Sepsis scenario Generic – Cellulitis
CASE STUDY – Alice McCallum
Location
Medical ward
Introduction
74yr old female Alice McCallum was admitted 3 days ago following refe
al form her GP with confusion and falls risk due to hyponatraemia.
Situation
Improved significantly with IV 0.9% Sodium Chloride but has become increasingly confused again over the last hour.
Background
PMH: T2DM, Hypertension
Drugs: Metformin 1g tds, Bendroflumethazide 2.5mg od (withheld at present)
Allergies: Nil
Social: Lives alone. Widowed for 10 years. 2 daughters, one lives nea
y the other lives in UK.
Assessment/Observations
A – patent. Talking in complete sentences
B – RR 25, Sp02 93% on RA, bilateral equal air entry clear. Mild increased WOB
C – HR 135, BP 98/60, CRT 4 secs, cool peripheries,
D – GCS 14 (E4, V4, M6). Confused to time and place, PERL, Pain 0
E – IVC looks inflamed and red. Painful to touch Appears a bit shivery. Temp 38.2
F – IVF continue at 80mls/hr. Poor oral intake. FBC shows - +ve balance over last 12 hours. Urine output 150mls over 8 hours.
G - BGL 15mmoLs
Investigations & results
FBC – WCC 18.3, Hb 147, Platelets 367
U&E’s – Na 136, K 3.8, U 11.2, Cr 132, HCO3 19.4, Glucose 15.6
CXR – NAD
ABG – pH 7.3, PaCO2 21, PaO2 68, HCO3 18, BE –4.2
Lactate – Lactate 3mmol/L
92442 CNC MS Summer 2018
Sepsis scenario Generic – Cellulitis
CASE STUDY: Christopher Collins
Location
Surgical ward
Introduction
Christopher Collins, is a 54 year old, male who was diagnosed with early-stage osteoarthritis in the left knee, causing pain and affecting mobility. Surgery was planned to take weight/pressure off the damaged side of the knee joint and therefore relieve pain and also help improve joint function.
Chris was admitted for a left high tibia knee osteotomy 5 days ago. A plate and screws were used to stabilise the tibia as part of the procedure. Antibiotics were given by the anaesthetist on anaesthetic induction. He had an uneventful post-operative period and was discharged two days later. Chris was discharged with non-steroidal anti-inflammatory medication for pain relief, non-weight bearing on crutches and fitted for a supportive knee
ace until his planned outpatient review in two weeks time.
Situation
This evening Chris re-presented at the ED. Complaining of pain at incision site, nausea and feeling shaky/shivery. Wound site left knee, sutured, skin appears ‘tight’, shiny and red. There are several small areas were dehiscence is evident with pus present. Oxygen therapy has been commenced.
Background
PMH: Osteoarthritis, asthma since child hood
Drugs: NSAID, Ventolin, Seretide accuhale
Allergies: Nil known
Chris is a non-smoker and regular swims (3-4 times a week) and occasionally participates in kayaking.
Assessment/Observations:
A – patent
B – RR 27, Sp02 94% on 60% oxygen, equal air entry – chest is clear. Ve
al report of feeling a little
eathless
C – HR 125, BP 98/57, cool peripheries, temp 38.3oC
D – GCS 15, PERL. Pain score - left knee 5/10
E – Wound site left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present
F – IV cannula inserted
G - Glucose 5.1. Nil hx diabetes
Investigations & results
FBC – Hb 112, WBC 18.4, Platelets 276
U&E’s – U 5.4, Cr 78, Na 141, HCO3 14, K 4.2, Glucose 5.1
CXR – normal
ABG – pH 7.3, PaCO2 21, PaO2 80, HCO3 18, BE – 4.0
Lactate – 2.8 mmols / L
92442 CNC MS Summer 2018
(COMPLEX NURSING CARE – MEDICAL/SURGICAL
ASSESSMENT TASK 1: Complex patient: plan of care and individual written report
ADDITIONAL GUIDELINES
PLEASE READ THE DESCRIPTION OF THE ASSESSMENT ITEMS IN THE SUBJECT OUTLINE IN CONJUNCTION WITH THESE ADDITIONAL NOTES
Assessment 1 - Complex Patient: Plan of Care
Your Complex Patient Plan of Care is to be submitted with your individual written report as an appendix. A template is provided at the end of these guidelines
COMPLEX PATIENT: PLAN OF CARE
Focus on patient assessment data, problem identification and optimal patient outcomes
Patient problem identification
Use the principles of the nursing process or clinical reasoning cycle and the assessment data from one of two case studies provided to identify actual or potential patient problems which can be dealt with using nursing interventions. Nursing interventions can be:
· Independent interventions – nurse led, nurse initiated
· Collaborative interventions – with other members of the multidisciplinary team
· Dependant interventions - for example dependant on a doctors order
The process to do this will involve:
Gathering the patient data and processing of the assessment data, which may comprise:
· Objective data: data which is empirical or which can be verified by an external source. Examples include: patient vital signs or lab tests.
· Subjective data: this is information which comes from the patient, family, or other sources and cannot be verified independently. An example is the quality of pain described by patients (it is the patient’s perception of pain and cannot be verified by tests), patient descriptions about how they are feeling or a patient’s history told by the patient or family.
Organising the data:
· Group the assessment data, for example using an A-G style format may assist or use an organising system such as Gordons Functional Health Patterns.
· After collecting both the subjective and objective data start to make connections between various assessment items and consider actual or potential health problems.
· Identify as many problems as you can for the patient then prioritise up to 6 patient or nursing orientated problems that are the most immediate for this patient. This will form your plan of care which will be the basis of your individual written report.
Problems may be:
• actual health problems: a health problem that is cu
ently present or occu
ing and needs intervention to either end or reverse its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.
Examples: Anxiety related to.....
Dehydration due to ........
Wound infection related to ......
Acute pain related to ....
Impaired skin integrity due to ....
Inadequate tissue perfusion related to……..
• potential health problems: a health problem which has not yet occu
ed, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
The patient is ‘at risk of’ falls due to ...
The patient is ‘at risk of’ developing a DVT due to....
The patient is at risk of infection due to………
Once the actual or potential health problems are identified, the patient and/or nursing outcomes need to be considered. The outcome, like the problem, needs to be of a patient focused or nursing orientated nature. This means that the intervention should be one that a Registered Nurse can perform/is involved with. The nursing outcomes (dot points) describe what we expect to achieve for the patient if appropriate nursing interventions are implemented.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
Actual or potential problem
Assessment data
Nursing outcome
Actual problem: the patient is dehydrated related to decreased fluid intake
· Low blood pressure (or ↓BP)
· Tachycardia
· Patient states he is thirsty
· Dry mucous mem
anes
· Patient will return to a normotensive state as evidenced by an acceptable blood pressure (for this patient) , stable and
· acceptable pulse
· Lack of reported thirst
· Moist mucous mem
anes evident.
The patient is ‘at risk of’ infection due to compromised host defences
· Low neutrophil count
· Receiving radiation therapy for cance
· Pt will remain free from any nosocomial
· Pt will ve
alise how to prevent acquiring infections
· Pt’s family, friends, and hospital staff will use appropriate infection control include PPE and HH
Note: you can use common a
eviations or symbols, e.g. BP for blood pressure.
INDIVIDUAL WRITTEN REPORT
The focus is on the implementation of nursing care, the rationale for care and its evaluation.
Select 2 of the problems identified on the Patient: Plan of Care – it is suggested that at least one should be an actual problem but this is not essential.
The individual written report expands on the information presented in the Patient: Plan of Care plan for 2 of the identified problems. The written report will need to hold more detail and explanation than in the care plan. In particular you will need to give the rationale for the nursing intervention (s), and the evidence for why this is the appropriate care to provide. In addition you will need to demonstrate an understanding of the underlying pathophysiology – as applies to the chosen interventions/nursing care.
As this is a written report assignment you can use headings/sub headings. It is your choice to use headings; they are not required but can make it easier to organise your work. There are two possibilities for the layout of the assignment:
1. Address each problem in turn, so all the discussion on problem one, followed by all the discussion on problem two.
2. Alternatively you could introduce both problems, then both outcomes, then all interventions and evaluations). This can work well if there is a relationship between the two patient problems.
3. Items to include in the report:
· Background on your patient (please keep it very
ief, only include enough for your reader to understand your content).
· Assessment data - this will only be needed in order to explain how you a
ived at your chosen health problems.
· Identified health problems- you will only need to choose two from the original list in your care plan.
· The identified health outcomes for your problems- these will be key to linking your health problem and interventions through to evaluation of care (s).
What you will need to accomplish within the report
· Using assessment data from the case study and scholarly evidence provide a pathophysiological rationale for a
iving at the two health problems from the collected data.
· Using scholarly evidence and reasoning provide a rationale for the chosen health outcomes.
· Using scholarly evidence prioritise the main nursing interventions which can be undertaken by a new graduate registered nurses to assist the patient to achieve the desired health outcome. What evidence, policy or guidelines supports these interventions. For some patient problems there