In the older adult population, the incidence of wrist fracture is common that causes poor health outcome. It is understood from the data of the World health organization that 30% of the population of age above 65 years (130,000) falls each year in Ireland (The European Republic 2020). Among total falls 58% of the cases are not reported to the health professionals resulting in 26,000 people with severe injuries (The European Republic 2020). According to Kelly et al. (2018) total of 1,472 older adult get hospitalized due to falls and more than 5000 experience fracture. Among all fracture, wrist fracture is highly common among women of age below 75 years and functionally independent. The wrist fracture may not as lethal as hip or vertebral fracture, however considering the hand as the fundamental aspect in performing daily living activities, a small degree of functional affectation is expected. Lack of research is noted on the impact and complexity of the wrist fracture in the Irish healthcare sector concerning patient and treatment. Therefore, the main of the assignment is to discuss the case study pertaining to the experience of wrist fracture by a woman admitted to the Emergency department (ED). It will first discuss the holistic assessment followed by the nursing care plan, nursing intervention and evaluation of nursing decision for care and action.

The case study describes the deteriorating health condition of a patient of 67 years addressed as Mary. A pseudonym is used to protect the confidentiality and privacy of the health information patient in line with the NMBI code of conduct (Nursing and Midwifery Board of Ireland, 2020). Mary presented to ED accompanied by her daughter for severe pain in her right wrist. On communication, she said that she tripped and tried to catch herself during the fall but landed hard onto her outstretched right hand. The pain was secondary to scaphoid fracture, although it was diagnosed but healthcare professional suspected the same. Mary is independent and lives with her husband who has a Cerebrovascular accident (CVA) with left-sided weakness. She is the only caregiver for her husband however her daughter lives down the lane and gets assistance occasionally. Mary has a history of hypertension and asthma. She does not report any surgical history of incidence of previous falls.

Nursing approach to care for Mary in Ireland

Holistic assessment: The holistic assessment is the approach that allows the nurse to gain health information required for accurate diagnosis, planning and implementation. Mills(2017) noted that holistic assessment provides support to the patient including physical, mental, social, emotional and spiritual wellbeing. The initiation of holistic assessment takes place by building good communication between nurse and patient. Wanget al. (2018) show that effective communication forms the basis for the optimum exchange of information regarding the treatment and medication. The survey analysis reported 39% of Irish patient to seek information on the health issue in understandable language(National Adult Literacy Agency2015).Research has shown that before assessing the patient, the introduction by the nurse about themselves is crucial to form a therapeutic relationship and provide person centred care (Eklund et al. 2019). Therefore, with evidence on the significance of the communication and self-introduction, the holistic assessment of Mary will initiate by giving brief information by the nurse about herself. Verbal consent needs to be sought from Mary before the holistic assessment. The consent contains information on the purpose of the assessment and included aspects for appropriate diagnosis of pain at the right wrist. Mitchell et al. (2018) state that consent from the patient help in including them in the care plan as trust and respect is built between the assessing nurse and patient. The consent taken from the patient requires to be documented in the report of nurses or midwifery notes and the patient’s consent form.

The holistic assessment of the patient will involve the following component:

1. Physical need: The physical need of the patient require investigation on the whole body. The use of Nursing assessment framework tools will allow a thorough check-up of the patient for any health complication. Since the patient has experienced a fall, there is the probability of other injuries that require assessment. Nursing assessment framework tools are effective in gaining health information of the patient along with its desire (Gallen, Kodateand Casey 2019). It is based on objective and subjective data that help to determine the underlying problem of the patient. The Nursing assessment framework tools involve information on general status in the form of five vital signs (heart rate, temperature, blood pressure, respiratory rate and pulse oximetry) including pain. Pain assessment scale using numerical rating is employed to assess the severity of pain as Mary complaint of right wrist pain due to its simplicity and high sensitivity (Rolls et al. 2020). The pain score of Mary was 6/10 which is considered to be severe. To continue the further checkup, a physical examination of the right wrist of the patient need to be conducted. As the patient complained of tenderness on the radial aspect of the dorsum of the wrist, she was asked to hyperextend the thumb with the wrist slightly deviated to in the radial aspect. On examination, she noted pain in the scaphoid area on longitudinal thumb compression. The same procedure was conducted on the left hand to compare the severity of the issue. X-ray analysis is required to diagnose scaphoid fracture as signs make the patient suspect for the same (Wijetunga et al. 2019). On receiving the report, the wrist fracture was diagnosed. Further, assessment related to Head, Ears, Eyes, Nose, Throat, neck, respiratory, cardiac, abdomen and pulses was considered due to history of hypertension and asthma. However, all such information was normal.
2. Mental/Emotional need: The patient needs to be communicated to assess her emotional and mental need. According to the case study, she is the only primary caregiver of her husband. The issue of the pain of her right wrist might make her stressed thinking about a way to take care of her family. Research has shown that health communication with the patient makes them able to share information and concern and ease establishing person-centred care (Cho et al. 2017). Therefore, the nurse requires to be communicated humbly and respectably and giving motivation and psychological support to cope with the treatment and health issue.
3. Spiritual need: Spiritual belief of the patients vary according to their different culture. It has a crucial role in demonstrating the health belief and perspective of the patient regarding the type of treatment given, as research suggests that some patient do not desire to get allelopathic assistance believing its potential side effect (Kennedy et al. 2017). The research by Coyne et al. (2018) emphasized that in person-centred care, the treatment and other aspects should be according to the desire of the patient and shall discuss key consideration about health condition as it helps to form trust and the therapeutic relationship. Therefore, for Mary, it is crucial to identify her spiritual need regarding wrist pain so that the care plan can be formulated accordingly.

Care plan and rationale for Mary in Ireland

The nursing care planning of a patient with a fracture is based on the prevention of further complication during the process of healing. The case study noted that the diagnosis of Mary’s pain in the right wrist was still ambiguous as the X-ray report does not provide the right information for the scaphoid fracture. The assessment noted severe pain in the right wrist, so there is an urgency to control it so that appropriate care can be given to the patient. Moreover, the assessment also outlined the existence of stress in the patient as she was the only caregiver to her husband. Therefore, on basis of assessment, the care plan includes the goal of:

• The patient will be able to stabilize and align the suspected scaphoid fracture.
• The patient will be able to show body mechanics that promote bone stability at the site of injury.
• The patient will verbalize the relief of pain
• The health condition, prognosis and therapeutic regimen will be understood by the patient and family.
• The patient will be able to participate in the daily living activities with minimal complaint.

Based on the nursing goal for the patient and the diagnosis made, the care plan will be formulated by communicating with the patient and family. According to the guideline of Garbi(2021), the healthcare professional including nurses is required to follow the below aspect in case of non-complex wrist fracture. First, while communicating with the patient and family, the nurse needs to manage the expectation of the patient, provide accurate health information, avoid misinformation, not speculate and be over-optimistic or pessimistic while communicating with the patient. Second, there is the need to ask the desire of the patient or any confusion, ask their patient wants to care of some family member. Third, the nurse should provide information on the type of injury to the patient, explanation about the investigation and treatment, provide transparent health information, expected outcome of the treatment, requirement of any home care activities, rehabilitation and others (Garbi 2021). Therefore, based on the evidence, the nursing care plan was based on the above-mentioned guideline. The case study notes that Mary was accompanied by her daughter, both of them were given information on the wrist fracture and planned intervention by doctors. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. When the patient agrees with the information, relative and carers should be involved in the decision making in the care plan.

Therefore, based on the health condition of the patient, the priority of care and plan involves:

• Preventing further injury: Research byHaller et al. (2021) emphasize that in case of fracture, it is crucial to protect from dislocation or movement as it can lead to severe injury like penetrating the skin. Therefore, as the patient was suspected to have a scaphoid fracture, the priority action would be to prevent any other tissue or bone injury.
• Alleviate pain: The study byFiranescu et al. (2018) has mentioned that extreme pain due to fracture makes the patient discomfort and make them reluctant to participate in the care process. Moreover, another evidence noted that relief of pain promote muscle relaxation and enhance participation (Ankawi, Kerns and Edmond 2019). Therefore, the second priority of care would be to control the pain of the patient as a 6/10 pain rate is indicative of a severe issue.
• Prevent complication: The issue of bone fracture or dislocation causes severe discomfort in the patient that can rise of health complication like high blood pressure (Bromfield et al. 2017). According to the case study, the patient has a history of hypertension and asthma, the third priority of care involves the prevention of complication so that patient can recover at the earliest.
• Provide information on prognosis and treatment:The nursing care plan involving transparency in the shared information results in the inclusion of the patient in the treatment that shows fast recovery and low rate of readmission (Karacaand Durna 2019). The patient Mary and her daughter will be provided with all the vital health information as the basis of patient-centred care.
• Ability to perform the daily living activity: The last priority of care would be to make the patient and family able to perform daily living activity for positive health outcome. As depicted in the case study, Mary is the primary caregiver of her husband with CVA, she must be able to perform her normal activities so that effective care can be taken.

Nursing care intervention

Based on the care plan, to prevent any further bone and tissue injury and avoid undertreatment of occult fracture, the intervention has given include cast immobilization below the elbow and the patient was advised to revisit the clinic after 10 days (Kweeand Kwee 2018). It will help in settingthe fracture by reducing the possibility of disturbing the alignment and muscle spasm and prevent any tissue injury (Kweeand Kwee 2018). The patient will be suggested for review after 10 days and perform a serial X-ray. It will provide visual evidence on alignment, callus formation, healing process and exact fracture line (Halvachizadehand Pape 2020). Such information can be used by the doctor for future intervention.

To control the severe pain in the right wrist, administration of oral paracetamol is prescribed. Research has shown that paracetamol is effective in treating pain with the least side effect on older adults and longer action (Saragiotto, Shaheedand Maher 2019). Moreover, the intervention of application of cast is also effective in alleviating pain because it promotes venous return and lowers any oedema that eventually leads to low pain (Saragiotto, Shaheedand Maher 2019). Moreover, as part of the care plan to provide crucial information on the prognosis and treatment, the nurse needs to communicate with the patient and her daughter for the same. Referring to the case study, Mary lives with her husband who has a stroke and affected left side, the nurse would discuss the issue that could be encountered during the treatment like inability to perform the daily living activity and the requirement of assistance.

Research has indicated that the presence of traumatic event changes the daily lives of the patient causing a shift from autonomy towards dependence and disability (Ouellet et al. 2019). The wrist fracture could cause a decline in the progressive function of the person (Shirzadi et al. 2020). Therefore, the nursing intervention involves consideration of the baseline functional situation and clinical characteristic of Mary. However, according to the case study, the daughter would not able to help her parent’s due busy life schedule. Therefore, to assist the patient and her husband with daily work, the nurse referred for Home Help and send Public Health Nursing(PHN) Referral form and informed that taking help from GP to request Home help can expedite the matter.

To assist the patient (Mary), the nurse require to assess her functional capacity before fracture so that accurate decision can be made for treatment and the requirement of rehabilitation (Nerz et al. 2019). It is also crucial for to nurse to assess the patient for any fragility so that a comprehensive answer to the complex need of the patient can be given. Therefore, the nurse would provide information on the importance of the PHN referral along with the involved process and procedure.

As part of the intervention, the nurse should assist the family to fill Public Health nursing Referral form and write a letter to GP requesting home help. The Registered General Nurse or Registered Public Health Nurse will be contacted to clarify and confirm the referral made for Mary. The nurse needs to seek verbal consent from the patient and her family for the intervention of home referral before proceeding with the process as it will make them aware of the purpose or any risk involved (Tehranineshat et al. 2019). The follow-up care of the patient with a health issue and daily living activities will be commenced by the home helper.

The other intervention that nurse could provide is an explanation of self-management and care which involve the performance of active and passive ROM exercise. It will maintain the strength and mobility of unaffected muscles and reduce any inflammation (Yang et al. 2018). The nurse will also provide emotional support to the patient (as her diagnosis was still not clear) with motivating to use stress management techniques like deep-breathing exercise and progressive relaxation. It will help in promoting a sense of control and improve coping abilities in treatment given for trauma and pain (Raad et al. 2021).

Evaluation of nursing care decisions and action

The evaluation of the nursing care decision involves discussion with the RGN, RPHN, patient, family member and contact person regarding the care plan and intervention given. The care plan needs to be documented in the clinical nursing record to track the follow up of the intervention given. On discussion with the patient and carer, the referral to the social and care service requires completion with their agreement. A dependency framework will be used to evaluate the nursing care decision (Goes et al. 2020). It assists the nurse in categorising the patient according to the PHN caseload as it reflects the level of dependency to another as their condition changes. If the score becomes low and dependency improves, it will indicate that nursing care decision is appropriate and the health condition of the patient is improving. The score will be revised and recorded following any subsequent assessments/reviews.

To evaluate the care action given to the patient, she will be assessed for sensation and motor function. Research has shown that sensation assessment will provide information on the proper functioning of body and motor abilities, that will depict recovery of the joints or fracture (Byrchak,Dumaand Aravitska 2020). After the review and follow-up of the patient after 10 days, she will be interrogated for any pain or discomfort. She will be assessed with the sharp end of the pin by touching it at the web space between the thumb and index finger, at the distal fat pad and distal surface to test sensation ability. Moreover, an X-ray will be performed to check for any fracture or any improvement, along with testing the motor function by asking the patient to hyperextend the wrist. If the patient can do it, without any pain, it will reflect the care action has improved the health condition of the patient.

Conclusion

Lastly, it concludes by saying that holistic assessment, care plan, intervention and evaluation requires to be done according to evidence-based to avoid any risk of error or complication. Effective communication with giving person-centred care to the patient is the key aspect of quality and safe care as it helps in building trust, respect and justified therapeutic relationship. The care of the patient will end by giving appropriate discharge information both written and verbal that includes a schedule of administering medicines and discharge advice to revisit in case of any health complication. It will help the patient to better understand the discharge instruction by giving space for any query. The discussion noted patient was anxious for ambiguous diagnosis, therefore it is crucial to explain to Mary the rationale for the inability to diagnose and reassure her for care plan by giving clear instruction to revisit if the pain does not subside.