NSG3201 Nursing care D – Clinical Deterioration

CASE STUDY
You are a nursing student working in an acute medical ward. You and your buddy nurse have just been handed over a new patient from the morning shift.

I: Mr Jheka is a 68 year old man. He is day two into his admission. He is designated goals of care A. He has no known allergies. You confirm the patient identity.

S: Mr Jheka has been diagnosed with community acquired pneumonia. He is still suffering from nausea and vomiting and not really eating or drinking much.

B: Prior to admission Mr Jheka had suffered three days of nausea and vomiting, lethargy and increasing shortness of breath. He was brought into the emergency department by his wife who was becoming concerned.

Mr Jheka has a past medical history of hypertension, GORD and benign prostate hyperplasia. At home he takes metoprolol 25mg daily and pantoprazole 40mg daily.

A: The nurse hands over that Mr Jheka’s chest x-ray displays some consolidation to his R) lower lobe. He is covid negative by PCR. The nurse states that he has decrease air entry to both lower lobes and R) sided crackles upon auscultation. She states that Mr Jheka is unable to deep breath and cough properly but his cough sounds moist and is non-productive. Mr Jheka has remained in bed this shift but is able to walk short distances independently. He has one 18g IV cannula in his R) cubital fossa and an in-dwelling catheter size 16f.

His latest set of vital signs are as follows:

HR: 90 bpm and regular BP: 100/60
SaO2: 94% on room air
Temp: 37.1
RR: 22 breaths per minute

R: Unfortunately the previous nurse has been busy, her other patient had a MET call and has required significant interventions. She has stated that there are some outstanding medications for administration and the observations need some catch up. The morning metoprolol was not administered as his BP was ‘a bit low.’

Q. 1: Describe the primary and secondary assessment you would perform on Mr Jheka, making note of any areas of priority considering his known condition.

Q.2:Part A: With reference to the case study and previous findings, identify the condition that Mr Jheka may be suffering from or developing. Linking the assessment data to pathophysiology, provide clear rationale as to how this may have developed

Part B: If left untreated, please identify and justify the potential further deterioration Mr Jheka may suffer. In your justification, include signs and symptoms you would expect to observe. Provide clear rationale to each deterioration point, analyzing how and why this would occur.

Q.3:You decide that Mr Jheka’s condition needs escalation. Examine and describe the appropriate escalation process and provide a concise ISBAR to handover the patient

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