Alice McCallum Case Study - Medical Ward - Nursing Assignment Help

Assignment Task

Introduction
74yr old female Alice McCallum was admitted 3 days ago following referral form her GP with confusion and falls risk due to hyponatraemia. On admission GCS was E4V4M6 with associated generalised muscle weakness and bilateral leg spasms.

Situation
Improved significantly with IV 0.9% Sodium Chloride with nil motor dysfunction and GCS E4V5M6. Over the past hour the patient has deteriorated with increased confusion and drowsiness GCS E3V4M6.

Background
PMH: T2DM, Hypertension
Drugs: Metformin 1g tds, Bendroflumethazide 2.5mg od (withheld at present)
Allergies: Nil
Social: Lives alone. Widowed for 10 years. 2 daughters, one lives nearby the other lives in UK.

Assessment/Observations
A – patent. Talking in complete sentences
B – RR 25, Sp02 93% on RA, bilateral equal air entry, nil adventitious sounds on auscultation, CXR clear. Mild increased WOB
C – HR 135, BP 98/60, CRT 4 secs, cool peripheries,
D – GCS 13 (E3, V4, M6). Confused to time and place, PEARL, Pain 0
E – IVC looks swollen, inflamed and red. Painful to touch. Appears a bit shivery. Temp 38.6. Nil other skin tears or breakdown. Patient is visibly thin. BMI 19.
F – IVF continue at 80mls/hr. Poor oral intake. FBC shows - +ve balance over last 12 hours. Urine output 150mls over 8 hours.
G - BGL 15mmoLs via finger prick. Ketones via finger prick - 0

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