Pramesh Gurung Taxsari

Born 10/14/1994 in Jhapa, Nepal

303-435-9859

pramesh.taxsari767@gmail.com and pranesh767@yahoo.com

Soccer Coach at Allegany College of Maryland

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Client #1 – Gladys Burkhart

Gladys is a 16-year-old female who presented to the Emergency department via ambulance following a trauma involving farm equipment where she was struck while helping harvest produce in the fields. She sustained fractures of her left radius and ulna and left sided pelvic fractures of the ischium and pubis where the steel wheel rolled over her lower torso. She sustained a left pneumothorax secondary to rib fractures, and a ruptured spleen. A chest tube was placed in the emergency department. She was emergently taken to the operating room to stabilize injuries and set fractures. Bleeding was stabilized. Hgb 6.8 She received 2 units of packed red blood cells in the operating room. She has a large laceration of her left thigh, debridement in the OR. A negative pressure wound vac placed. She was initiated on IV antibiotic, Zosyn 3.375 g q 8 hours.

PMH: non-contributory

Allergies:  No known allergies

Admission Medications:  No home medications prior to admission.

Social History:  She lives at home with her parents and 4 siblings. She is the oldest child and helps care for her younger siblings. She is also helps on the family farm where they grow produce for local sale. Her family lives in a 2-story home where her bedroom and full bathroom are on the second floor. There is a ½ bath on the main living level. There are 3 steps to enter the home.

Insurance:  Mennonite Mutual Insurance

Hospital Course: Gladys was admitted to the neurosurgical trauma unit for 2 days. Post-op day 1 labs:  Hgb 9.2, WBC 10.2.   VS – Respiratory rate 18, Temp 99.1, BP 102/66, HR 88. Chest tube was removed post-op day 2. She was then transferred to a step-down unit. She participated in PT and OT sessions during her admission. On day 4 she went back to the operating room for closure of her (L) thigh laceration requiring 30 staples and covered with xeroform gauze covered with non-adherent gauze and a roller wrap. During her recovery she complained of blurry vision and a scratchy feeling of her left eye. Evaluation determined a corneal abrasion of her left eye sustained during surgery. She was cleared for discharge to home with her parents on day five. IV antibiotics were discontinued. VS stable as follows: BP 108/68, HR 68, Respiratory rate 16, Temp 98.3 F

Discharge Orders as follows:

• Medications
  • Enoxaparin 40 mg SQ daily
  • Diclofenac 0.1% 1 drop, 4 times per day for 2-3 days
  • Percocet 5-325mg po every 6 hours prn for pain
• Equipment and Supplies
  • Durable medical equipment for home: donut seat cushion, tub bench, walker with left upper extremity platform
• Follow Up appointments/Referrals
  • Home health: PT, OT, nursing for wound cleansing, assessment, and dressing changes every other day with stitch removal on day 7. Orders for xeroform, non-adherent dressing, gauze wrap, and staple remover included
  • Follow up with primary care physician in 1-2 days
  • Referral for ophthalmology to evaluate corneal abrasion 3 days
  • Follow up with orthopedic surgeon 2 weeks

Slide One (Cover page)

Slide Two (Introduction of the client)

In this case, the client/patient (Gladys Burkhart) lives with her parents and four siblings in a 2-storye home. She helps her parents with farm work and taking care of her siblings. However, she was presented to the emergency department after a traumatic accident on the farm while harvesting. She sustained multiple fractures necessitating admission to the neurosurgical trauma unit for a surgical operation. She had no significant medical issues in the past. Upon discharge, she was placed under enoxaparin, diclofenac, and Percocet medications. She required durable medical equipment for use at home and medical referrals and appointments for managing her condition effectively.

Slide Three (Collaborative care needs)

Gladys requires effective interprofessional collaboration to improve her health status after discharge. The required team members include nurses for home health, primary health physician, ophthalmologists and orthopedic physicians. This team will enable effective follow-up appointments, diagnostic tests, and effective home health for the patient. The team members conduct differentiated tasks such as patient care by the nurses, screening of health status by the primary care physicians, eye health by ophthalmologists, and joint management by orthopedists.

Slide Four (Client’s safety needs)

After hospital discharge, patients should follow effective safety practices to enable a successful healing process. In this case, the client requires post-discharge surveillance to overcome the possibility of health problems emerging after the surgery. She also requires effective transition care from the nurses to enable the success of the laid down home health practices. Due to potential sensory deficits, the client requires regular physical exercises to maintain blood flow in the eyes, rinse repeatedly with clean water, and blinking regularly to reduce the chances of eye complications from cornea abrasions. There is also the need for community safety considerations such as reducing exposure to hazardous materials to effectuate the treatment and healing processes.

Slide Five (Nursing considerations)

The effectiveness of the laid down safety concerns relies heavily on nursing considerations. In this case, the appropriate nursing considerations for managing Gladys’ condition include timely communication and relationship development between the healthcare providers and the relatives, effective transition care, and reduced exposure to hazardous materials.

Slide Six (Medication teaching)

Gladys was exposed to enoxaparin, diclofenac, and Percocet medications. However, Percocet is an effective medication for managing pain. Therefore, diclofenac and enoxaparin played a pivotal role in fostering effective patient treatment and care. The mechanism of action of enoxaparin involves binding and potentiating the drug to anti-thrombin III to overcome the activity of Xa factor while diclofenac halts prostanoids synthesis. However, these medications have side effects such as anemia, bleeding, thrombocytopenia, and serum aminotransferase elevation for enoxaparin and increased blood pressure, sweating, and constipation for diclofenac. As such, there is a need for nursing considerations such as assessing bleeding, hemorrhage, excessive anticoagulation, skin color, lesions, and renal impairments. These considerations provide an effective basis for managing Gladys effective and efficiently after hospital discharge.

Slide Seven (References)