NURBN2022 Case Study 3 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.
Due date: Monday, 24th of April 2023, at 23:59 hours
Submission: Turn-it-In via Moodle
Length: 1600 words (+/-10%). Work outside of this range will be marked down accordingly.
Weighting: 40% of the overall course grade.
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
The current case is regarding Sarah Smith, who is a 36 years old female who has been admitted to the respiratory ward. Sarah was admitted due to a 3-day-long history of shortness of breath and productive cough, as well as fever. Based on the initial assessment by chest x-ray and blood and sputum culture report, it can be identified that she is suffering from community-acquired pneumonia (CAP). Uni assignment help, the patient went through a Covid-19 PCR test; however, the influenza PCR test is not done yet. The covdi1- PCR report provided a negative result, and the patient had no history of taking influenza vaccine; thus, there is high susceptibility to CAP. Her medical history reported asthma though she is not a smoker, and she had been vaccinated for pertussis and covid-1 but not for influenza. This case study analysis of Sarah will focus on documenting further health assessments required for her and details of nursing intervention for the issues identified mainly based on the assessment, which are ineffective oxygen and Pyrexia.
Collect cues
The assessment and previous health records highlight that Sarah’s influenza test is still pending. This test must be completed to define the current condition of infection based on which medication can be administered. Her current health condition highlights a high fever of 39.2 degrees C and a pulse rate of 100 beats/minute, as well as a respiratory rate of 28 breaths/minute. She has a blood pressure of 110/60 mm Hg, and her SpO2 level is 92 with 2L oxygen through nasal prongs. Her urine output has been 350 ml for the last 12 hours, mostly orange. While analysing subjective data it can be identified that she is suffering from shortness of breath and she is taking small sips of fluid. Sarah also has dry mucous membranes and sunken eyes; thus, there are also symptoms of dehydration. Thus, her cough, fever, as well as blood pressure is needed to be managed along with other symptoms of influenza. As mentioned by Davis (2020), there are certain common symptoms of influenza, including chest tightness and coughing, as well as general aches. Based on the assessment, it can be identified that Sarah has shortness of breath and constant production cough; thus, there is a high suspicion of influenza, and CAP has already been suspected for her.
Process
Abnormal data in their medical history of Sara include mild asthma, as her subjective data signifies, she has a pale skin colour, as well as diaphoretic, and she appears exhausted. While assessing pain, she reported 2/10 for pleuritic thoracic pain and declined analgesia. Based on the assessment, the major clues or information that highlight the potentiality of the health condition, such as deficiency of oxygen and excessive temperature (Kumar, 2020). In the case of influenza and pneumonia, there is the development of respiratory distress syndrome due to the infection of the lungs and respiratory tract. Due to excessive respiratory distress in the case of Sarah, there is the presence of shortness of breath. The continuous generation of cough has led to trouble breathing which has impacted her pulse rate also. Har fever is also high, which needs to be controlled properly to avoid future consequences. Her pale skin and dry mucous membrane signify the possibility of dehydration associated with a high fever. As stated by Fan et al. (2021), place skins are common in 70 percent of cases of pneumonia, and these cases are known as erythema. Based on their current symptoms, Sarah can be identified as clusters, symptoms signify severe chest infection, and shortness of breath signifies continuous progress in a cough that can lead to a severe condition in future. Due to her breathless condition, she is feeling too exhausted to speak, and it is also affecting her eating and drinking frequency. Thus, there is a need to manage the chest infection and ensure enough hydration and nutrition to build immunity against chest infection.
Justification of two issues
Ineffective oxygenation can be explained as a situation where the breathing pattern and rate are altered, and the breathing pattern is abnormal. This situation occurs due to impaired oxygen and carbon dioxide exchange in the lungs, impairing breathing. Infective oxygenation is a result of disrupted breathing or a blocked airway. In the case of Sarah, the issue is a blocked airway through the continuous production of cough and chest infection. Effective oxygenation has resulted after the shortness of breath and has impacted her blood pressure level and pulse rate. As stated by Tarrant et al., (2019), cough clearance measures must be applied to promote oxygenation flow in the lungs. In the case of Sarah, her oxygen levels are low she requires oxygen treatment for nasal prongs. Her ineffective oxygenation issues need to be managed.
Pyrexia can be defined as high body temperature and the normal temperature is considered 37 degrees. In the case of Sarah, her temperature is 39.2 degrees C, thus more than 2 degrees higher than the normal temperature of the significant presence of Pyrexia. In this context, Robertson and Hill (2019) mentioned that there are certain consequences of Pyrexia, including vasodilation and hypertension are the initial stages through which the body releases the temperature through radiation. During the rapid increase in temperature, the person can suffer from shivering, and certain episodes of feeling cold and the body temperature evaporates through the skin. There is a need to monitor changes in a temperature increase of Pyrexia continuously; similarly, in the case of Sarah's, there is a need for similar measures. One of the major methods of dealing with this condition is maintaining hydration which is also needed in the case of Sarah.
Establishing goals
? For infecting generation, there is necessary to ensure cough clearance measures to clear the airways, track and continue oxygen support, and monitor the progress of chest infection.
? For managing pyrexia temperature, Sarah needs to be managed. Proper hydration is needed to be ensured, and monitoring of temperature and recording temperature is needed. In case of severity, there is a need to consider immediate consultation with a doctor.
Taking action
Currently, Sarah is dealing with oxygen deficiency and breathing trouble; thus, oxygen therapy is recommended for her. Storgaard et al. (2020) mentioned that while applying oxygen therapy, continuous monitoring and assessment are needed to understand any discomfort a patient faces. In the case of Sarah here thus a 35-degree bed position needed to be maintained, and there was a need to check changes in breathing and pulse rate for changing oxygen therapy levels. Further, there is a need to ensure that throughout the process, the patient feels safe, and it is also necessary to ensure that there is no infection when the patient is administered.
Pyrexia is needed to be managed by maintaining proper hydration. Hsiao (2022) stated that Pyrexia must be managed through antipyretics and physical cooling. In the case of Sarah, thus, based on the condition, both are needed to be applied. Also, there is a need to maintain adequate hydration.
Evaluate
In case of ineffective oxygenises there is a need to maintain oxygen balance in the blood and reduce respiratory issues and breathing trouble. In general, the SpO2 level is needed to be 94 percent, and in the case of Sarah, the level is 92, and she is administered 2 L oxygen via the nasal prongs. Thus, during the administration of oxygen therapy bed position is maintained. McNicholas et al., (2019) mentioned that sleep position or bend position during oxygen therapy helps to ensure clear away to avoid breathing trouble.
In the case of Pyrexia, proper hydration will be maintained, in the improvement in the condition will be witnessed through a reduction of temperature.
Reflection
This coursework has allowed me to complete case assessments considering the clinical reasoning cycle. In the case of Sarah, I have become able to understand the importance of depending on existing information and identifying future information needs to ensure evidence-based care facilities. This learning cycle and the case have allowed me to assess any case based on existing data and based on future data requirements for proper diagnosis of a healthy condition. Further, this learning has helped me to focus on immediate issues identified in the case of a patient with infective organisation pyrexia in the current case.
Based on the case, I have identified that there is a need to focus on areas of oxygenises as well as body temperature in case of influenza and pneumonia is suspected. In the case of Sarah, CAP was suspected, and they thought there was a high possibility that an influenza test was pending. Thus, I have learned that before diagnosis, to ensure accuracy in diagnosis, there is a need to go through a series of tests to make the right decision.
In the future, I will further work to improve my knowledge of diagnostic tests. I will focus on identifying the most suitable diagnostic tests for the specific health issues for the evidence-based care facilities.
Conclusion
Thus, based on the case assessment, it can be identified that in the case of Sarah, there is a severe chest infection which is still needed to be properly diagnosed. She lacks hydration, for which dry mucous membranes and place skin colour are witnessed. There is also a need to focus on areas of managing temperature and reducing cough production leading to scarcity of oxygen. Sarah is also suffering from high temperature or Pyrexia, which is needed to be managed through monitoring of temperature changes and consultation of medication.
References
Davis, S. (2020). Managing the symptoms of colds and flu. SA Pharmacist's Assistant, 20(1), 10-11. https://journals.co.za/doi/abs/10.10520/EJC-1e4363ebc8
Fan, X., Luo, Y., Lu, J., Xu, J., Chen, Q., Guo, H., & Jin, P. (2021). Erythema multiforme major associated with community-acquired pneumonia: lessons from a case report. Frontiers in Pediatrics, 9, 698261.doi.org/10.3389/fped.2021.698261
Hsiao, B. H., Tzeng, Y. L., Lee, K. C., Lu, S. H., & Lin, Y. P. (2022, June). Impact of an Educational Program on Improving Nurses’ Management of Fever: An Experimental Study. In Healthcare (Vol. 10, No. 6, p. 1135). MDPI. https://www.mdpi.com/2227-9032/10/6/1135
Kumar, V. (2020). Pulmonary innate immune response determines the outcome of inflammation during pneumonia and sepsis-associated acute lung injury. Frontiers in immunology, 11, 1722. doi.org/10.3389/fimmu.2020.01722
McNicholas, W. T., Hansson, D., Schiza, S., & Grote, L. (2019). Sleep in chronic respiratory disease: COPD and hypoventilation disorders. European respiratory review, 28(153). https://err.ersjournals.com/content/errev/28/153/190064.full.pdf
Robertson, M., & Hill, B. (2019). Monitoring temperature. British Journal of Nursing, 28(6), 344-347. https://nrl.northumbria.ac.uk/id/eprint/39063/1/Monitoring%20temperature%20-%20BJN%20approved%20final%20draft%20pre-printed%20version_.pdf
Storgaard, L. H., Weinreich, U. M., & Laursen, B. S. (2020). COPD patients’ experience of long-term domestic oxygen-enriched nasal high flow treatment: a qualitative study. COPD: Journal of Chronic Obstructive Pulmonary Disease, 17(2), 175-183. https://www.tandfonline.com/doi/pdf/10.1080/15412555.2020.1736998?needAccess=true&role=button
Tarrant, B. J., Le Maitre, C., Romero, L., Steward, R., Button, B. M., Thompson, B. R., & Holland, A. E. (2019). Mucoactive agents for adults with acute lung conditions: a systematic review. Heart & Lung, 48(2), 141-147. https://ltu-figshare-repo.s3.aarnet.edu.au/ltu-figshare-repo/32024300/Thesis.pdf?AWSAccessKeyId=RADjuIEnIStOwNiA&Expires=1681735449&Signature=y1Qk8rHTGSwakzElbBd%2FjOLwdtI%3D#page=50
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