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Roper Logan Tierney Model of Nursing

The Roper Logan Tierney model of nursing is essentially a practice-centered theoretical model that is grounded in accessibility and realism (Williams, 2017). In clinical settings, it is based on activities of daily living recorded in the concerned patient (ADLs or ALs). The model gets its name from the initials of the founders and the prevalence of its utilization and implementation is widely recorded in the United Kingdom. It is used to assess how the life of the patient changes after an injury or illness, for planning ways of improving a patient's independence and overall life quality (Mudd et al., 2020). The objective of the assessment is to create plausible interventions for supporting areas of independence for the patient. Nurses use this cognitive approach to organize care and induce the right support or treatment methodologies. The activities include maintenance of safer environments, communication, consumption of food and water, and physical parameters. Kristy's condition has developed due to a sudden fall that induced pelvic fractures and a head injury. The model can be utilized for assessing various experiences

Biological factor: Kristy had been admitted to the hospital roughly 2 hours after the incident. X-ray results of her pelvic girdle imply a fracture caused in two places on the right side of her pelvis. A CT scan done on her head projected cerebral contusions on the right side. Bruises in her brain have been expected as she started having problems with memory and remained intermittently confused, post the incident. The string blow to the head can also cause cerebral lacerations or tears in the tissues of the brain. Cerebral contusions can also cause swelling or bleeding in the brain, deep cellular damage, and resultant tissue hematoma or necroses can cause inflammation. Visual and spatial perception would be highly altered for Kristy.

Psychosocial factor: This would entail the impact of emotions, beliefs, and cognition for Kristy after the injury. The societal expectations based on class and status can also influence Kristy (Holland & Jenkins, 2019). As contusions can expand and progress the risks for disability are increased. Kristy would be forgetful, indifferent, and excessively tired in general. This can affect her work on the farm as they have simple country living standards and earn money through the physical labor of running a cattle farm. She will not be able to focus on her work due to attention disorders, inability to induce anticipation, and inflexibility after the injury. The quality of her relationship with her husband, peers, and neighbors would be negatively affected by her cognitive impairment. She also has a young child and it would induce pressure on her husband to handle daily chores. The patriarchal mindset of the society can observe men working in the family to be a viable constraint.

Legal Concept of Consent, Doctrine of Necessity, and Enduring Guardianship

Spiritual factor:   The cause of a brain injury would make Kristy gain a newfound sense of appreciation for life. She has faced a traumatic brain injury and was extremely close to death. Having a closely-knit family might make her want to increase mindfulness and awareness. She can be found to meditate and induce prayers for the betterment of her condition and free her family of the hard toil that they are going through. Improved faith in god can result in positive signs of betterment.  Research suggests that the left lobe of the brain has a correlation possibility with spirituality so no major signs should be expected.

Cultural factor: The expectations and values of the patient Kristy in carrying out daily activities with independence should be highlighted. She would have to adapt to lower levels of self-esteem, impairing her abilities of daily functioning. Increased bursts of loneliness can be observed in Kristy for her incapability to interact efficiently with people. Insufficient communication with close ones can make her aggressive in certain cases if expectations are not suitably met. Cultural inhibitions where she would find her husband assisting with a majority of household work, for her physical immobility can bring about mental health issues.

The legal concept of consent emphasizes on individuals have the capacity and freedom to speak by their choice (Dove et al., 2017). Kristy has to approve or promote compliance to activities done in her absence in the house. The husband is bound to integrate ethical measures in significantly handling work in Kristy's absence. Kristy should also be allowed to place her inherent demands on caregivers after going through the intense incident. She should also be questioned by nurses before conducting activities of care and support. The chances of people being indifferent to her words would be maximized for her cognitive state but that should be negated. The doctrine of necessity identifies how situations of overwhelming urgency can make an individual respond by breaking the law (Santoni de Sio, 2017). If under unfortunate circumstances anyone tries to molest or harass Kristy due to her fractured pelvis, she can utilize this law to cause harm to the culprit. An enduring guardian is a person who is legally appointed for making decisions for the concerned affected individual facing poor health and lifestyle events. In this case, Kristy can appoint her husband to legally take up responsibilities and be the best judge of her health to initiate improvement measures.

Preoperative Nursing Activities

Preoperative nursing activities aim at conducting assessments on the patient's physical, social and psychological states, preparing them for surgery, and successfully implementing interventions (Nilsson et al., 2019). The nurse should make the right decisions for Kristy before her surgery to repair her pelvis.

  1. A preoperative nursing assessmentwould help the nurse in reviewing laboratory and diagnostic studies while reviewing the health records of the patient. Kristy’s physical needs should be assessed while administering correct nutrition intake and sleep before operation. Physical parameters like blood count, serum electrolytes, blood type, and match can be recorded for Kristy. Vital signs need to be monitored along with checking Kristy's level of consciousness, drowsiness, and unresponsiveness. It will help in understanding the utilization of required sedatives or medicines for reducing calamities. Basic exercises can be taught to her for aiding the affected muscles. The nurse should inform Kristy regarding ways to control pain and edema, after complete diagnosis.
  2. Obtaining informed consent: The nurse would have to make Kristy sign surgical consent forms and operative permits. All procedures requiring anesthesia have multiple risks of complications and the patient should be aware of them, if not worried. In this case, since Kristy is facing confusion about her brain injury, her husband can sign the consent form. Preoperative teachingshould include surgical expectations and procedures for inducing a sense of comfort in Kristy (Edwards et al., 2017). Patients would be able to be more alert when they adhere to pre-conceived information. Deep breathing, feet and leg exercises, position changes can be introduced before operation.
  3. Physical preparation of the patientwould ensue for the administration of nutrition, fluids, hygiene, and care of valuables, prostheses, embolic stockings, and safety protocols. Usually "NPO after midnight" is observed for anesthetics to not depress gastrointestinal functions in the patient, consequently inducing vomit and aspiration (Sacramento & Manchikanti, 2019). Consumption of clear liquids is also monitored. Enemas can be ordered if the surgery of the bowel is planned. Commonly utilized preoperative medications include antiemetics, anticholinergics, antibiotics, and sedatives. The nurse should also assess elevated vital signs like temperature and blood pressure in Kristy. Mobility aids can be given to her for assistance.
  1. Capillary refill time (CRT) of three seconds:

Prolonged CRT indicates the significant presence of a circulatory shock (Hiemstra et al., 2017). A CRT noted longer than two seconds reflects poor peripheral vasoconstriction or perfusion. Tissue perfusion depends on adequate blood pressure of the aorta, determined by cardiac output or the amount of blood coming out from the left ventricle in a minute and peripheral resistance. CRT also helps in the assessment of the blood volume of a patient and their shock etiology. Kristy should be having lowered the delivery of oxygen to vital tissues and reduced circulating blood volume. Peripheral vasoconstriction is associated with cold extremities and assessment is levied through palpation of distal limbs. The shock can be either cardiogenic or hypovolemic in Kristy’s case, as she has lost nearly 400 mls of blood intra-operatively.

Circulatory shock is characterized by an imbalance between oxygen demand and supply (Stand et al., 2018). It is linked to tissue hypoperfusion and leads to delayed capillary refill amongst other responses. It is exhibited by the inability of blood flow by organs and oxygen delivery for meeting metabolic demands. The ensued sympathetic outflow from the brain would stimulate epinephrine secretion from adrenal glands. Muscular glycolysis is compartmentalized using cytosolic glycolytic enzymes (Yellen, 2018). One pathway can be channeled into "oxidative metabolism" and the other enables Na+-K+ exchange in the cell membrane. Cells shift to an anaerobic kind of metabolism associating high carbon dioxide production and elevated lactate levels of blood. Epinephrine stimulates prevalent β2-adrenergic receptors to consequently increase ATPase activity and enhancement of ADP increases glycolytic flux as well as lactate production.

  1. BGL is 6.5 mmol/L:

A normal blood glucose level is observed to range less than 100 mg/dL (5.6 mmol/L). A level of 100-125 mg/dL (5.6-6.9 mmol/L) can be diagnosed as prediabetes. Type 2 diabetic patients pass through impaired tolerance and fasting of glucose called the pre-diabetic state. Basic defects found in pre-diabetes include insulin resistance as well as early beta-cell failure. The rapid oscillations of secreting insulin are lost while decreasing the amplitude of larger pulses.

Glucose is the body comes from digested food when sugar enters the bloodstream. Insulin allows sugar to enter cells and lowers the amount of sugar in the blood. Insulin produced by the pancreas is sent to the blood on eating. It is regulated according to the amount of blood glucose level.

Identification of Post-Operative Nursing Assessment

Hyperglycaemia causes insulin production and release by pancreatic beta cells (Haythorne et al., 2019). Excess insulin exposure for long time intervals diminishes insulin receptor response, where open glucose channels cause glucose entry into cells. Decreased insulin receptor function would further cause hyperglycemia, perpetuating metabolic disturbances, and developing diabetes type 2 and metabolic syndromes.

  1. Changes in skin color, bilaterally cold feet:

These abnormal signs noted in Kristy can be characterized by peripheral vascular disease (PVD) which is a progressive and slow circulation disorder. Blockage, narrowing, and blood vessel spasms generally lead to PVD, which consequently affects blood vessels outside the heart (Min et al., 2021). Organs that are supplied blood through these vessels tend to not receive blood to function properly. Kristy's limb injury in the body can lead to the chances of PVD, after examination of the pertinent symptoms of decreased skin temperature and non-uniformity in skin color.

In PVD, blood flow decreases as the blood vessels get narrowed. Functional CVD includes no physical blood vessel damage, but vessels tend to narrow and widen according to brain signals and temperature changes. Emotional stress, use of drugs, operations can affect the blood flow in the body and is termed the “Raynaud’s phenomenon” (Musa & Qurie, 2021).  Blood vessel constriction episodes are known as vasospasms. Poor healing of wounds, restricted mobility, severe pain are instances of complications due to PVD.  PVD affects low extremity vascular beds, but large arteries like iliac arteries and abdominal aorta.

Body temperature recorded at 35.8 C: The dropping of body temperature in Kristy’s case portrays chances of hypothermia. If left unattended, it would lead to complete heart or respiratory failure. Confused thinking, clumsiness, lack of coordination, and consciousness due to hypothermia are common. Although Kristy's temperature is 35.8, it is also significantly low as lack of attention can drop it further to fatal levels. Overall confusion caused by hypothermia also causes the prevention of self-awareness. Kristy has been under strict dosages of heavy anesthetic drugs like sedatives which could have had modified the ability of the body to regulate temperature. Interruption of blood flow results in inadequate temperature control.

References

Dove, E. S., Kelly, S. E., Lucivero, F., Machirori, M., Dheensa, S., & Prainsack, B. (2017). Beyond individualism: Is there a place for relational autonomy in clinical practice and research?. Clinical Ethics, 12(3), 150-165. https://doi.org/10.1177/1477750917704156

Edwards, P. K., Mears, S. C., & Lowry Barnes, C. (2017). Preoperative education for hip and knee replacement: never stop learning. Current reviews in musculoskeletal medicine, 10(3), 356-364. https://doi.org/10.1007/s12178-017-9417-4

Haythorne, E., Rohm, M., van de Bunt, M., Brereton, M. F., Tarasov, A. I., Blacker, T. S., ... & Ashcroft, F. M. (2019). Diabetes causes marked inhibition of mitochondrial metabolism in pancreatic β-cells. Nature communications, 10(1), 1-17. https://doi.org/10.1038/s41467-019-10189-x

Hiemstra, B., Eck, R. J., Keus, F., & van der Horst, I. C. (2017). Clinical examination for diagnosing circulatory shock. Current opinion in critical care, 23(4), 293. 10.1097/MCC.0000000000000420

Holland, K., & Jenkins, J. (Eds.). (2019). Applying the Roper-Logan-Tierney Model in Practice-E-Book. Elsevier Health Sciences.

Min, J. Y., Choi, Y. S., Lee, H. S., Lee, S., & Min, K. B. (2021). Increased cold injuries and the effect of body mass index in patients with peripheral vascular disease. BMC Public Health, 21(1), 1-10. https://doi.org/10.1186/s12889-020-09789-w

Mudd, A., Feo, R., Conroy, T., and Kitson, A., 2020. Where and how does fundamental care fit within seminal nursing theories: A narrative review and synthesis of key nursing concepts. Journal of clinical nursing, 29(19-20), pp.3652-3666. https://doi.org/10.1111/jocn.15420

Musa, R., & Qurie, A. (2021). Raynaud disease. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499833/

Nilsson, U., Dahlberg, K., & Jaensson, M. (2019). Low preoperative mental and physical health is associated with poorer postoperative recovery in patients undergoing day surgery: a secondary analysis from a randomized controlled study. World Journal of Surgery, 43(8), 1949-1956. https://doi.org/10.1007/s00268-019-04995-z

Sacramento, C. A., & Manchikanti, L. (2019). ASIPP guidelines for sedation and fasting status of patients undergoing interventional pain management procedures. Pain Physician, 22, 201-207. https://www.painphysicianjournal.com/current/pdf?article=NjMwMQ==&journal=120

Santoni de Sio, F. (2017). Killing by autonomous vehicles and the legal doctrine of necessity. Ethical Theory and Moral Practice, 20(2), 411-429. https://doi.org/10.1007/s10677-017-9780-7

Standl, T., Annecke, T., Cascorbi, I., Heller, A. R., Sabashnikov, A., & Teske, W. (2018). The nomenclature, definition and distinction of types of shock. Deutsches Ärzteblatt International, 115(45), 757. 10.3238/arztebl.2018.0757

Williams, B. C. (2017). The Roper-Logan-Tierney model of nursing. Nursing2020 Critical Care, 12(1), 17-20. 10.1097/01.CCN.0000508630.55033.1c

Yellen, G. (2018). Fueling thought: Management of glycolysis and oxidative phosphorylation in neuronal metabolism. Journal of Cell Biology, 217(7), 2235-2246. https://doi.org/10.1083/jcb.201803152

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