Mr Dominic Harve Case Study - Nursing Assignment Help

Assignment Task:

Task:

• Location Surgical ward

• Introduction Dominic Harvey, is a 54 year old male who has worked in construction since he was 15.

• Dominic was admitted for a compound # tibia/fibula L) leg at a workplace accident 6 days ago. Surgery was done to repair.

• A plate and screws were used to stabilise the injury as part of the procedure. Antibiotics were given by the anaesthetist on anaesthetic induction. He had an uneventful post-operative period and was discharged three days later. Dominic was discharged with non-steroidal anti-inflammatory medication for pain relief for 7 days, and opiates for 24 hours, non-weight bearing on crutches, he has an appointment for review with surgeon in 2 weeks.

• Situation Early this evening Dominic re-presented at the ED. Complaining of pain at incision site, nausea and feeling shaky/shivery. Wound site left knee, sutured, skin appears ‘tight’, shiny and red. There are several small areas were dehiscence is evident with pus present. Oxygen therapy has been commenced.

• Background

• PMH: Osteoarthritis, asthma since childhood, tonsillectomy aged 11, #L) wrist age 16, height 168cm, weight: 104kg.

• Drugs: NSAIDS, Ventolin, Seretide accuhaler

• Allergies: Tartrazine (yellow food colouring), cats.

• Social: Dominic is a non-smoker and swims regularly (3-4 times a week), he occasionally participates in squash and tennis with some work friends. He drinks 2-3 units/day on weekends only, he has 5 alcohol free days/week. He has a partner, 52-year-old, Boris Gordon who lives near Dominic and they see each other each day.

• Assessment/Observations:

• A – patent

• B – RR 27, Sp02 94% on 60% oxygen, equal air entry – chest is clear. Verbal report of feeling a little breathless.

• C – HR 125, BP 98/57, cool peripheries, temp 38.3oC

• D – GCS 15, PERL. Pain score - left knee 5/10, 2/10 headache.

• E – Wound site left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present.

• F – IV cannula inserted, PUIB, (too painful to walk to toilet) shortly after admission, 200ml last void, clear straw coloured output, denies need to void since this time. Bowel not open since admission, HNPF.

• G - Glucose 6.1mmol/L at 1900hrs. Nil hx diabetes

• Investigations & results

• FBC – Hb 119, WBC 17.9, Platelets 276, U&E’s – U 5.4, Cr 78, Na 141, K 4.2, Glucose 5.9

• CXR – normal

• HCO3 18, pH 7.2, PaCO2 50, PaO2 90, BE = -4.0, lactate = 3.4

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