Assessment 2: Guided case analysis: The Deteriorating Patient
You are required to complete the guided case analysis, focusing on the clinical side and management for the case scenario of Mr Odd,. (see SIAN, private hospitals or aged care. Using the guided case analysis evaluate the health care needs of the client by cowering the following points:
• Clearly outline the issues and concems that you have identified in the scenario, ensure you are holistic in your writing • Discuss assessments and interventions appropriate for rho client with rationale, ensure you stay relevant to your clinical area and are culturally safe • Outline a Man of care by using the available data and provide a rational for each nursing action based on evidence based and best practice • Describe how you would evaluate and monitor progress towards the expected goals and outcomes
• You are required to provide at least BY 0 contemporary and relevant references for this assessment item. • This assessment item is to be submitted electronically v. Meat via Turnain and will be returned to you by your tutor in the same way. For information on submitting your assessment go to the Student Support Centre in CAInect • Please ensure that your assignment is saved as a Microsoft word document or is Microsoft word compatible. All other formatting should be as per the ACN, Rue. guideline' published on <Wriest
The purpose of this assessment is to use analytical and problem solving skills to create a holistic, culturally safe and evidence based practice approach to assessment and care planning. Using a case analysis approach, you have the opportunity to develop a deeper understanding of safety and quality in health care, assessment, being responsive to care outcomes and identification of a deteriorating patient.
You are required to complete the guided case analysis, specifically referring to your clinical practice area in either public hospitals, private hospitals or aged care. Using the guided case analysis evaluate the health care needs of the client by covering the following points: • Clearly outline the issues and concerns that you have identified in the scenario, ensure you are holistic in your writing • Discuss assessments and interventions appropriate for this client with rationale, ensure you stay relevant to your clinical area and are culturally safe • Outline a plan of care by using the available data and provide a rational for each nursing action based on evidence based and best practice • Describe how you would evaluate and monitor progress towards the expected goals and outcomes
Within your client allocation you are looking after Mr Orkins, an 84 year old gentleman who has been admitted to your unit following a collapse at home. Mr Orkins identifies as being Aboriginal and lives in Broken Hill. Two weeks ago he came to Sydney with his wife to visit his relatives. His past medical history includes: Type 2 diabetes mellitus, hypertension and hyperlipidaemia.
Mr Orkins takes the following medications: • Diamicron 80 milligrams twice daily • Amlodipine 5 milligrams in the morning • Simvastatin 20 milligram in the evening
You receive the following information during morning shift handover: • Last night he was brought to accident and emergency department accompanied by his wife and relatives after his wife found him collapsed at their relative's place • According to his wife he was unresponsive for a short period of time but was orientated to time, person and place afterwards. • According to night duty staff, Mr Orkins had a reasonably good night sleep, walked twice to bathroom under supervision, bowels not open. • His vital signs taken at 0600 hours are between the flags and no pain voiced. After receiving handover from the night nursing staff you enter Mr Orkins' room to greet him and conduct an initial assessment. Upon entering Mr Orkins' room your findings are as follows: • Mr Orkins looks at you blankly when you greet him and introduce yourself • Mr Orkins is lying on the bed slightly slumped onto his right side • When you enquire about how he was feeling, you notice that Mr Orkins makes an attempt to respond to you, however, he has slurred speech. His face is drooped towards his right side and saliva is drooling from his mouth • You notice that there is an odour of urine present in the room.
You check Mr Orkins' vital signs which are as follows: • BP = 150/98 • HR = 98 bpm • RR = 24 bpm • Sp02 = 93% on room air • Nil pain voiced.
You also check his blood sugar level which is 10.4 mmol/mL You conduct a neurological assessment: • GCS = 13/15 (E=4, Y=3, M=6) • Pupils reactive, right = size 4, left = size 2 • Strength = 3/5 for upper and lower extremities right side, and 4/5 for upper and lower extremities on the left side.
While trying to assess him he seems reluctant for you to attend to his personal hygiene, you seem to remember that from your training that sometimes people prefer nurses of the same gender for personal cares and you are a female.
Question Part 1: Clearly outline the issues and concerns you have identified during your primary, secondary and focused assessments in relation to Mr Orkins' current status.
Question Part 2: Explain the process for conducting primary, secondary and focused assessments in the context of this patient.
Question Part 3: Discuss the nursing interventions appropriate for this patient based on your concerns and issues identified in Part 1, your findings and available data. In your discussion include interventions that are holistic, culturally safe and evidence based best practice. Provide relevant rationales for each of your nursing interventions and describe how you would evaluate and monitor Mr Orkins' expected outcomes.
Case study analysis
Answer to the question no- 1
Emergency department nurses will be in charge of the intense evaluations of patients presenting with trauma. The essential primary assessment and focused assessment takes into account the identification of life threating conditions and the right administration to be executed. The segments that make up the base will be talked about in more detail. The tables beneath layout the issues and concerns recognized amid primary, secondary and focused evaluation in relation to the Mr. Orkins’ current status (Bernstein, 2019) .
•84 years old
Chief complaint- difficulty in speaking
Secondary or focused assessment - In a secondary assessment we are looking for the full set of the vital signs. It must be needed to know the specific condition the patient may have-
Nil pain voiced
Answer to the question no-2
The primary assessment helps to identify the life threating conditions and the right administration to be executed. The primary assessment is designed to identify and detect all immediate threats to life. The following abbreviation ABCDE gives the foundation of the essential evaluation and it is a simple method to recollect the correct order for assessing patient presenting to the emergency department. Generally the primary assessment has a 6 six component (Peterson, 2015).
General appearance of the subject- The general appearance of the subject will help to you to identify gravity of the subject’s condition on the basis of his level of discomfort and frame of mind (Stedman, 2016).
Check for the patient mental status- It will help you to determine if the patient is receptive or unaware. Identify the mental status condition by the AVPU scale.
Alert- we talked to the Mr. Orkins’ to check if he will be awake, responsive and aware.
verbal- The patient who is unreceptive at the first, however will react to a loud verbal stimulus from you- Note that the term verbal does not mean that subject will indulge in proper discussion with you. The subject may respond in form of grunts, moans or even snorts (Musen, & van Bemmel, 2017).
P - Painful. Many times when subject does not respond to verbal stimulus, he is still capable of responding to pain such as applying pressure to breastbone or shoulder (Cheesbrough, 2011).
U - Unresponsive. What happens if the subject fails to respond to verbal as well as painful stimulus?
Check for the subject’s airway- is the subject’s airways open? The airways are the most important component that should be maintained to prevent the hypoxic condition. As a nurse you have to assess the patient:
•For airways obstruction,
•To clear the open airways,
•Check for loss teeth,
•Check for bleeding, edema and vomitus
Check for the patient Breathing- Breathing will be checked after the airways but during the times of acute injury and trauma the respiratory system can be compromised.
•Observe chest wall symmetry
•Check for tracheal wall positioning
•Look for cyanosis
•Observe and count the RR (respiratory rate)
•Auscultate the lungs
•Listen for stridor, wheezing or grunting sounds
Check for the patient’s Circulation-Sufficient circulation must need to maintain the cellular oxygenation. This are must involve the heart, vessels and blood volume. Is there heartbeat in subject? Is there serious blood loss? Was there significant blood loss from your arrival?
•In the event that the patient isn't breathing; check the beat at carotid area
•In the event that the patient is breathing; you can check the carotid or wrist area
•In the event that you record the nearness of a carotid heartbeat however the outspread heartbeat is missing this may speak to a stun circumstance. A quick or feeble heartbeat may likewise speak to a stun circumstance.
•Any uncontrolled draining may progress toward becoming dangerous; you are just worried about Profuse bleeding amid the underlying evaluation
•Blood that is light red might originate from an artery
•Bleeding that is murkier normally mirrors a venous origin
•You should worry about the aggregate blood lost, not how quick or moderate the blood loss is.
•Additionally check for the skin signs – color or temperature. Anomalous discoveries, for example, pale, cool and moist skin could be a sign of concussions (Kraf, and Lanros, (2019).
Secondary and focused assessments-
A focused assessment must be performing just after the primary assessment. The focused assessment includes a physical check-up that targets the specific injured area and rapid examination from head to toe. It is also the step taking the patient history from their family to find any past medical condition and vital signs. In case of Mr. Orkins we did the secondary focused examination and conclude that it has the problem with their right side facial nerve (SELL, 2019).
Patient history- The subject’s medical history gives us insight on the current status or conditions, as well as the past medical conditions that could be related to the current condition. When we are talked to Mr. Orkins’ family to know more about the Mr. Orkins’ than we found that he has (Wise GEEK.., 2019).
History of present illness-
•Difficulty in responding
•Face drooped towards the right side
•Saliva is drooling from his mouth
•He was very uncomfortable and restless
•Pulse rate, blood pressure and respiratory rate was normal
Other medical condition-
•type 2 diabetes mellitus
Medications taken by Mr. Orkins;
•Diamicron 80 mg twice daily
•Amlodipine 5 mg in the morning
•Simvastatin 20 mg in the evening
After taking the patient past history we conduct the focused assessment to find the specific injury or any medical complaint-
Vital sign- Mr. Orkin’s vital signs after assessment-
•HR- 98 bpm
•RR- 24 bpm
•sp02- 93% on room air
•blood sugar level- 10.4 mmol/ml
Answer to the question no-3
After conducting the initial and secondary assessment to the patient we able to find that the patient has the lesion in the facial nerve due to trauma. A neurological assessment to check motor and sensory deficits is important to check the level of consciousness because it can affect the airways, breathing and circulation. When we conduct the neurological assessment than following date we get (Treloar, 2019).
•Pupils reactive, right- 4, left- size 2
•Strength – 3/5 for upper extremities right side and 4/5 for upper and lower extremities on the left side (PRACTICE GUIDE, 2014).
Intervention the nurse can implement-
Ongoing neurological assessments- The neurological evaluation is an integral part in care of the neurological patient and it can enable the health care professional to distinguish the presence of neurological malady or damage and screen its development. It will likewise help the individual directing the evaluation decide the type of consideration to be given, and check the patient's reaction to those intercessions. Explicit signs and indications showed by the patient are related with particular zones of the brain and medical attendants watch for these signs and side effects that might be irregular and connect them to general zones of the sensory system that might cause the unsettling influence. One should likewise perceive when further neurological damage is showing and mediate fittingly, and inform the doctor in control for an adjustment in plans with respect to the patient
Observe for signs for increased ICP- After ongoing neurological assessment nurses observe the patient for increased Intra cranial pressure that may be link to the lesion that may be found in the neurological assessment and it is your responsibility to notify the physician about the patient condition on time.
Splint any deformed limbs- If the patient found with any deformities in the limbs than nurses have to provide support to the patient to do his usual activity.
Patient positioning- note for the patient positioning and notify about the patient positioning to physician it will help to diagnose the further information in case of emergency.