Introduction
This article presents the case of O.J., a 67-year-old Caucasian male admitted to the neuro ICU following a motor vehicle crash. O.J. has multiple injuries, including rib fractures, mandibular and nasal fractures, tongue lacerations, and head and torso lacerations. This article focuses on O.J.’s nursing diagnosis, interventions, collaborative management, therapeutic modalities, and reflections on the nursing role.
Patient Assessment
O.J.’s assessment reveals a history of smoking, daily alcohol consumption, and hepatitis C. He has a noticeable scar on his back, indicating a previous back surgery. On arrival at the ER, O.J. presented with multiple rib fractures, mandibular and nasal fractures, and lacerations from being ejected from the car. His vital signs were relatively stable, but he displayed signs of confusion due to head trauma. O.J. experienced pain, nasal swelling, and bleeding.
NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries
Nursing Diagnoses and Outcomes
The nursing diagnoses for O.J. include imbalanced nutrition, ineffective breathing pattern, and risk for infection. The desired outcomes are improved oral intake, maintenance of a patent airway, prevention of disease, and overall improvement in the patient’s well-being. Nursing interventions include effective pain management, encouragement, support during meal times, deep breathing exercises, wound care, and observation for signs of infection.
Routine Nursing Management
To address O.J.’s pain, a Patient-Controlled Analgesia (PCA) pump was utilized, allowing him to regulate the administration of morphine and achieve better pain control. Enteral nutrition was also provided to ensure O.J. received adequate nutrition for faster wound healing. Despite his reluctance to eat, the nursing staff provided attention and assistance during meals to alleviate anxiety and pain, promoting a more comfortable eating experience.
NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries
Collaborative Management
Collaborative interventions involved various healthcare team members. Occupational therapy assisted O.J. with assistive devices for eating and drinking, while physical therapy promoted mobility and pain relief. Wound management, surgical services, and nutritional consultation were also incorporated into O.J.’s care plan to facilitate wound healing and overall recovery.
Therapeutic Modalities
Therapeutic modalities employed for O.J. included reducing swelling associated with the nasal fracture. Swishing with Peridex solution, an oral antimicrobial rinse, helped protect the open wound in the tongue and provided pain relief. These modalities contributed to the patient’s comfort and facilitated the healing process.
NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries
Nursing Role Reflection
Various communication styles were observed during the patient’s care, including passive, aggressive, passive-aggressive, and assertive. The assertive communication style was the most effective in promoting open lines of communication, fostering relationships among the staff, and ultimately facilitating better patient outcomes. Additionally, caring for comatose patients posed a challenge, highlighting the importance of providing compassionate and empathetic care to meet their needs.
Teamwork was another key facilitator observed, as the nursing staff collaborated to provide optimal patient care. The support and guidance from senior staff nurses and other healthcare professionals contributed to consistent, high-quality patient care. However, a recommendation was made to increase the availability of lifts on the floor to enhance patient and nursing staff safety during patient transportation.
Conclusion
O.J.’s case exemplifies the importance of effective communication, collaboration, and comprehensive care in promoting positive patient outcomes. The nursing interventions, collaborative management, therapeutic modalities, and reflections on the nursing role provide valuable insights for future practice. Nurses can enhance patient care and improve patient outcomes by adopting assertive communication, prioritizing patient needs, and fostering teamwork.
