Case Study Report
This assessment item requires you to submit a report in which you discuss your assessment and management of the patient in the case study provided below. In addition to a brief introduction and conclusion, your report should contain the following sections:
Patient Assessment – In this section you are required to:
•Provide an explanation of the primary/secondary survey assessment framework and explain why you would apply this framework to your assessment of the patient in the case study
•Identify and briefly explain each stage of the primary/secondary survey framework
•Use the primary/secondary survey framework to extract relevant assessment data from the case study
Underlying Pathophysiology- In this section you are required to:
•Choose five (5) of the abnormal assessment findings you identified in the previous section and discuss the disruptions to normal physiology that have caused these clinical manifestations.
Nursing Interventions – In this section you are required to:
•Identify and prioritise according to clinical urgency five (5) nursing interventions that the patient will require during the next eight (8) hours
•Provide a rationale or explanation for each intervention which clearly identifies its clinical indication (or how it will address the underlying pathophysiology of the patient’s condition) and demonstrates that it is consistent with current best practice.
Your report should adhere to academic writing and referencing conventions and contain correct nursing/medical terminology. Sub-headings should be used for each section.
Wendy Jones is a 61 year old who presented to the Emergency Department earlier this morning with a 3 day history of worsening nausea, vomiting and abdominal pain. Her observations on presentation were: HR 98, RR 18, BP 120/70, and Temp 37.8. She has a history of Type 2 diabetes, diverticulitis and osteoarthritis. A CT scan revealed a ruptured diverticulum and Wendy was transferred to theatre for an open Hartman’s procedure.
Wendy was transferred to the ward from theatre 2 hours ago. You have just started your evening shift on the surgical ward and have received the following handover from your colleague:
This is Wendy Jones, she is 61 and has returned to the ward about 2 hours ago following an open Hartman’s procedure for a ruptured diverticulum. She has a history of Type 2 diabetes which she takes insulin for.
The operation went well and they estimated a blood loss of about 800 mls. Her observations have been stable but have started to change a bit when I just did them. Her heart rate is 115, her respiratory rate is 22, and her oxygen saturations are 94% on O2 at 2L/min via nasal prongs. Her BP is 100/50. She is afebrile. She has N/Saline running at 125 mls per hour via an IVC in her right hand. She has an IDC insitu and her urine output has been 10-20 mls per hour since she came out of theatre. The dressing to her midline incision is intact with a small amount of ooze. She has an NGT on free drainage with 4th hourly aspirates which has drained 500 mls of brown/green fluid in the past hour. I haven’t aspirated it yet . She is on sliding scale insulin. Her stoma looks OK and isn’t draining anything. She has a morphine PCA and says her pain is 3/10 but it hurts to move. I have just paged the doctor but she hasn’t answered yet.
When you enter Wendy’s room you note that she is in the supine position. Her eyes are closed but she rouses easily when you talk to her. She is now rating her pain at 5/10 and says that it hurts to move or take a deep breath. Her observations are: HR 120, BP 90/50, SpO2 90% on O2 at 2 L/min via nasal prongs. You check her notes and find the following post-operative orders:
· N/Saline 125 mls hour
· Sliding scale insulin
· IDC on hourly measures
· NGT on free drainage with 4th hourly aspirates
This assessment tasks addresses the following subject learning outcomes:
•be able to collect, interpret and document subjective and objective assessment data in the acutely ill person
•be able to link the underlying pathophysiology of selected acute health challenges to their clinical manifestations .
•be able to apply theoretical knowledge, critical thinking, problem solving and the use of best evidence to the planning and implementation of safe and appropriate nursing interventions for people experiencing selected acute health challenges
Please use the following books a reference:
Berman, A., & Snyder, S. ( 2012). Kozier and Erbs Fundamentals of Nursing. Melbourne: Pearson Education.
Brotto,V., & Rafferty, K. (2012). Clinical Dosage calculations for Australia and New Zealand. Sydney: Cengage Learning