Marita was transferred to the orthopaedic ward from surgery theatre , as she had fracture due to falling, last night at 10:30pm. It is now the following morning and you are assigned to care for Marita. You assess Marita at 08:00 hours and your assessment findings are:
She is awake and alert. She is orientated to time, place & person. Her right eye is bruised and almost shut due to an extensive haematoma. She is quite teary & asks if she is going to be ugly due to the facial grazes and her other scars. She's extremely worried she'll never get full use of her right arm back. She is also very concerned that she won't be able pay for this as she's not covered by Medicare.
There is blood staining the dressings on her leg. The right leg drain has about 70ml of frank blood in it. Her right arm is swollen and bruised. The fingers on her right hand are also swollen. She has good movement and normal sensation in the fingers of her right hand. The skin is the same colour as her left hand apart from some bruising.
The fingers to her right hand are cool to touch, and the capillary refill time is 3 seconds. Marita is complaining that the cast feels tight.
Her vital signs are: Temperature: 37.6C, Pulse: 115 & regular, Blood Pressure 92/58 mmHg, Respirations: 20 & shallow, Oxygen Saturation: 95% on 3LNP. She says it hurts to breath.
She is complaining of a dry mouth and being thirsty. There is no record of her passing urine since her return from surgery. Marita can't remember when she last used the toilet.
She did not eat much of her breakfast but drank some of the orange juice and half a cup of coffee. She said it hurt her face to eat and the coffee was cold and not real coffee. She has a PCA in place and says her pain is bearable at the moment if she doesn't move too much or try to breathe deeply or cough.
Her PCA and IVT are connected to the cannula in her left arm. She has a litre of Normal Saline running at 40mls/hr.
1. Identify and justify three (3) important health issues that need to be address. Identify and explain the significance of the clinical cues you have used to prioritise your selection.
2. Provide one SMART Nursing goal each for three health issues identified.
3. Provide two nursing interventions on the basis of current evidence-based literature and explanations of the actions to manage each of the health issue.