Problem: Synthesise- identify the main clinical issue for the patient to determine a nursing diagnosis. Make sense of the data and understanding the clinical manifestations (approx. 300 words).
Why does it make sense the patient has presented with these signs and symptoms in this situation
Jane Wilson is a 30-year-old female who presents to the regional Emergency Department (ED) by herself. She is hobbling up to triage whilst holding her left leg. Jane reports she had fallen off her horse and has suffered a deep and dirty penetrating laceration to her left thigh. Jane appears alert and orientated. Jane can recall all history of events and answer questions appropriately. Jane has wrapped her thigh with a towel to stop the bleeding. In the ED the towel is removed, and the wound is irrigated with normal saline before being redressed with a pressure bandage. It is not possible to insert a peripheral intravenous (IV) canula, so a decision to obtain access through a Central Venous Access Device (CVAD). The CVAD has been performed on Janes L) Jugular vein under sterile technique. The CVAD is patent and secured with sutures and a transparent IV 3000 dressing. Triage Observation Airway: Patent, own, RR: 16 Sp02: 92% on Room Air (RA) BP: 105/52 HR: 118, regular T: 35.5 Pain 6/10 GCS 15 BGL: 5.5 Medical History Nil allergies Denies any alcohol intake or illicit drug use Independent and active Investigations Hb: 89g/L (Cross match report: AB+) X-ray: No bony fractures or abnormalities visible. CT: Deep laceration to left medial thigh. No associated vascular injury present. In the ED, one unit of Packed Red Blood Cells (PRBCs) is administered through the CVAD. After the first unit of blood, Jane is admitted to the surgical ward to wait for surgery as the ED is now becoming overcrowded. 1g Paracetamol and a Stat dose of Ceftriaxone has been administered by ED staff. School of Nursing, Paramedicine and Health Science NRS283_202360 Assessment item 1: Case Analysis. 3 You are working as a Registered Nurse on the Surgical Ward and when you assume care of Jane and when you introduce yourself to Jane it is 1430. Jane appears anxious and remains in pain. Jane can recite her full name, date of birth and can tell you the time and place. It is obvious Jane is worried and tries to call her wife, Emily, but is unable to get in contact. Initial admission observations to the ward Airway: Patent, own, RR: 16 Sp02: 93% on RA BP: 107/60 HR: 105, regular T: 34.9 Pain 6/10 GCS 14 (Eyes open to voice, orientated and obeying commands) BGL: 5.4