Running Head: SCENARIO 5 1

Scenario 5

University of Technology, Jamaica

College of Health Sciences

Caribbean School of Nursing

Specialized Nursing (NUR4002)

Lecturer: Mrs. Deneise Walters

Academic Year: 2023/24

Semester 1

Group 5 Members:

Orlyah Bryan 1802755

Shay-Ann Charlton 1905477

Kemara Jackson 2000875

Jannell Lawes 2001675

Melissa McLean 1703714

Date of Submission: December 7, 2023

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Scenario 5

A 40-year-old male presented to the emergency department with a history of sustaining multiple

injuries from a motor vehicle accident. He is groaning and utters, “my belly”. On assessment-

Patient is pale and drowsy but arousable to voice. He has a large bruise over the right side of his

scalp. Breath sounds over his right chest are diminished, abdomen painful to touch and there is

obvious deformity to the right ankle. His initial vital signs revealed: Pulse 126 beats per minute;

Respiratory rate 34 breaths per minute; Blood pressure 88/46 mmHg; SPO2 88% on 15L

humidified oxygen via non rebreather mask.

Questions

1. State what other aspects of the health history you would obtain and give the rationale.

Health history is a way of collecting subjective data from the patient or their family.

According to the Chippewa Valley Technical College (2023), a comprehensive health history is

done on admission by the registered nurse to investigate the following areas: demographic and

biological data, reason for seeking health care, current and past medical history, family health

history, functional health and activities of daily living and a review of body systems.

Brouhard (2022) explains that the mechanism of injury is the method used to determine

how damage or trauma to skin, muscles, organs and bones happen. Finding out the mechanism

of injury is a priority in caring for a patient. The patient or person who accompanied the patient

to the emergency department will be asked questions such as: “How did the injury occur? Where

did it occur? Did you lose consciousness?” Additionally, the nurse will ask if the patient is

currently on any medications to rule out any possible drug interactions. It is also important that

the nurse asks about any known allergies that the patient may have in order to document as well
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as select the most suitable course of therapy. Furthermore, finding out when the patient last ate

or drank is important for assessing the risk of complications if surgery or certain procedures are

needed.

Acquiring a thorough medical history is beneficial in customizing the course of

treatment, foreseeing issues and comprehending underlying medical disorders that might affect

the patient’s reaction to interventions. It helps the medical team to make well-informed decisions

about the treatment and management of patients.

2. State your likely findings of a rapid initial assessment (primary assessment – ABC etc. of

this patient. (6 marks)

When a patient presents with trauma, the emergency department nurse has the duty to do

an acute assessment. The identification of potentially fatal conditions and the implementation of

appropriate management are made possible by the primary assessment. The foundation of the

initial evaluation is provided by the abbreviation ABCDE, which also makes it simple to recall

the proper sequence in which to evaluate patients who arrive at the emergency room,

(Fundamentals of Nursing Blog, 2016).

The most crucial element to develop and maintain in order to stop hypoxia and eventually

death is the Airway. This entails examining the airway for obstruction, which is indicated by

stridor, a changing voice, and “see-saw” respiration. For this patient, he is groaning and utters,

“my belly”. The patient responding in a normal voice may be a sign that the airway is patent.

However, he may be at risk due to diminished breath sounds over the right chest. The nurse

would quickly move on to the second element which is Breathing. Essentially, this describes an

individual's ability to adequately absorb oxygen into their blood and lungs. The likely findings of
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this patient may include: Nasal flaring, pursed lip breathing, blue lips, rapid breathing (which

accounts for his respiratory rate 34 breaths per minute), and diminished breath sounds which

may indicate fluid or air in the lungs (consolidation). Immediate attention is required for

respiratory support.

The third element is the Circulation assessment. This entails checking the body for signs

of inadequate blood flow. The nurse may palpate to check the time of capillary refill in the limbs

of the patient which may be greater than 3 seconds. Furthermore, she would assess the central

pulses of the carotid and femoral artery of this patient which may be rapid and irregular in

pattern. Lastly, the nurse would check the patient’s blood pressure in both arms. As indicated by

the scenario, the patient has tachycardia (pulse of 126 beats per minute) and hypotension (blood

pressure of 88/46 mmHg), indicating compromised circulation. Hemodynamic support is

essential.

The fourth element which the nurse will assess is Disability. To ascertain the patient's

status, a quick evaluation of their level of consciousness (LOC) is performed. This is done by

applying a physical exam known as the Glasgow coma scale. The likely findings of this would

be GCS 12/15 (Eye movement 3, Verbal response 4, Motor response 5). However, due to the

large bruise over the right side of the scalp which may be indicative of a head injury, further

neurological assessment will be required in the secondary survey.

The final element would be Exposure. There is an obvious deformity to the right ankle,

and the abdomen is painful to touch therefore additional examination is needed to assess the

extent of injuries.
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3. Triage - State what ESI level would you assign this patient and give justification for your

answer. (4 marks)

According to Kirvan and Wigmore (2023), the term triage originates from the French verb

“trier” which means “to sort.” The triage procedure determines how critical a patient’s condition

is. Based on the patient's health history and present state, the triage registered nurse may use the

Emergency Severity Index (ESI) to determine each patient’s priority level. The ESI is a

standardized triage system which consists of five (5) levels: Level 1- Resuscitation or Immediate

life-threatening, Level 2- Emergency or Imminently life-threatening, Level 3- Urgent or

Potentially life-threatening, Level 4- Semi-urgent or Situational Urgency and Level 5- Non-

urgent or Less Urgent (St. Mary’s Regional Medical Center, 2022).

Level 1-Resuscitation or Immediate life-threatening is the ESI level that can be assigned to

the 40-year-old male patient in the scenario. Firstly, he is in a state of severe respiratory

compromise as evidenced by his pale appearance, diminished breath sounds over his right chest,

abnormal vital signs: pulse 126 bpm, respiratory rate 34 bpm, blood pressure 88/46 mmHg and

SPO2 88% on 15L humidified oxygen via non rebreather mask. Secondly, the patient is

exhibiting signs and symptoms of severe shock including: tachycardia (126 bpm), hypotension

(88/46 mmHg), he is pale and drowsy but arousable to voice. Thirdly, he was presented to the

emergency department with a history of sustaining multiple injuries from a motor vehicle

accident that could have caused multisystem trauma as evidenced by patient is groaning and

utters, “my belly”, he has a large bruise over the right side of his scalp, diminished breath sounds

over his right chest, abdomen painful to touch and there is obvious deformity to the right ankle;

his initial vital signs revealed: pulse 126 bpm; respiratory rate 34 bpm, blood pressure 88/46

mmHg; SPO2 88% on 15L humidified oxygen via non rebreather mask. Finally, a mildly altered
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level of consciousness (LOC) is indicated by his GCS of 12/15: E3 (Patient is drowsy but

arousable to voice), V4 (He is groaning and utters, “my belly” and he has a large bruise over the

right side of his scalp suggesting that he may have suffered a contusion and/or concussion, which

may affect brain function and cause confusion, memory loss, speech impediment, vision

problems or balance issues) and M5 (He has a large bruise over the right side of his scalp, his

abdomen is painful to touch and there is obvious deformity to the right ankle).

4. State your likely findings of the focused assessment of the major system/systems

affected– give no more than two systems. Give the pathophysiological basis for the findings.

(2 marks)

System #1: Respiratory System

Right and left sides of the thorax are asymmetric. Skin is pale and diaphoretic. Chest expansion

is unequal. Skin is cold, tactile and vocal fremitus is decreased on the right side of the chest.

Diaphragmatic excursion is normal 4cm. Dullness noted on percussion of the lower lobe of the

right lung. Breath sounds over the right lung are diminished.

Pathophysiological basis: The right lung is unable to expand due to accumulation of blood at its

base due to trauma to the right side of the chest, which causes diminished breath sounds.

System #2: Abdomen

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Asymmetrical or there is asymmetrical abdominal enlargement noted. Periumbilical bruising

(Cullen’s sign) noted on inspection. Bruit auscultated over iliac, renal and aortic arteries.

Extreme tenderness and guarding noted on light palpation of upper right and left quadrants.

Pathophysiological basis: These findings may be signs of internal hemorrhage or contusion of

organs located in the abdominal cavity caused by blunt trauma to the abdomen.

5 (a) State the major diagnostic tests that would be done for this patient and give the

rationale. (4 marks)

I. Head Computed tomography (CT) scan: Take a visual representation inside the head

and neck. It gives doctors a look of the skull, brain, eyes, nasal passages, veins, arteries,

and tissue (Rich, 2022).

Rationale: To detect if there is serious head injury, stubborn headaches, brain and skull

birth defects, brain diseases, and stroke. Doctors decide when a person needs a CT head

scan.

II. Chest X-ray: A type of radiation that passes beams through the chest, including the

heart, lungs, airway, and blood vessels that are absorbed by these body structures to

generate pictures of the chest (Mayo Clinic, 2022).

Rationale: To visualize why breath sounds on the right side of the patient are diminished,

Eg: fluid in lungs/lung spaces, collapsed lung

III. Electrocardiogram: A graph that measures and records the electrical activity of the heart

(Mohr et al., 2023).

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Rationale: To detect if there is any damage to heart muscle tissues causing the decreased

blood pressure and increased heart rate

IV. Abdominal Ultrasound scan: Examines the internal organs of the abdomen such as

liver, gallbladder, pancreas, bile ducts, spleen and abdominal aorta (Health Direct, 2022).

Rationale: To visualize and check the abdomen cysts, tumors, collection of pus

(abscesses), obstructions, fluid collection, blockages (clots) in blood vessels, infection,

aortic aneurysm and stones in the gallbladder, kidneys, and ureters.

V. Complete Blood Count (CBC): Evaluates various parts of the blood such as red blood

cells that transport oxygen from the lungs to the rest of the body; white blood cells that

fight infections and other disorders; platelets help your blood coagulate and halt bleeding;

hemoglobin, a protein in red blood cells that transports oxygen from the lungs to the rest

of the body and hematocrit measures the proportion of blood that is made up of red blood

cells and size of red blood cells (National Library of Medicine, 2022).

Rationale: To provide a baseline for treatment and to detect a variety of conditions such

as infections, anemia, diseases of the immune system, bleeding disorders and blood

cancers.

VI. Arterial Blood Gas (ABG) test: Measures the amounts of carbon dioxide and oxygen in

your blood by taking a sample from an artery in the body. It also measures the pH

balance, or the ratio of bases to acids, in the blood. (Cleveland Clinic, 2022)

Rationale: To provide further details on why the patient’s SpO2 is so low even while on

15L humidified oxygen via non rebreather mask.

(b) Interpret the likely findings. (2 marks)

SCENARIO 5 9

● Head CT shows a contusion which appears as a small hemorrhagic lesion over the right

temporal lobe.

● Chest X Ray shows signs of occupation by pleural fluid, meniscus of fluid blunting the

costophrenic angle or diaphragmatic surface and tracking up the pleural margins of the

right chest wall. With pleural fluid with a hematocrit of greater than or equal to 50% of

the peripheral blood hematocrit.

● Electrocardiogram shows sinus tachycardia with a normal upright P wave in lead II

preceding every QRS complex.

● Abdominal Ultrasound scan shows hemorrhaging from a rupture of an enlarged section

of the aorta.

● CBC lab results show normal values for red blood cell count, hemoglobin,

hematocrit,white blood cell count and platelet count are all within normal range.

● ABG test shows pH 7.32, PaO2 70 mmHg and PaCO2 47 mmHg.

Diagnosis

1. Prioritize this patient’s needs (2 marks)

Need 1 - Elimination and Exchange

Need 2 - Comfort

Need 3 - Activity/Rest

2. Formulate three (3) priority nursing diagnosis for this (3 marks)

1. Impaired gas exchange related to decreased oxygenation secondary to multiple injuries,

evidenced by diminished breath sounds over the right chest and low oxygen saturation

(SPO2 88%).
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2. Acute pain related to activation of nociceptors secondary to traumatic injury as evidenced

by the patient groaning and uttering, “my belly”, his abdomen is painful to touch and

there is obvious deformity to the right ankle.

3. Ineffective peripheral tissue perfusion related to trauma secondary to the motor vehicle

accident as evidenced by deformity to the right ankle, decreased blood pressure (88/46

mmHg) and absent pulse of the posterior tibial artery and dorsalis pedis artery.

3. Include one {1} risk diagnosis ( 1 mark)

Risk for Shock as evidenced by decreased blood pressure (88/46 mmHg) and increased heart rate

(126 beats per minute).

Planning

4. Outline objectives of care (3 marks)

The objectives of care for the 40-year-old male involved in a motor vehicle accident are:

1. Immediate Stabilization: Prioritize stabilization of vital signs, especially addressing the

low blood pressure and respiratory distress.

2. Airway Management: Ensure a patent airway and consider advanced airway support if

respiratory distress persists.

3. Breathing Assessment: Evaluate and address diminished breath sounds, potentially

indicating a chest injury. Administer oxygen to improve oxygen saturation.

4. Circulatory Support: Administer intravenous fluids to address hypotension and support

perfusion.
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5. Pain Management:Address pain, particularly in the abdomen and ankle, to improve

patient comfort and cooperation.

6. Neurological Assessment: Monitor and manage any signs of altered mental status,

considering the head injury and potential intracranial issues.

7. Focused Abdominal Examination: Perform a detailed abdominal examination to

identify and manage any internal injuries, given the patient's complaint of abdominal

pain.

8. Orthopedic Assessment: Evaluate and immobilize the right ankle deformity to prevent

further injury and pain.

9. Diagnostic Imaging: Order appropriate imaging studies (e.g., CT scans) to assess the

extent of injuries, especially head, chest, abdomen, and ankle.

10. Consult Specialties: Engage relevant specialists (e.g., trauma, orthopedics) for further

evaluation and management of specific injuries.

11. Continuous Monitoring: Maintain close monitoring of vital signs, neurological status,

and pain levels.

12. Timely Reassessment: Periodically reassess the patient's condition and adjust the

treatment plan accordingly.

Overall, the primary focus is on stabilizing the patient, addressing life-threatening issues and

initiating a comprehensive assessment to guide further interventions.

Acute Pain Care Plan: Patient Outcomes

1. Patient will express feeling of comfort and relief from pain.

2. Patient will rate the pain at a level that is satisfactory for example, less than a 3 or 4 on a

0-10 rating scale.

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3. Patient will exhibit signs of improved health, including vitals within normal range for

respiratory rate of 12-20 bpm, pulse rate of 60-100 bpm, blood pressure of 120/80mmHg

and relaxed muscle tone or posture.

4. Patient will verbalize non-pharmacological strategies to relieve pain such as guided

imagery; distraction with reading, television, music, games or conversations; breathing

exercises and hot/cold therapy.

Implementation

5. Identify any pain management needs – if applicable (2 marks)

Fractured Ankle:

● Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen

can help manage pain and reduce inflammation.

● Rest and Elevation: Elevate the injured ankle to reduce swelling, and avoid

putting weight on it.

● Ice: Applying ice to the affected area for short periods can help alleviate pain and

swelling.

Abdominal Aortic Aneurysm:

● Pain Control: Pain management for an abdominal aortic aneurysm may include

medications such as opioids.

● Surgery: In some cases, surgical intervention may be required to repair the

aneurysm and alleviate pain.

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6. State how the pain would be best managed. (1 mark)

Due to the nature of the injury, it would be best to use Opioids for pain relief. According

to Watson (2023), “Opioids are a type of pain medication used to treat moderate to severe pain

that do not respond to other medications”. Morphine or pethidine are common opioids used to

relieve severe pain. These drugs can be given orally, intramuscularly or intravenously. Morphine

can be given 10mg tds while Pethidine can be given 75mg.

7. Outline implementation of care –give at least four (4) interventions with rationale

(4 marks)

1. Administer analgesics as prescribed by doctor: To relieve pain

2. Apply ice pack to right ankle: To reduce inflammation and swelling

3. Elevate affected area above the heart: To encourage venous return

4. Educate the patient about the use of diversional therapy such as listening to music: To

redirect patient’s focus from the pain and reduce stress and anxiety

8. State three (3) ethico- legal principles that would be utilized in the care of this patient. (6

marks)

1. Autonomy: Taking into account the patient’s capacity, respecting their autonomy entails

including them in decision-making to the greatest extent feasible. In this case, the

cognizant patient can make decisions regarding their care by being told about treatment

options and associated dangers.

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2. Beneficence: According to the beneficence principle, healthcare professionals must

behave in the patient’s best interest, seeking to maximize advantages and reduce

disadvantages. In this instance, the principle of beneficence is upheld by timely and

appropriate measures including treating respiratory distress and stabilizing vital signs.

3. Non-maleficence: The principle of nonmaleficence places emphasis on the duty to “do

no harm.” Healthcare professionals must carefully weigh measures to prevent patient

damage or unnecessary risks. An example of adhering to the principle of non-maleficence

would be making sure that the right ankle deformity is properly immobilized and

avoiding operations that could cause injuries to worsen.

Evaluation

9. State the likely outcome of care given to this patient based on the Care plan formulated.

(3 marks)

Within 8 hours of nursing and collaborative care, the patient verbalized a relief in pain

rating at 4/10 on pain scale. Patient also stated that listening to music took his mind off the pain

and the application of the Ice pack to his ankle helped to reduce the swelling. Vitals decreasing:

T - 36.8 °C, P - 100 bpm, R - 25 bpm, BP - 110/68 mmHg. Patient appears more relaxed with

limited guarding of the abdomen and grimacing of the face.

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References

Brouhard, R. (2022, May 12). Understanding mechanisms of injury helps determine severity of

trauma. Verywell Health. https://www.verywellhealth.com/mechanism-of-injury-

1298672

Chippewa Valley Technical College. (2023, August 28). 2.3 components of a health history.

Wisconsin Technical College System. https://wtcs.pressbooks.pub/nursingskills/

chapter/2-3-components-of-a-health-history/

Cleveland Clinic. (2022, February 18). Arterial Blood Gas (ABG): What It Is, Purpose,

Procedure & Levels. Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/

‌22409-arterial-blood-gas-abg

Fundamentals of Nursing Blog. (2016, December 28). Primary and secondary assessments.

Nursing 101 Fundamentals of Nursing Blog. https://fundamentalsofnursingblog.

wordpress.com/2016/12/28/primary-and-secondary-assessments/

Health Direct. (2022, July 13). Ultrasound. Health Direct.

https://www.healthdirect.gov.au/ultrasound#what-is

Kirvan, P., & Wigmore, I. (2023, March 27). What is triage in IT?. TechTarget.

https://www.techtarget.com/whatis/definition/triage#:~:text=The%20term%20triage%

20comes%20from,of%20soldiers%20wounded%20in%20battle.

Mayo Clinic. (2022, March 5 ). Chest x-rays. Mayo Clinic.

https://www.mayoclinic.org/tests-procedures/chest-x-rays
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/about/pac-20393494

Mohr, C., Morgan, D., Dunsford, C., Sebaratnam, D., Bandera, A., & Patterson, C. (2023,

November 29). Electrocardiogram - ECG. MyDr.com.au. https://mydr.com.au/tests-

investigations/electrocardiogram-ecg/

National Library of Medicine. (2022, April 4). Complete Blood Count (CBC). Medline Plus.

https://medlineplus.gov/lab-tests/complete-blood-count-cbc/

Rich, R. (2022, July 6). CT Head Scan. Family Doctor. https://familydoctor.org/ct-head-scan/

St. Mary’s Regional Medical Center. (2022, April 6). Emergency care - what to expect.

St. Mary’s Regional Medical Center.

https://www.stmarysregional.com/services/emergency -services/emergency-care-

what-to-expect#:~:text=The%20triage%20registered%20

nurse%20might,Level%205%20%E2%80%93%20Non%2Durgent.

Watson, S. (2023, September 22). Opioid (narcotic) pain medications: Dosage, side effects, and

more. WebMD. https://www.webmd.com/pain-management/narcotic-pain-medications