain Spo2 of 92% or greater
ABGs are repeated every 4 hours
Discontinue PCA and consult pain management
Administer tetanus and flu immunizations before discharge

As you review the assessment data and physician orders, you plan client care and determine six nursing interventions you believe are appropriate and should be completed in this order within the next hour:

Administer 2mg Morphine IV now for breakthrough pain
Apply anti-embolism stockings bilaterally
Call the physician to get an order for a Nicotine Patch and report decreased urinary output with amber urine.
Input consult for pain management into the electronic order system
Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring
Administer tetanus immunization

Content

As you write down the proposed interventions, the nurse manager checks your progress and asks you a few questions regarding your decisions. The nurse manager is disappointed and states, “One of these actions is incorrect. I want you to write down what you believe is the best choice from your list to do immediately and the action you believe is incorrect and should not be done. I will be back in 10 minutes to discuss your thoughts.”

On a document, provide detailed responses to these questions:

What is the best action to perform first from the six actions identified as part of planned client care for this particular client?
What is the best action to perform the second of the six actions identified as part of planned client care for this particular client?
What is the best action to perform a third of the six actions identified as part of planned client care for this particular client?
What is the best action to perform fourth of the six actions identified as part of planned client care for this particular client?
What is the incorrect action?