Subject Code & Title: NUR2004 Health
Weighting: 50% of overall grade
Length: 1500 words
Individual Assignment
Assessment Type: Case Study Report
Rationale: The purpose of this case study is to assess the student’s ability to interpret clinical observations, recognise deterioration and link theory to practice in regards to communication, and patient care.
NUR2004 Health Assessment – Southern Cross University Australia.
Case Study Scenario:
You are a registered nurse who works in the fracture clinic at your local public hospital. Brian Lawson broke his left foot 7 weeks ago after he tripped at home. It was a complicated fracture requiring surgery to insert pins and after 6 weeks they removed his cast and discovered a small pressure injury on his left heel. They have given Brian an orthopaedic ‘moon boot’ and begun light weight bearing activity, but Brian must visit the clinic every 2 days to check and dress his pressure injury.
The wound healing is progressing well, but on the last visit 2 days ago you noticed that Brian said he was not ‘feeling 100%’ and hadn’t been able to move around very well as his fractured foot was ‘giving him grief’. Up until now, his pain has been well controlled and he only needed Paracetamol at night.
When he arrives today, you notice he is slow to walk across the room, is using his crutches again,and he doesn’t seem his friendly self and so you conduct an A-G assessment to see what you can reveal.
PMHx:
• Longstanding Type 1 Diabetes
• Arthritis
• Family history:
o Mother Alzheimer’s
o Father: hypertension, myocardial infarction 20 years ago, 2 stents inserted.
NUR2004 Health Assessment – Southern Cross University Australia.
Social History and Diet
• Strong family support- lives with wife and has two adult children
• Moderate exercise and socially active.
• Enjoys 1-2 beers a night.
• Doesn’t drink very much water but watches what he eats to keep his diabetes under control
Medications:
• Insulin Glargine (Lantus) 100U/mL dose varies according to blood glucose level
• Actrapid PRN for intermittent Hyperglycaemia
• Ramipril 5mg in the morning for Hypertension
• Paracetamol 1 Gram when needed.
A-G observations:
Airway and Breathing:
• Respiratory rate: 22pbm
• O2 saturations 98% on room air
Circulation:
• Blood Pressure 129/67
• Heart Rate 89bpm regular
• Temperature 36.6C
• Left foot appears more swollen than 2 days ago.
Disability:
• GCS: 15, orientated to time and place
• Pain:
o 7/10 in left leg.
o Cramping pain in his left calf
o Tells you he needed to take an End one tablet last night.
Exposure:
• Wound assessment: The pressure area wound is pink and granulating which is the same as the last visit.
• The skin on the left calf looks red, is warm, and Brian complains that it feels like he has a constant cramp in it and it is sore to touch.
Fluids:
• Brian says he has been eating and drinking enough.
• He has not opened his bowels today
Glucose:
• His BGL: 7.1mmol
TASK: Case Study Report
1.Introduction: Provide a brief introduction explaining the content of this report and the scope of the discussion. Introductions are designed to capture the reader’s attention and outline the content of the report succinctly.
2.Consider the Cues:
After considering the patient scenario, discuss the observations that are of most concern to you, and how they differ from normal. Identify and discuss other types of assessment that you should conduct to provide you with more information and provide your reasons for why you have chosen them.
3.Process information:
You suspect that Brian may have a Venous Thromboembolism (VTE). Using high-quality evidence from the literature, discuss the pathophysiology of this disease and the potential outcomes and complications that could occur for this patient if the problem is left untreated. Review the Australian Clinical Standards for VTE prevention and discuss how VTE risk is assessed, and prevented for an inpatient in a QLD or NSW facilities.
4.Nursing Action:
You are required to report your findings to the ortho paedic surgeon during Brian’s visit.Discuss the importance of both verbal and written communication when escalating patient deterioration, the evidence-based methods you can use to communicate and the QLD or NSW policy guidelines that guide your communication.
5.Conclusion:
Summarise your report succinctly describing all the main findings to the reader.
NUR2004 Health Assessment – Southern Cross University Australia.
6.Reference List (not included in the word count)
Your assignment will also have a reference list at the end. Ensure all references that appear in the Case Study report are listed in your reference list.
1.The reference list is not included in the word count
2.The Case Report must include at least 8 reputable references to support your statements. These only include textbooks, government documents, websites,guidelines, and policies or peer-reviewed literature sourced through the library databases.
3.References will be no more than 5 years old.
4.Use APA 7th reference style.
5.Ensure the reference list is on a new page and they are listed in alphabetical order
6.For access to the online APA 7th style of referencing guide
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