The following excerpts have been taking from a patient – Maisie Wilson’s, electronic medical record.
Maisie Wilson
DOB: 14/10/1948
Sex: F UR: XXXXXXXXXX
Ambulance Notes:
1620 hrs A
ived to find pt lying at bottom of the stairs on her left side. Facial laceration to left
eye
ow approx. 3 cm. Pt reporting pain in L) hip and unable to get up. States she “tripped
on the rug” just after 8am and has been on the floor since, denies falling down the stairs or
LOC. Her husband found her about 1600 when he returned home. GCS 14 – (E4, V4, M6),
orientated to place and person but confused to time. PEARL 2+, BP 150/83mmHg, PR 98
pm, RR 16, SpO2 95% RA, Temp 36.3, Pain 7/10. Pt has been incontinent of urine and
faeces.
1623 hrs IVC inserted and IV morphine 5mg given. C-spine collar placed.
1624 hrs Left leg externally rotated and shorter than right
1628 hrs PR 91 bpm regular, BP 145/75mmHg, RR 14, SpO2 95% RA IV morphine 5mg
1635 hrs Transfe
ed to stretcher with spinal precautions, legs splinted for transport
ED Notes:
1650 hrs, Nursing Notes: New patient Maisie Wilson, 74, admitted to ED via ambulance after a fall at
home. Pt reports being “stuck on the floor” for about 8 hours until her husband found her and called
the ambulance. Pt was found at bottom of staircase from upstairs bedroom but denies falling down
the stairs, stated “I tripped on the rug and hit my head on the banister as I fell”. Pt unsure if LOC
occu
ed but doesn’t think so. Incontinent of urine and faeces while on floor. Pt states hasn’t eaten
or drunk anything today. History of HTN, osteoporosis, osteoarthritis, and a hysterectomy in 2009.
Normally takes atenolol, Panadol osteo and alendronate but pt doesn’t think she had any tablets
today. CNS: Pt alert but confused to place and time, orientated to person. GCS 14 – (E4, V4, M6) and
PEARL 2+. Reports 6/10 pain to L) hip and 4/10 pain to head. Pt given IV morphine 5mg. Spinal
precautions and collar insitu due to fall and head strike. Pt encouraged to lie still but attempting to
get up or move around in the bed. Spinal precautions explained but little change to behaviour, pt
unable to explain why she wants to get up. Pt can move all 4 limbs with normal strength except left
leg which is weaker and painful on movement. No abnormal sensation reported. CVS: PR 100, BP
148/96, pulses palpable in all 4 limbs. Cool to touch centrally and peripherally, temp 36.4. Capillary
efill <3 seconds to all limbs and colour normal. R)cubital fossa IVC inserted by ambulance, no signs
of infection and dressing intact. Resp: RR 19 and SpO2 96% on RA. Chest sounds clear. GIT: Pt c/o
thirst. Given mouth care but NBM at this time. Abdo soft and non tender, bowel sounds present.
Incontinent of faeces while on floor, pt denies normally having any problems with incontinence.
Renal: Denies needing to void now, incontinent of urine earlier. Endo: BGL 3.5mmol/L, no history of
diabetes according to patient. Skin: Laceration to left forehead just above pt’s eye
ow, approx. 3cm
long, awaiting Dr review. Dry blood to face and cut, oozing still when cleaned. Bruising to L) side of
face and L) hip noted. L) leg externally rotated and shorter than R) leg. Grazes to arms noted but
superficial and no dressings required. No other skin
eakdown noted although awaiting log roll to
check pt’s back. Social: Pt’s husband John, in attendance, bought in by ambulance. John stated he
was out playing golf with friends today and found Maisie on his return home. John is very teary and
apologetic to patient, stating “I’m so so
y” and “This is my fault”. Attempted to reassure John he did
nothing wrong. John and Maisie have a son, Michael who lives in Geelong. John has contacted
Michael who is coming in. They also have a daughter Kathy who lives in Canbe
a, she is waiting to
hear from the doctors before she flies down as she is caring for her grandchildren this week. Plan:
Log roll and complete wash and skin assessment of patient once morphine has reduced pain. For Dr
eview and further tests. N.Stewart (RN)
1700 hrs Nursing notes: Pt c/o nausea. IV ondansetron given as per Dr. Bed tilted head up while
maintaining spinal precautions. Further mouth care given as tongue and lips very dry and
cracked. N.Stewart (RN)
1720 hrs ED Dr Nguyen
Admitted post fall at home, on floor 8 hours.
Alert and restless. Confused to time and place, orientated to person. Head strike during fall.
Laceration to face – will need gluing together.
Chest clear, abdo soft
Fasting all day
Pain to L) hip, leg externally rotated and shortened
Plan: L) hip and pelvis xray
Head and spine CT
IV fluid as charted
Glue to face laceration.
NBM till results
Dr K. Nguyen
1830 hrs Addit: CT clear and no spinal tenderness on palpation, remove collar and cease spinal
precautions. Xray shows fracture to left NOF.
Refer to ortho. Pt will need open reduction and internal fixation.
Admit to ward, RIB till post-surgery.
Still c/o significant hip pain despite regular morphine – refer to anaesthetics for fascia iliac nerve
lock.
Dr K. Nguyen
1930 hrs Anaesthetics Dr Kyle
L) leg fascia iliac nerve block given. Pt reports no allergies or previous surgery to area. Ultrasound
guided insertion of ropivacaine 0.375% 35ml completed using sterile technique. Pt now reports pain
3/10. Will need 15-minute monitoring for 2 hours then 4 hourly. Report increased pain to on call
anaesthetist overnight. Dr Kyle
4:49 pm Thu 23 Ma
= ¢*ACU
AUSTRALIAN CATHOLIC UNIVERSITY
T= NRSG XXXXXXXXXXSemester 1
National
= Participants
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[3 Information and resources
3 Communication and support
[DO Week 1 - Introduction
Week 2 - Case Study 1
Week 3 - Case Study 1
Week 5 - Case Study 2
oO
oO
[3 Week 4 - Case Study 1
oO
oO
Brisbane Campus
A Home
ast Calenda
= My units
T= Academic Integrity 2022
T= Academic Skills Unit
Lx)
leo.acu.edu.au @
2. Assessment 1 Case Study Information
Students will appraise an individual's holistic health care needs and
subsequent interventions and management to assist with the application
of theory into practice.
An excerpt of clinical notes and charts are provided in a folder on the LEO
assessment tile to provide the clinical information for the patient — Maisie
Wilson.
Using this information answer all the following:
o Identify and discuss all 6 of Maisie’s presurgical risks. What
investigations does she need prior to surgery? Explain how they are
linked to her surgical risks. (400 words)
Discuss what is required for legal consent. With reference to the
elevant legislation, explain why or why not Maisie can provide
consent? (200 words)
Identify two (2) medications used in this case study and provide:
the mechanism of action
side effects
co
ect dosage
o contraindications
For both medications - discuss why they were prescribed for Maisie.
(600 words)
o Describe the biopsychosocial factors that will impact Maisie and he
family as a result of this accident. (May include spiritual or cultural
elements XXXXXXXXXXwords)
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leo.acu.edu.au &
ASSIGNMENT 1: Written Assessment based on a surgical case study
Due date: Wednesday 29/03/2023 at 1400hrs
Weighting: 50%
Length and/or format: 2000 words ~~ +/- 10%
Purpose: This is a written essay based on a surgical case study.
Students will appraise an individual's holistic health care needs and subsequent interventions and
management to assist with the application of theory into practice.
An excerpt of clinical notes and charts are provided in the NRSG258 LEO site to provide the clinical
information for the patient — Maisie Wilson.
Using the information on LEO answer all the following:
e Identify and discuss all 6 of Maisie’s presurgical risks. What investigations does she need
prior to surgery? Explain how they are linked to her surgical risks. (400 words)
e Discuss what is required for legal consent. With reference to the relevant legislation,
explain why or why not Maisie can provide consent? (200 words)
e Identify two (2) medications used in this case study and provide:
o the mechanism of action
o side effects
o co
ect dosage
o contraindications
For both medications - discuss why they were prescribed for Maisie. (600 words)
e Describe the biopsychosocial factors that will impact Maisie and her family as a result of
this accident. (May include spiritual or cultural elements XXXXXXXXXXwords)
Learning outcomes assessed: LO1, LO3, LO4, LO5, LO6
How to submit: Students will submit their written assessment task via the Turnitin
link in the NRSG258 LEO site national assessment tile.
Return of assignment: Feedback and marks will be returned via Turnitin 3 weeks afte
submission. If this is not possible, students will be notified via email
or LEO
Assessment criteria: This assessment task will be graded against a standardised
criterion referenced ru
ic. Please follow the criteria closely during
the planning and development of your assessment task.
(Appendix 1).
Page 9 of XXXXXXXXXXExtended Unit Ouiling.sehRSG2n Sa EINAL MOQRERATER XXXXXXXXXXAustralian Catholic University 2023