 The place, an Army drop zone. The day, not as luckiest most, for Sergeant John Rogers. Sergeant John Rogers, aged 27, in more pain than he's ever experienced before in his life. I'm going to get this stretch. Sergeant Rogers will receive prompt care for his injured right ankle. And as he does, the nurses hear us in all Army medical treatment facilities who use the nursing process from the time he is admitted until he is discharged. Properly documented, the nursing process will play a vital role in the quality of care given every patient. Sergeant Rogers? Yes. Hi, I'm Lieutenant Farrell. It looks like you've had a little bit of an accident here. I know you're uncomfortable, so we'll try to move you just as little as possible. The doctor will be in just a minute to see you, but first he'd like us to get some x-rays of your leg. I also need to take your blood pressure. So let me help you sit up and we'll get your shirt off, okay? And so it begins, the nursing process. A process that's used for every patient, whether his condition is acute or chronic. Help me someone down to take you to x-ray in just a few minutes. Proper documentation of the process is vital for every patient. Nursing care often involves nurses from many specialty areas, and their nursing care plans serve as the basis for the nursing plan as the patient moves from one unit to another. Do you have the x-rays? Yes, we do. These are what readings are. Thank you. We're not going to be able to repair this now. Half of it admitted and I'll meet him upstairs in the cast room. We'll have to put some more immobilization on before we take him upstairs. Sergeant Rogers? You have a fracture of your right ankle. Because of the swelling, we're not going to be able to set it now. We're going to immobilize you in a posterior splint in a couple of days. When the swelling goes down, we'll be able to do more for it. Would you please give him a dimerall I am 100 milligrams before he goes upstairs? Okay then. Lieutenant Conant, may I help you please? Hi, this is Lieutenant Farah on the ER. We're admitting a 27-year-old patient. Sergeant John Rogers with a fracture of the right ankle. He injured it this morning during a parachute jump in. He's in the cast room now with Dr. Jacobson getting a posterior splint. They'll call you before they send him up. Is there anything else I should know? Well, I understand you received 15 milligrams of morphine from the medic this morning after the injury. And I just gave him 100 milligrams of dimerall I am about 10 minutes ago. So everything's charted here on his ER chart. Okay, thanks for letting us know. Bye-bye. Hi, Sergeant Rogers. I'm Lieutenant Conant. This is Ward 47. How are you feeling today? Not too good. My ankle is really hurting me. This is supposed to be like being in a hospital. I'm glad I was never in one before. I'm really hurting, Nurse. Can you get me something for pain? Let me check and see. The nurse in the emergency room gave you some dimerall not too long ago. Let's try and see if some other things will help you feel better first. You've had a bad injury and you've had a lot of manipulation to your leg today. So there's going to be some swelling. That's why I have you elevated on these pillows. I'm going to put these ice packs on and that should help the swelling, too. That should help you feel better. I hope so. I'm really tired. I've been up since early this morning. I know it's rough on you, but better rest, keeping your foot elevated and the ice packs on will help you feel better. We'll be coming in from time to time to check on your toes. We want to be sure that the cast isn't too tight or that the fractures causing you any problems. If you have any questions about what we're doing, please ask. Okay. While you're awake, we can use your help, too. If you feel any tingling in your toes, if the cast feels too tight or if you get cold or anything like that, just let us know. Here's your call bell. If you have any problems or need anything, just call someone come as soon as possible. I'll be back a little bit later to see if you need that pain medicine. Having seen the patient, the nurse can now begin to write up the assessment of the patient on this nursing assessment and care plan form, DA 3888-1. We couldn't ask Sergeant Rogers all these questions now, but let's see what I do know. Patient continues to complain of discomfort and ankle. Right foot elevated on the pillows, toes are warm to touch. His problems are pain and swelling. Let's see. My nursing orders will be elevate the leg on pillows, apply ice bags, and check the circulation in the toes. The urgency of Sergeant Rogers' condition so far has required that assessments and plans be made and implemented quickly. Much of the assessment made since he arrived may not have been apparent, yet both the ER nurse and the ward nurse have used the process and have put the nursing care plan into action and documented those actions on the appropriate nursing forms. It started with the ER nurse assessing that the patient was acutely injured. And learning from the patient, he had no allergies. He was in pain. Lieutenant Ferro implemented the doctor's order to give him something to relieve the pain. Once the patient left the ER for the cast room, Lieutenant Ferro documented his assessment and the nursing care given. This record was sent to the orthopedic ward. When the patient arrived on the ward, the nurse on duty made a second assessment based on her observation of the patient after his leg was put in the posterior splint. Her observations, plus the data documented by the ER nurse, will now be used in the nursing care plan for the patient while he is on the ward. A nursing care plan that will have to be updated as the patient's condition changes. Lieutenant Conan's initial assessment of Sergeant Rogers' problem will be used as the basis for the nursing care plan for the patient, a plan that will be used by the nurses on the next two shifts. Hi, how are you? Hi, I'm sure glad to see you. Hi, thanks, go on. Oh, it's been busy as usual, not too bad, though. Gamble and Wolf came back from Convalescent League and we got a new admission. Who's new admission? Sergeant Rogers, he fractured his right ankle. Well, since you weren't so busy, did you get a chance to get a look at a nursing history? I got some. He's been in a lot of pain and he's sedated now, but I got enough to do an initial care plan. Lieutenant Conan's decision, not to complete the interview right now, was made as a result of her assessment of the patient. Sergeant Rogers, Sergeant Rogers, your foot has swollen a little bit. I'm going to re-wrap the ace bandage. At 04.30, the ace bandage was unwrapped and the ankle re-wrapped a little more loosely. And this nursing action was then noted on the nursing notes by the nurse on duty. Lieutenant Bartlett is letting all nursing personnel know what action she took. She will also document the patient's response to the intervention. Her nursing actions that night are now a part of the patient's permanent medical records and would have been of interest to Lieutenant Conan when she reported for duty the next day. But Lieutenant Conan did not report for duty the next day. Good morning, Captain. Good morning, Lieutenant Wiles. Come on in. I'm really glad you could come and help us this morning. We're really short-handed. Lieutenant Conan's left on emergency leave this morning and she had six patients. Fortunately, she's very good about charting and you'll find complete documentation in each of their charts. She only has one patient for surgery tomorrow and that's Sergeant Rogers. Let's see what she has along the line in nursing care plans. Seems like they all are permitted since then. Yes, that was done right after Dr. Jacobson explained the procedure. She used to be prepped tonight. I see her she didn't have time to do the pre-op teaching and the history needs to be completed. So would you take care of that? Sure. And I'll start getting an appointment with him and my other patients now also. Good morning, Sergeant Rogers. Good morning. I'm Lieutenant Wiles, your nurse for today. How are you feeling? So-so, I guess. Well, I see you've already eaten breakfast and had a bath. Do you feel like talking a little bit? Well, I do. Okay, I'd like to ask you a few questions about your general health and style of living and hopefully your answers will give us a better idea about you and how we can help you. Okay. Sergeant Rogers, how would you describe your general state of health? Pretty good. I really never get sick. From here on, I see you told the ER nurse that you're not allergic to any medications, but are you allergic to any foods of any kind? No, not that I know of. Do you take anything to help you sleep? No. Good. I know our nurse anesthetists would be glad to hear that. Do you smoke? No, I've tried it, but it's really not for me. Very good. You'll be able to tolerate your anesthesia much better. And the coughing and deep breathing exercises you have to do afterwards won't seem near as hard. Do you take your deep breaths? The next day, Sergeant Rogers' Day of Surgery. Everything needed has been attended to. The OR prep, the teaching, the pre-op medication, and most importantly, the documentation in the patient's charge. Sergeant Rogers, how are you feeling? Can you feel this ear? Okay. How about down here? Good. How about down here? Okay. Can you take a nice, slow, deep breath for me and let it out? Good. Okay. How about down here? Can you lift your leg over here? Good. Wiggle your toes on your right foot. Very good. For Sergeant Rogers, surgery was uneventful. And here in the recovery room, he will be closely watched until the anesthesia wears off. Sergeant Rogers, you're doing very well. I'm going to be going back to the ward in just a few minutes. Here, as everywhere else, he will be given the best in nursing care. It will be documented on this chart by the recovery room nurse. The anesthesia doesn't get settled, and he'll be able to... Orthopedics, Lieutenant Lyles, can I help you? This is Katyn Zimmerman in the recovery room. We have Sergeant Rogers about ready to return to you. He did have an open reduction in internal fixation of his fractured right ankle, and this was done under spinal anesthesia. His blood pressure is stable at about 122 over 74. He is able to move his toes. At 1400, he voided about 200 cc's He has an IV of D5.5 with 20 of K. And this can be deced after he's tolerating fluids. He has about 300 cc's left to go. Does he have a cast? Yes, he has a short-lay cast on, and there's a small amount of drainage on the inner aspect of the ankle. It's been marked and doesn't seem to have increased. Okay, thank you. We'll be looking for him. Again, the nurse on duty, meeting Sergeant Rogers upon his return from surgery, carries out several steps in the nursing process in a few seconds. Upon the conclusion of her rounds and checking on other patients, she now documents the data she observed and what actions she carried out. 1400. Sergeant Rogers returned from OR, but I read D5.5 from almost sailing with 20 of K, infusing in left forearm. Right leg and short leg cast elevated on pillows. I supplied. Using her new assessment as a baseline, she will identify the nursing care problems that now exist after surgery and establish new goals, all of which she will document on the patient's clinical nursing record. Problems. Still pain and swelling. Drainage on his cast. And so, a post-op assessment and nursing plan is prepared and entered on the patient's chart. As the patient's condition changes, so will the goals and the methods of implementation. The process is the same for all patients. The plan changes as the patient's status changes. In the process of admitting Sergeant Rogers from ER to post-op, a minimum of six nurses have already assessed, contributed to the nursing care plan, and constantly revised the plan as necessary to meet each new development in the patient's condition. Notice that every step of the way, nurses not only responded, but documented their actions. This written record of the nursing care given to the patient during his or her hospitalization will become a part of the patient's permanent medical record. The record, when analyzed by the next shift or any time in the future, will give all who read it a complete picture of the nursing care given and the evaluation of that care to be administered it. Good. Looks like the swelling's going down. I don't think we'll need these ice bags anymore. How long does it usually take for it to heal? And do you think I'll be able to jump anymore? Well, at this point, I don't know if anyone can say. But what would it mean to you if you couldn't jump anymore? As the priorities determined by the patient's condition change, the focus of the nursing care will also change. Good morning, Sergeant Rogers. Hi. How are you doing? Fine. How are you today? Oh, fine. Well, I picked up your shoe this morning from the gray shop, and they've built up the sole on it to be approximately the same height as your walking cast. So whenever you walk in your crutches, you'll need to wear this shoe. Within the next 10 days, Sergeant Rogers progresses to walking with crutches. This progress must also be documented in the chart. In Sergeant Rogers' case, he now spends time learning skincare and how to take care of his walking cast. As the nursing care of the patient changes, and he assumes more and more responsibility for his own care, the nurse does not relinquish her responsibilities. She continues to use the nursing process and proper nursing records in documenting the patient's care. Much happier move? Yes. I'm really excited about seeing my family and starting my convalescence leave. Where are you going on leave? I'll be going home to Florida. What are you going to be doing? I'll probably go out on the beach, even though I can't swim. Even as the patient prepares for convalescent leave, the nurse must continue to use the nursing process to help update this charge plan. The nurse must identify what the patient's needs will continue to be and how to best meet these needs by linking up the patient with the appropriate support systems in the military or in the community, whichever best serves the purpose. Keep the sand from getting under your cast. If you have any problems, go to the nearest military hospital and look at it for you. And above all, remember to do your exercises. Gotcha. You've seen how the nursing process and action is adapted to work for an acute patient. All of the nurses, the nurse in the emergency room, the nurse in the recovery room, and nurses on the ward all use the nursing process in caring for Sergeant Rogers. By each of them documenting the nursing process they used while the patient was in their care, they offered maximum continuity and the nursing care offered to patients in the hospital. Proper documentation of your nursing actions not only offers the patient the best possible nursing care from the day of admission until the day of discharge. It provides a permanent record of your actions as a professional. It shows not only how you implement your plans, but how you evaluate your own work and the patient's progress. You accept the responsibility for your actions and you are accountable for them.