Nursing Diagnosis

Nursing Diagnosis
Student Name
Student ID
University Name



Contents
Introduction……………………………………………………………………………………………………………………………….3
Background………………………………………………………………………………………………………………………………..4
Management……………………………………………………………………………………………………………………………..5
Potential complications and post-operative education ……………………………………………………………..13
Involvement of the interdisciplinary team …………………………………………………………………………………14
Conclusion………………………………………………………………………………………………………………………………….14
References ………………………………………………………………………………………………………………………………..15



Introduction 
In the given case study, we need to identify the nursing process while managing the wound management and the medical history of the patient (Ackley, 2018). We would be further evaluating the discussion around the nursing management and would also create an analysis related to patient post-surgery. There would be careful in general and would further interpret prioritized nursing diagnosis/ problems. 
The nursing process is one of the systematic and scientific approaches that help in managing a range of patients. Through this report, we would be understanding how the nursing process can help in while taking care of the post-surgery patients that have been admitted.
The nursing process involves a healing process and is used as a tool to provide a quality of patient care. The nursing process has essential steps such as the assessment, diagnosis, planning, implementation, evaluation. 

Background 

Identify 	Fall from the bicycle during the marathon, transported through ambulance to ED
Situation	Josie has a pain in the right lower leg, resulting in the deformity, gradually leading to the swelling, and a 10cm lacerated wound. Under the observations checked the T-36.4oC, HR-90bpm, RR-22pm along with the BP-136/72mmHg, O2-95% RA, and pain score 10/10 on movement (Cabaço, 018). 

Observations	Josie has shown reactions to the Penicillin along with the oral contraceptive pill, but so far no problems.
Background	Josie needs to have an opioid analgesia during the ED. From the x-ray shows the fracture within the Right tibia and fibula. Subsequently the orthopedic team, did a quick operation upon the surgery in order to reduce the open reduction along with the internal fixation (ORIF) with respect to the fracture.

Agreed Plan	The patient as such returned from the 12.30 hrs post-op orders as per the routine observations, wound dressing which needs to be for 72hrs.
Also additionally there needs to be a bung IVT placed with the current bag completed and also a neurovascular observations within the two-hourly duing the first 48-hours, and also need to put on non-weight having crutches. 
So far the condition is drowsy but alert to voice; and also has a dressing upon her right lower leg requiring a minimal sanguineous ooze evident. 
The condition is: T-35.5oC, HR-66bpm, RR-16pm, BP-109/71mmHg, O2-97% via HM at 6LPM, and pain score 2/10. 
Given a quick prophylactic Ceftriaxone 2g IV during surgery. 
Also anesthetist has given the medication of Paracetamol 1g IV/PO 6 hourly, Ibuprofen 400mg PO TDS, Tramadol SR 100mg PO BD prn, and Ceftriaxone 2g IV/ IM 6 hourly for 2 further doses. IV Compound Sodium Lactate 1L which is at six-hourly rate with respect to the Josie's left arm.
Read Back	Need to provide timely medication and monitor the patient current condition.

Management 
To provide quality care to the post-surgery patient, the nurses need to follow an evidence-based practice. In the postoperative surgery, it helps the nurses to identify and address problems which are related to the individual patient. It is important as a nursing student to understand the preoperative condition of the patient and apply suitable nursing process (Butcher, 2018). There should be a comprehensive plan of care, which would be based on the assessment along with the focus on the outcomes which would help in the improved care and the reduced pain. The main aim is to help women patient have a faster recovery from the given major surgery.  There should also be a progressive goal associated that would provide nursing care with respect to the patients which can help in achieving the procedure to be evaluated. Through this report, we would be understanding the nursing process and would also help in delivering nursing care to the patients.
Assessment of Data
Subjective Data
Complain of pain in the patient right lower leg, causing a deformity along with the significant swelling  (Caldeira, 2016). A surgery for open reduction and internal fixation (ORIF) of the fracture. It has been observed from the post-op orders to check the routine observations wound dressing in order to keep the 72hrs and also making the bung IVT to check the neurovascular observations. Current condition is drowsy but alert and responsive to voice. So far dressing on the right lower leg, with minimal sanguineous ooze evident. 

Objective
The vital signs of the patient is T-36.4oC, HR-90bpm, RR-22 


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