NS3881: Nursing Practice 5 - James Cook University - Litia Nelson - Case Study Assessment Answer

Subject Code: NS3881

Case Study Assessment Answer

Assignment Task: NS3881 A primary and secondary assessment has been performed, along with radiology and pathology for Litia Nelson. You are to read the following information, extract the important points and present your findings in a systematic primary and secondary format including both her pre-existing and current health conditions. Litia is a 5-year-old female child back seat passenger in a vehicle travelling at approximately 80km/hr that rolled and landed on its roof. Litia was sitting on the passenger side in an adult seatbelt that was not appropriate for a child her age. Her mother was also involved in the accident and is currently in surgery at this hospital. 3 other occupants were transferred to a nearby clinic and Litia and her mother were flown via RFDS to this tertiary facility. She was fully conscious when first responders arrived and still in the vehicle, although upset as she doesn’t know what has happened to her parents. She had 2 PIVC inserted, given 20mcg IV fentanyl and she slept in the plane. Vital Signs at the scene – HR 142 and regular, RR 33, BP 88/63, SpO2 97% RA GCS – 15/15A hospital discharge letter was found with her medications and outlines the following information: Nil known allergies. Diagnosed with epilepsy when she was 3 – in 2017 Litia loves unicorns and rainbows. She was recently discharged from hospital 2 days ago after being treated for a right middle and lower lobe pneumonia She had 5 days of IVAB’s and is now on oral AB’s, although none have been taken as yet. No other history is known to you. 1The results of her primary and secondary survey were: ECG – sinus tachycardia. FAST scan performed, no free fluid identified. airway patent, C-spine was cleared by the consultant following a CT scan and she is now sitting up, although drowsy. Peripheries are cool to touch, cap refill 4 seconds, central capillary refill <2 seconds PR 152 and regular, BP 90/65. She has a laceration to the left temporal region and a head CT shows a small linear skull fracture, and a fractured left zygoma. Litia has 2 older brothers and 3 dogs. No cerebral bleeds are detected. No obvious blood or fluid from ears or nose. Dried blood to face from head laceration, trachea midline. Other occupants of the care were transported to a nearby clinic, so there is no other family present. ILO called to stay with Litia, and contact the family. Nil pain to posterior region, nil obvious injuries. RR 38, Sp02 91% on room air, NP at 1L/min were applied and sats increased to 96% Use of accessory muscles noted, intercostal and subcostal retraction, tracheal tug, and nasal flaring decreased breath to sound right side. CXR shows a small pneumothorax right side. Doctors need to speak with Litia’sb mother Estelle who is currently being prepped for theatre. Some bruising noted to the right lateral chest, no other scars or deformities noted. You have been asked to set up for the insertion of a chest drain. 2 x IVC left and right CF, both flushed and patent. No IVT infusing at the current time. She was incontinent of urine at the scene and has passed urine in a pan while in the department, Bladder scan post void showed little residual volume. Pathology – FBC, UEC, LFTS, group and hold, ABG taken. GCS 13/15 (E3V4M6), PEARLA. Confused to place and time, drowsy and responsive to voice. Says she has pain to her head and right side chest, on the Wong-Baker scale she indicates a 6. IV fentanyl 20microg administered. Temp 35.2, clothes removed, and dressed in a gown, all 4 limbs inspected, nil deformities detected. Nil obvious external bleeding. Covered with a warm blanket. Estelle is Litia’s mother and is currently in theatre.

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