Analysis in the Case of Maggie with a Fractured Neck of Femur

” Assessment is the first stage of the nursing process, in which data about the patients’ health status is collected and from which a nursing care plan can be devised” (Oxford dictionary for Nurses 2008). This assignment will critically discuss the assessment and planning of care in relation to case study of Maggie. Here the assignment will also discuss the effective assessment tools that are used to assess current the health condition and holistic needs of Maggie by discussing the rationale, benefits and challenges of using of these assessment tools in Maggie’s case.

Maggie, a 73 years old lady has been admitted to the emergency ward with a fractured neck of femur and head injury after a fall. Three days ago, Meggie has had a surgery for her fractured neck of femur. Meggie does not have an appetite that may cause deterioration in post-operative wound healing. To put it another way lack of nutrition caused by poor diet would have a negative impact on wound healing (Ryan, 2013) (Stechmiller, 2010).

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On admission of Maggie, her wound is assessed by using Bates-Jensen Wound assessment tool (BWAT). This is one of the most effective wound assessment tools that health professionals use in modern health care field to assess the overall status of patent’s wound thereby tracking the healing process (McCaughan et al. 2018). BWAT consists of 15 items that are used by the nurses in Maggie’s case to observe the status and assess the measurement of her wounds. BWAT has 13 score items that are used to check the severity and chances of deterioration of patient’s wound (Elia, 2017). The higher the score of the wound is, the higher the severity or chances of deterioration of wound. In case of Maggie the BWAT score is 8 which shows that her wound is severe which needs immediate treatment otherwise there is high chances of further inflammation of the wound by bacterial colonisation (Onyekwelu et al. 2017). By using this BWAT, size, edges, necrotic tissues, depth of the wound, exude type, peripheral tissues, oedema and skin colour of the surrounding region of the wound have been assessed [NICE, 2018]. Based on the score and the assessment result of the BWAT, doctors have made an effective treatment and care plan for treating Maggie’s wound. Under this care plan the regular observation is done by the nurse to check the status of the wound. NMC (2018) mentioned that, while treating surgical wounds, nurses must have clear knowledge on how to prevent the surgical site infection [SSI] at the wound [NMC, 2018]. In case of Maggie, a regular hydrogel dressing has been performed by nurse to ensure that there is no chance of further infection or bacterial colonisation at the wound site.

Another important assessment tool that is used in case of Maggie is MUST tool. Malnutrition Universal Screening Tool (MUST) is widely used by care professionals to pass through five step process for checking whether the patient is under the risk of malnutrition (Fernández-Torres et al. 2020). NICE (2018) mentioned that, in case of wound healing there is strong association of proper nutritional and dietary plan. PHE (2018) recommended, malnutrition can be considered as the major cause of delayed healing of surgical wound. This is because malnutritional is associated with different health issues such as fast weight loss or gain, metabolic dysfunction and abnormal BMI which impacts on the ability of body’s resistance against the infection at wound site (Thomas et al. 2019). In case of Maggie, nurses use MUST tool to check three different biological parameters such as her BMI, presence of acute illness and weight loss in the last six months. The higher the MUST score is the more the patient would be at the risk of malnutrition which would enhances the chances of further surgical site infection at the wound site. Maggie’s MUST score is 3 which shows that she has moderate risk of malnutrition. By checking the BMI, it is seen that Maggie’s BMI is higher than that of the normal range and she has a significant weight loss of 3 kgs in the last 6 months. The MUST assessment shows that Maggie does not suffer from any acute health condition which is positive sign for the fast recovery of her wound (Coccia and Rozzini, 2017). Based on the result of MUST assessment, dietician prescribes a healthy and nutritional diet to Maggie which will boost her immune system facilitating the fast healing of her wound. Additionally, Maggie is prescribed to take the antibiotics on regular wise till the course is completed.

For conducting effective wound management for Maggie, TIMES (tissue, infection, moisture, edge of wound and surrounding skin) model is used by nurses (Nasreen et al. 2020). NICE (2018) mentioned that along with assessing the status of wound and developing an effective dietary plan for patients with surgical wound, an effective wound management is crucial for fastening the healing process of surgical wound [NICE, 2018]. NMC (2018) mentioned that, nurses must use the effective and highly relevant tools or model in conducting a systematic wound management that will minimise the further infection at the wound site. By using this model nurses check the appearance of wound bed, the severity of inflammation at the wound site, the moisture imbalance in the exudes and the colour and the status of the skin surrounding the wound (Maurício et al. 2018). By using TIMES tools nurses first perform Debrisofting of skin (by using the debrisoft wound healing process) and then use the aqua-hydrogel dressing for minimising the chances of further bacterial colonisation at the infection site.

All these assessment tools that are used in treating the surgical wound in case of Maggie are effective and appropriate. The Bates-Jensen Wound assessment tool (BWAT) is proved to be highly effective in relation to check the size and depth of wound, the nature and status of wound, the moisture at site condition of exude, type of the wound tissues and the standard of the wound bed (Geoghegan et al. 2021). The challenges that nurse face while implementing this tool in Maggie’s case are the lack of expertise of health care staffs to operate this tool, the poor cooperation from the senior nursing professionals while using the Likert tool to check wound score and lack of face-to-face communication with doctors and surgeon while implementing this assessment tool.

MUST tool is also proved to be highly effective in case of Maggie, which enables nurses to check whether she suffers from malnutrition which is strongly associated with her wound healing process (Wang et al. 2020). This tool is highly effective for providing up-to-date information regarding the nutritional needs and dietary plan for Maggie that are important for eliminating the risks of malnutrition (Klemenc-Ketis et al. 2020). The challenges faced by nurses while implementing this MUST tool is that this tool only prioritises the nutritional intake and dietary routines of patients while developing the care plan for wound healing but it does not consider the other important factors that are also associated with risks of malnutrition such as irregular lifestyle, lack of social support and the cultural trend.

TIMES model is highly effective in case of Maggie to maintain an effective wound-management thereby reducing the pain and the chances of infection at the wound site (Nasreen et al. 2020). Although this tool is effective but lack of skill and knowledges of nurses and other healthcare staffs in collecting the wound tissues, proper dressing technique and the appropriate compression therapy pose barriers on the effective implementation on this tool.

Recommendations for this case study of Maggie for improving the overall assessment and management of surgical wound are as follows:

Effective assessment, dressing and compression therapy should be used by nurses in maintaining an aseptic environment surrounding the wound site which will reduce the chances of further infection at the wound site of Maggie. In this context nurses must have the clear and good knowledge as well as expertise in using the appropriate would management tool such as TIMES tool, thereby ensuring the wound is protected from any kind of further infection.

Nurses should consider the psychological aspects of wound that will assist them to determine the emotional and psychosocial needs of Maggie. Nurses should use the holistic and person-centred care [PCC] approach that will enable them to provide the emotional, psychological and spiritual support to Maggie. The psychological and emotional wellbeing will assist Maggie to develop the self-management and stress management skill thereby making her mentally strong for coping up with her wound.

Maggie must be provided with the good oral nutrition in which she must be served with foods that are enriched with protein, essential fatty acids, mineral and vitamins, that will maintain a heathy body and mind.

Tube feeding should be implemented in case of Maggie immediate after her surgery. During the tube feeding the nurse must ensure that the feeding tube is safely inserted into the mouth of Maggie. Here nursing professionals must ensure that they apply all the safety measures to protect Maggie from any kind of needle stick infection.

Parenteral nutrition can be recommended if Maggie faces difficulties in taking the oral nutrition. In this route, nutrition is administered to patients on intravenous way. Through the process of parenteral nutrition medicines and liquid food supplements are administered to Maggie’s body to provide her with proper nutrition.

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In conclusion, MUST assessment and wound assessment would be most appropriate in Maggie’s case. MUST assessment would indicate if she were at risk of malnutrition. Moreover, the MUST assessment score would have a massive impact o wound healing. Wound assessment would show the progress in wound healing. Both assessments together would provide the nurse with the information necessary to create an appropriate care plan and recommendations.

Reference list:

Ayhan, F. and Üstün, B., 2021, April. Examination of risk assessment tools developed to evaluate risks in mental health areas: A systematic review. In Nursing Forum (Vol. 56, No. 2, pp. 330-340).

Bapen2016 Introducing 'MUST' available at: [assessed on 2020]

Coccia, F. and Rozzini, R., 2017. Goals of surgery and assessment tools for elderly patients referred for cardiac and noncardiac surgery. Monaldi Archives for Chest Disease, 87(2).

D’Souza, A.N., Said, C.M., Leggett, N.E., Tomkins, M.S., Kay, J.E. and Granger, C.L., 2020. Assessment tools and factors used to predict discharge from acute general medical wards: a systematic review. Disability and Rehabilitation, pp.1-15.

Elia, M., 2017. Defining, recognizing, and reporting malnutrition. The international journal of lower extremity wounds, 16(4), pp.230-237.

Fernández-Torres, R., Ruiz-Muñoz, M., Pérez-Panero, A.J., García-Romero, J.C. and Gónzalez-Sánchez, M., 2020. Clinician assessment tools for patients with diabetic foot disease: a systematic review. Journal of clinical medicine, 9(5), p.1487.

Geoghegan, L., Super, J., Machin, M., Gimzewska, M., Onida, S., Hettiaratchy, S. and Davies, A.H., 2021. Are Venous Thromboembolism Risk Assessment Tools Reliable in the Stratification of Microvascular Risk Following Lower Extremity Reconstruction?. JPRAS Open.

Klemenc-Ketis, Z., Gorenjec, N.R., Kovač, M.B. and Susič, A.P., 2020. Risk for malnutrition in family practice non-attenders living in the community: A cross-sectional study from Slovenia. Nutrition, 72, p.110657.

Maurício, S.F., Xiao, J., Prado, C.M., Gonzalez, M.C. and Correia, M.I.T.D., 2018. Different nutritional assessment tools as predictors of postoperative complications in patients undergoing colorectal cancer resection. Clinical Nutrition, 37(5), pp.1505-1511.

McCaughan, D., Sheard, L., Cullum, N., Dumville, J. and Chetter, I., 2018. Patients’ perceptions and experiences of living with a surgical wound healing by secondary intention: A qualitative study. International journal of nursing studies, 77, pp.29-38.

Nasreen, S., Maryam, S. and Nabeela, S.U., 2020. Evaluation of efficacy of Nutritional screening tools to assess Malnutrition among Elderly patients in a tertiary hospital in Telangana, India. International Journal of Food and Nutritional Sciences, 9(4), p.54.

Nice2012 https://www.nice.org.uk/guidance/QS24

Onyekwelu, I., Yakkanti, R., Protzer, L., Pinkston, C.M., Tucker, C. and Seligson, D., 2017. Surgical wound classification and surgical site infections in the orthopaedic patient. Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews, 1(3).

Thomas, J., Kaambwa, B., Delaney, C. and Miller, M., 2019. An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit. British Journal of Nutrition, 122(6), pp.689-697.

Wang, Z., Xu, J., Song, G., Pang, M., Guo, B., Xu, X., Wang, H., Zhou, Y., Ren, L., Zhou, H. and Ma, J., 2020. Nutritional status and screening tools to detect nutritional risk in hospitalized patients with hepatic echinococcosis. Parasite, 27.

Wilson,B (2017), Transparency in Healthcare, BSN, RN available on: https://thenerdynurse.com/transparency-in-healthcare/


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