AT3 Nursing Case Study Sample
Written analysis of case-based scenario
Purpose: To demonstrate your knowledge and application of clinical reasoning with the best evidenced based nursing practice to the given nursing scenario.
Description: Use the Clinical Reasoning Cycle (Levett-Jones, 2018) to detail the provision of evidence-based, person-centred care for the case study provided.
The following should be included:
1. Detail the person's situation
2. Collect cues/information
3. Process the information
4. Justify the two problems/issues provided to you
5. Establish realistic and relevant goals
6. Take action
7. Evaluate your actions
8. Reflect on what you have learned
Please refer to the details below.
LO Assessed: K1, K2, K3, K4, S4, A1, A2; Assessment criteria: A team of markers will mark the assessment through Turnitin in Moodle. Please see the marking guide on the assessment tab below. To ensure equality in marking across all student cohorts, pre and post-moderation processes will be undertaken for this assessment task.
Referencing Style: Using APA 7th edition, you must reference at least eight contemporary academic sources.
Return of assessment: Results will be released via Moodle grades.
Use the Clinical Reasoning Cycle (Levett-Jones, 2018) to detail the provision of evidence- based, person-centred care for the case study provided. This should detail the person's situation, collection of cues, processing, justification of the issues provided, establishing realistic and relevant goals, taking action, evaluating your actions, and reflecting on what you have learned.
Please use the information below to structure your case report:
Introduction/ Situation (150 words):
• Introduce the case scenario and briefly detail what you will write about
• Briefly identify what you know about the patient
• Consider Sarah's situation focusing on her current health, past health history, and social circumstances.
Collect cues (200 words):
• Document what further information you may need to know about Sarah
• Recall what you know about her current health condition
• Relate information to supporting literature
Process (300 words):
• Identify abnormal detail in Sarah's history and health data provided
• Cluster or group important cues, with patterns of health identified
• Develop inferences/hypotheses of cause of illness/potential problems
• Relate information to supporting literature
Justify the following two problems/issues (200 words):
• Ineffective oxygenation
• Pyrexia
Establish goals (100 words)
• Identify goals of care related to the two issues provided
Take action (350 words):
• Detail with supporting literature the nursing care for Sarah to address the issues to achieve your established goals.
Evaluate (100 words):
• Evaluate your nursing care strategies with what you anticipate Sarah's response will be.
Reflect (100 words):
• Reflect on the process of new learning.
• What did you learn by completing this case study?
• Where do you need to focus your efforts for broader understanding?
Conclusion (100 words):
• Briefly describe what you wrote about and a summarising statement.
References:
• At least eight contemporary academic sources, using APA 7th ed.
Case study scenario:
You are caring for Sarah Smith, a 36-year -old female in the respiratory ward in a large metropolitan hospital.
Sarah presented to the Emergency department yesterday with a 3-day history of increasing shortness of breath, a productive cough, and a fever. On examination, Sarah has decreased air entry and the presence of coarse crackles in the middle-left thorax. A chest X-Ray confirms consolidation in the middle-left lobe. Blood cultures and sputum cultures confirm that Sarah has Community Acquired Pneumonia (CAP). The Covid-19 PCR test is negative, and Influenza PCR is pending.
Medical History
• Mild asthma since childhood, which is well managed with Seretide MDI (Fluticasone propionate) and occasional salbutamol inhaler
• Non-smoker
• Vaccinated for pertussis & Covid - 19 but not influenza
Social History
• Lives with partner Michael and two children aged 8 and 6
• Works part-time as a primary school teacher
Objective data
Temperature 39.2° C
Pulse rate 100 beats/minute
Respiratory rate 28 breaths/min
Blood pressure 110/60 mm Hg
SpO2 92 with 2 L oxygen via nasal prongs GCS 14
A peripherally inserted intravenous catheter (PIVC) L) hand with Normal Saline 1000mls @125mls/hour
Urine output 350mls for the last 12 hours, orange in colour.
Subjective data
• speaking in 5-word sentences, is too breathless to eat and takes small sips of fluid.
• Sarah experiences a constant productive cough with green/light brown sputum.
• Sarah is resting on two pillows.
• Sarah is pale in colour, diaphoretic, and appears exhausted.
• Sarah reports 2/10 pleuritic thoracic pain and declines analgesia.
• Dry mucous membranes and sunken eyes.
Solution
Introduction/ Situation:
The case study focuses on a 36-year-old lady named Sarah Smith who was admitted to the emergency department due to continuous three days of suffering from shortness of breath which was rapidly increasing, high fever or piracy as well as the productive cuff. It has been found that Sarah sustained decreased entry of air as well as the occurrence of coarse crackles within her middle-left thorax. University Assignment Help, after conducting a chest x-ray it was found that the middle-left lobe sustained consolidation and further septum and blood culture confirmed the condition of community-acquired pneumonia (CAP). The medical history of Sarah highlights mild asthma since she was a child as well as no vaccination for influenza for which an Influenza PCR has been performed. The following assessment will focus on analyzing clinical condition of Sarah and preparing a well-structured treatment plan using a clinical reasoning cycle in order to provide better recovery from her condition.
Collect cues:
Focusing on the condition of Sarah, it will be necessary to sustain further information and health and health analysis in order to evaluate the underlying causeway of the health deterioration and development of community-acquired pneumonia. It has been found that Sara has not been vaccinated against influenza, thus influenza PCR results may play a piece of the necessary information to evaluate her health condition. Her current health condition highlights deterioration as she is unable to speak properly and uses 5-word sentences to communicate. Also, she is sustaining an increased state of breathlessness as well as difficulty eating or intake fluids. Sarah's health assessment highlights increased production of green or light brown sputum with cough as well as pyrexia. A major change in the color of sputum and increased production of cough major bacterial or viral infection associated with pneumonia (KARNA et al., 2022). She is also found to be exhausted, and diaphoretic as well as turning pale in color. The pleuritic thoracic pain assessment report highlights 2/10 which indicates severe pain and suffering. It is associated with community-acquired pneumonia as a patient with CAP sustains major chest pain due to inflammation associated with infection (Ticona, Zaccone, & McFarlane, 2021). It has been found that patients suffering from community-acquired pneumonia often suffer from increased shortness of breath severe cuff and fever.
Process:
A Normal human body temperature in adults is 36.6°C to 37.2°C Whereas body temperature of Sarah was increased to 39.2° C which indicates one of the abnormalities in her health assessment. Her respiratory rate at the resting stage of Sarah was 28 breaths/min which abnormally exceeded the normal reference range of 12 to 16 breaths per minute in an adult woman (Marchello et al., 2019). It was found that pressure and pulse rate of Sara was within the normal reference range which indicated no abnormalities. It was also found that Sarah was witnessing a low oxygen saturation level of 92 % despite 2L oxygen flow with the help of nasal prongs where the normal range indicates SpO2 95 %. The Glasgow Coma Scale report of Sarah was 14 which indicated mild condition where she is fully alert and conscious. It was also found that sunken eyes were another major abnormality in the case of Sarah which was associated with dehydration or infection. It has been found that often sunken eyes are associated with inflammation of the sinuses or any major infection (Hamad et al., 2022). On the further assessment of Sarah's health condition, it was found that she sustained abnormal urine output as it was 350 milliliters in 12 hours which was orange in color. In a healthy human body, the urine output volume for 24 hours is around 800 to 2000 milliliters.
Focusing on the abnormalities and changing normal health assessment It has been found that Sara is suffering from community-acquired pneumonia which can be urine output volume associated with the infection of influenza. A wide range of research evidence highlights the fact that community-acquired pneumonia often follows the infection of influenza. As it has been found that Sara was not vaccinated against influenza as well as the influenza PCR result is pending, community-acquired pneumonia associated with influenza can be hypothesized as the cause of her illness
Justify the following two problems/issues:
• Ineffective oxygenation
Analysis of the health condition of Sara it was found that ineffective oxygenation was one of the major issues that were associated with health deterioration impaired gas exchange or oxygenation is known to be the disruption of the carbon dioxide and oxygen exchange within the lung tissues. Sarah had a medical history of asthma since childhood which can be one of the major underlying causes of shortness of breath and impaired oxygenation. Infection with community-acquired pneumonia has a potential impact on underlying asthma symptoms as it exaggerates and causes difficulty in breathing and oxygenation (Gattinoni et al., 2021). Impact gas exchange in patients suffering from asthma as well as pneumonia as the air sacs within the lungs becomes inflamed as well as drowned with increased production of mucus.
• Pyrexia
Fever or pyrexia is one of the major symptoms associated with community-acquired pneumonia. In such a condition the core body temperature of the suffering individual elevates to an abnormal range controlled by the thermoregulatory center within the hypothalamus. Often inflammation and associated infection within the body lead to a systematic inflammatory response which further increases the normal body temperature of the suffering individual (Cuesta et al., 2019).
Establish goals:
Focusing on the developing abnormalities in Sarah's health condition, it is necessary to establish certain goals to manage the underlying complications. One of the primary goals that need to be established is to manage the rising body temperature to the normal range to overcome the condition of pyrexia. It will be necessary to control and prevent increasing fever with the help of regular monitoring and medical assistance. Another goal that needs to be established in the treatment process minimize the increased production of mucus as well as overcome inflammatory response in order to maintain stable and effective oxygenation (Wheeldon, 2020).
Take action:
Nursing care for pyrexia will focus on monitoring the change in body temperature in order to implement various strategies to reduce the temperature as soon as it starts to elevate. Another significant intervention that needs to be implemented as nothing care while assisting Sarah with increased fever is to maintain optimal hydration and avoid the development of dehydration. It is necessary to increase fluid intake as well as maintain the elimination of waste through the body to manage the rising body temperature. Another nursing care that highlights better recovery from Piraxia is to encourage and provide proper rest and sleep to the patient in order to minimize the rising oxygen as well as metabolic demand within the body (Dutton, 2020). It is because, with increased body temperature, the increased demand for oxygen, as well as metabolism, is also witnessed which often deteriorates the health and stability of the patient. Thus in such conditions, hydration, as well as a proper supply of nutrients, needs to be maintained in the case of Sarah to overcome the state of Pyrexia and the associated complication of ineffective oxygenation.
Nursing care for ineffective oxygenation that needs to be addressed in the case of Sara will focus on providing routine monitoring of oxygen saturation. Regular monitoring of oxygen saturation levels with the help of proper monitoring tools will provide an opportunity to assess the abnormality and avoid and avoid further deterioration. Also, it will be necessary to administer 2 liters of oxygen per minute along with pneumonia rehabilitation in order to maintain a stable oxygen supply as well as a normal level of oxygen saturation (Wheeldon, 2020). Pulmonary rehabilitation will provide the patient with an opportunity to overcome the developing lung inflammation as well as experience better breathing. the conditions where the above-mentioned interventions are ineffective, Sarah needs to be evaluated to analyze and acknowledge the need for mechanical ventilation and intuition it is necessary to provide mechanical ventilation as well as intubation as an early intervention in order to overcome the issue associated with impaired oxygenation and avoid total decompensation (Zhao et al., 2020).
Evaluate:
After implementation of the provided nursing care strategies, Sarah will witness normal body temperature with minimized risk of elevation as well as dehydration. The intervention will ensure that the body temperature is normalized and associated risk factors are also maintained under normal conditions (Dutton, 2020). Further, the nursing strategy for ineffective oxygenation will ensure that a normal oxygen saturation level is maintained with minimized risk of increased oxygen demand. It will ensure that oxygen and carbon dioxide are exchanged through normal breathing patterns without any ventilation or oxygen therapy.
Reflect:
The process of new learning provided me with greater knowledge and understanding regarding the need for proper health assessment as well as the clinical reasoning cycle. With the help of the clinical reasoning cycle, it was easier to assess and evaluate the health condition of the patient as well as the different complications that were progressing toward health deterioration It also provided me with an opportunity to plan better nursing care with an aim overcome the complications and maintain stability in health. It is necessary to understand the clinical reasoning cycle in a much better manner in order to evaluate the status of a patient in a much more complex matter as well as maintain critical thinking and decision-making capabilities.
Conclusion:
The assessment focused on analyzing the case study of Sarah and based on the evaluations, the health issues and complications, as well as the health cues, have been clearly established. It has been found that Sarah was suffering from community-acquired pneumonia which is suspected to be associated with influenza. Further based on the complications and issues witnessed by the patient appropriate care goal and a nursing care plan has been provided to ensure better recovery from the condition.
References:
Cuesta, M., Slattery, D., Goulden, E. L., Gupta, S., Tatro, E., Sherlock, M., ... & Thompson, C. J. (2019). Hyponatraemia in patients with community?acquired pneumonia; prevalence and aetiology, and natural history of SIAD. Clinical Endocrinology, 90(5), 744-752. https://doi.org/10.1111/cen.13937
Dutton, H. (2020). Assessment and recognition of emergencies in acute care. In Acute Nursing Care (pp. 1-34). Routledge. https://doi.org/10.4324/9780429434938
Gattinoni, L., Gattarello, S., Steinberg, I., Busana, M., Palermo, P., Lazzari, S., ... & Camporota, L. (2021). COVID-19 pneumonia: pathophysiology and management. European Respiratory Review, 30(162). Retrieved from: https://err.ersjournals.com/content/errev/30/162/210138.full.pdf
Hamad, A. J., Albdairi, A. J., Alkemawy, S. N. Y., Khudair, S. A., & Abdulhadi, N. R. (2022). Assessment of the incidence and etiology of nosocomial diarrhea in a medical ward in Iraq. Journal of Medicine and Life, 15(1), 132. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8852629/pdf/JMedLife-15-132.pdf
KARNA, G., PATTAR, S., PANDA, P. K., & SHAH, R. (2022). Chronic Indolent Community-acquired Pneumonia due to Pseudomonas Infection in an Immunocompetent Patient-A Case
Report. Journal of Clinical and Diagnostic Research, OD7-OD9. Retrieved from: https://www.researchgate.net/profile/Prasan-
Panda/publication/358785488_Chronic_Indolent_Community-acquired_Pneumonia_due_to_Pseudomonas_Infection_in_an_Immunocompetent_Patient_-_A_Case_Report/links/62151a6b6164255c72faf16f/Chronic-Indolent-Community-acquired-Pneumonia-due-to-Pseudomonas-Infection-in-an-Immunocompetent-Patient-A-Case-Report.pdf
Marchello, C. S., Ebell, M. H., Dale, A. P., Harvill, E. T., Shen, Y., & Whalen, C. C. (2019). Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: a systematic review and meta-analysis. The Journal of the American Board of Family Medicine, 32(2), 234-247. Retrieved from: https://www.jabfm.org/content/jabfp/32/2/234.full.pdf
Ticona, J. H., Zaccone, V. M., & McFarlane, I. M. (2021). Community-acquired pneumonia: A focused review. Am J Med Case Rep, 9(1), 45-52. Retrieved from: http://article.americanmedicalcasereports.com/pdf/ajmcr-9-1-12.pdf
Wheeldon, A. (2020). The patient with acute respiratory problems. In Acute Nursing Care (pp. 135-183). Routledge. https://doi.org/10.4324/9780429434938
Zhao, H. M., Xie, Y. X., Wang, C., Chinese Association of Rehabilitation Medicine, Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation
Medicine, & Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation. (2020). Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chinese medical journal, 133(13), 1595-1602. Retrieved from: https://mednexus.org/doi/epdf/10.1097/CM9.0000000000000848
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