NRSG370 - High Dependency - Mr. Daniel Hughes Case Study - Nursing Assessment Answer

Assessment Task:

NRSG370: High Dependency Nursing Assessment Answer

Mr. Daniel Hughes

Mr. Daniel Hughes is a 28-year-old man admitted to the High Dependency unit (HDU) of a large metropolitan hospital. Daniel was brought in via the Emergency Department early this morning by his mother and girlfriend, following a 2-day history of generally feeling unwell, vomiting, polydipsia and malaise. He is also recovering from a very mild cold. You are the nurse caring for Daniel in HDU 24 hours post his hospital admission.

History: T1DM for 10 years, and ICU admission for DKA 5 years ago otherwise well, uneventful appendicectomy 5 years ago. Non-smoker, social drinker, NKDA. Lives with girlfriend works full time.

Medications: Humalog 8 -16 u/s PC, Lantis 28u/s nocte

On admission in HDU:

•  Vital signs: SpO2 98% on RA, HR 125bpm, RR 35 (Kussmaul type with acetone smell), Temp  37.3° Celsius, BP 100/60; GCS 14/15 PEARL, pain 3/10 central abdomen.
•  Physical assessment: restless, c/o thirst and nausea with intermittent vomiting. Abdo is lax, chest is clear, skin in dry.
•  Urine output 0.25ml/hr

Investigations:

1.  BGL 26.1 mmol/l
2.  Ketones high on finger prick
3.  Urinalysis: Ketones +++, Glucose ++, Micro haematuria.
4.  FBE: mildly elevated WCC and haematocrit, otherwise NAD
5.  Urea & Electrolytes: Sodium 150mmol/l, Potassium 3.3mmol/l, Calcium normal range, Magnesium & Phosphorus mildly low.
6.  C-Reactive Protein: Mildly elevated
7.  Blood Cultures: Nil growth after 1 day
8.  Troponin: Within normal limits
9.  Chest XRAY: Clear
10.  Arterial Blood Gas (ABG): pH 7.15, PaO2 105, PaCO2 35, HCO3 14

Interventions:

1. 18g cannula in Left Cubital fossa, with 4hourly Dextrose (5%) alternating with Hartmanns Solution 1L bag insitu (with supplemental KCL in bags)
2.  20g Cannula Right Cubital fossa with Insulin infusion commenced 50u/s Actrapid in 50mls of NSaline (1u/ml) at 4mls/hr
3. Normal ABG ranges: pH 7.35-7.45, PaO2 85-90, PaCO2 35-45, HCO3 22-26

Assessment Task 3: Case Study

Students will complete a case study which discusses the provision of ethical, legal, evidence- based, holistic person-centred care including the establishment of realistic and relevant goals through the theoretical examination of a particular nursing specialty case study using the Clinical Reasoning Cycle (Levett-Jones, 2018).

Student are expected to use the Clinical Reasoning Cycle (Levett-Jones, 2018) as a framework to plan and evaluate person-centred care. You are being asked to think through the case scenario and then discuss how data was collected and the type of data collected, identify problems and nursing issues, identify and state the objectives and discuss how care was provided in order to address the issues and evaluate the interventions carried out: (analyse and identify a nursing issues/problems/needs, set objectives, discuss the nursing interventions and evaluate the interventions of care carried out).

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