NRSG370 - Medical Surgical - Bianca Lane Case Study - Nursing Assessment Answer

NRSG370: Medical Surgical Bianca Lane Case Study Nursing Assessment Answer

Assessment Task:

Assessment Task 3: Case Study – Medical/Surgical #1

Bianca Lane, 20 years of age, Peritonitis following ruptured appendix Ms. Bianca Lane presented to the Emergency department with a history of 2-3 days of severe
Right Lower Quadrant abdominal pain, lack of appetite, nausea and fever. She has a past medical history of asthma and depression, with her current prescribed and
compliant medications list which includes:

•  Salbutamol
•  Seretide
•  Sertraline

Physical examination of the abdomen and an ultra-sound diagnosed a perforated appendix, which required emergency laparoscopic surgery. Bianca is now 36 hours post-operative and her observations are as follows:

•  BP 94/45mmHg
•  HR 136
•  Temp 38.5°Celcius
•  RR 24/min and shallow
•  SpO 2 95% on room air

She has been complaining of increasing nausea, feeling ‘bloated’ and increasing centralised abdominal pain, that is worse with any movement and respiration, giving it a score of 7/10. Physical examination identifies a distended rigid abdomen, with generalised abdominal guarding and no bowel sounds. To investigate her condition further, a FBC, electrolytes, blood cultures and an abdominal X-ray were organised. Pathology results reveal a raised white blood cell (WBC) count and CRP, blood
cultures are pending. Abdominal X-ray identifies oedematous and gaseous distention of the small and large bowel. You are the RN caring for Bianca post-operatively on the surgical ward.perforw

Identified issue
- Oedematous and gaseous distension of the small and large bowel
- Increasingcentralised abdominal pain
- Sepsis

Introduction

• Assessment and presentation of the condition based and supported by information in the scenario

• Identification of nursing problems based on the clinical scenario and the condition. Identify three nursing problems (You need to support and give rationale to support the identification of the problems.

Identify and discuss one problem at a time). This stage requires of you to read and look for literature to support what you are talking about.

Do not concentrate on the pathophysiology but you need to give rationale based on the understanding of what causes the problem; Example; state the problem and the likely cause of the problem as per condition and why the problem has occurred or is likely to occur 1. 1. 1. Potential to develop dehydration supported by patient vomiting three times (explain and given rationale relate to scenario) 2.

2 ------------------- 3.
3 ------------------- o Do not just identify the problem give a short explanation

• Discuss the nursing interventions and nursing management of the three identified problems (as per appendix D in unit outline). Discuss one nursing problem at a time.
For example: o

1. Potential to develop dehydration. You need to state the goal and then discuss the nursing interventions that you would carry out to manage this condition or issue; give rationale to substantiate what you are doing and why you are managing the condition the way you are based on the clinical/client condition supported with literature which in this case talks about how dehydration is managed in this particular condition. o 2. Problem 2 discussed in same format as above

o 3. Problem 3 discussed in same format as above This stage also requires you to search for information to support your discussion of nursing interventions.

• Conclusion

APA referencing and intext

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