NRSG370 Jane Austin Case Study - Clinical Reasoning Cycle - Level Of Consciousness - Nursing Assessment Answer

Jane Austin Case Study Clinical Reasoning Cycle Level Of Consciousness Nursing Assessment Answer

Assessment Task:

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.

Case Study

Jane Austin

Mrs. Jane Austin is a 59-year-old woman admitted to the operating theatre for a laparoscopic cholecystectomy under general anaesthetic following a diagnosis of cholelithiasis and cholecystitis.

Mrs. Austin has a past medical history of hyperlipidaemia, hypertension, a body mass index of 28 and is a smoker. She is compliant with her regular medications Lipitor and Perindopril, and her blood pressure is well controlled.

Emergency department assessment (pre-operative):

Mrs. Austin presented to the emergency department following several bouts of severe right upper quadrant abdominal pain associated with uncontrolled nausea and vomiting. On examination she was tachycardic, febrile (elevated c-reactive protein) and complained of right upper quadrant tenderness on palpation. Mrs. Austin also complains of a recent intolerance to fatty foods, resulting in nausea when ingested. A duel diagnosis of cholelithiasis and cholecystitis was made via ultrasound. A pre-operative chest X-ray is clear.

Post-anaesthetic recovery room (PACU):

You are working in the PACU and receive Mrs. Austin following her surgery (laparoscopic cholecystectomy). The anaesthetist reports the patient had some mild haemodynamic instability during insufflation and maintenance of pneumoperitoneum, and that the procedure was slightly longer than usual because the surgeon had difficulty visualising the common bile duct due to the patient’s weight.

PACU Admission Assessment:

• Level of consciousness – awake and alert;

• Pain 6/10 referring to shoulder tip;

• 4 incision dressings – dry and intact (nil ooze);

• Intravenous therapy running at 125ml/hr Hartmann’s solution;

• Vital Signs: RR 28, HR 115, BP 125/70, SpO2 89% on RA, Temp 37.5° Celsius;

• Blood cultures – negative (no growth after 3 days);

• WCC – within normal limits;

• C-reactive protein – elevated;

• Auscultation – RESP: no air entry to the bases, otherwise clear; GI: no bowel sounds.

• Palpation – mild abdominal distension, abdomen soft on palpation

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