Scenario 1: Miss Jane Green
Consider the patient situation
Miss Jane Green is a 30 year old female who was hit by a car that ran a red light whilst she was crossing at a pedestrian crossing. The impact caused Jane to been thrown into the ke
resulting in an obvious left lower leg fracture. She has just a
ived on your ward from the emergency department. You introduce yourself to the patient and ask how she is going. She winces visibly but answers that she is wo
ied about her mother who is in the early stages of dementia and for whom she is the sole carer. You also notice that she has a bad graze on her left shoulder. The time is 0800.
Collect Cues
Review:
Examine existing documentation available via the assessment resources folder in MyLO.
Gather new information (patient assessment):
Upon undertaking a further assessment of Miss Green you obtain the following new information:
Vital signs
BP: 155/90
Pulse: 107bpm
RR: 22
Sa02: 97%
Temp: 36.6
Other data
GCS: 15
Pain score: 9/10 on movement. 8/10 on rest
Patient becoming anxious in regards to her mother’s welfare.
Neurovascular assessment
Capillary refill rate of >3 seconds.
Complaining of tingling in the toes of left leg
Increased pain at rest and upon passive movement of affected lim
Left leg appears more pale than right leg
Recall:
Recall and apply your existing knowledge to the above situation to ensure you have a
oad understanding of what is/may be occu
ing before proceeding with the rest of the cycle (self-directed)
Process Information
Interpret:
List the data that you consider to be normal/abnormal below (not included in word count)
Normal
Abnormal
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Relate & Infer:
· Relate the two most significant abnormal findings to the underlying physiology/pathophysiology to justify why it is considered abnormal in this context.
· Based on your interpretation of all the information/cues presented, form an overall opinion on what may be happening and justify your answer (400 words).
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Predict:
What may happen to your patient if you take NO action and why? (100 words)
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Identify the Problem/s
List in order of priority at least three key nursing problems (not included in word count)
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Establish Goals & Take Action
From the above (identify problems), use the top 2 nursing problems identified and for each of these establish one goal and then list related actions you would undertake, including detailing any relevant nursing considerations (350 words)
Problem 1
Goal
Related actions
Rationale
Problem 2
Goal
Related actions
Rationale
Evaluate outcomes & Reflect on new learning
Briefly describe how you would evaluate the effectiveness of the care provided (i.e. what do you want to happen?) and reflect on how this encounter has informed your nursing practice if you were to encounter a similar situation in the future (150 words).
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Progress notes
Miss Jane Green
Hospital ID: 123456
DOB 4th January 1988
49 che
y tree lane
Oldtown 8956
Today 0700
Patient admitted via ambulance at 0600 following being hit by a car (unwitnessed)
esulting in fractures of the left lower leg. X-ray attended and awaiting review from
surgical team for query open reduction internal fixation. Backslab applied. Patient
cu
ently in severe pain. Prescribed morphine with good effect. Obs stable. GCS 15, Chest
clear, Graze to left shoulder.
_____-Dr. Levett, Emergency Registrar_________________________________________________
Today 0730
Patient admitted via ambulance at 0600 following being hit by a car. Patient describes
she was walking to work and was struck by a car that did not give way to her at a
pedestrian crossing pushing her a distance into the ke
. Brought in by ambulance and
attended my medical staff. X-ray attended. Backslab and bandage applied pending
surgical review. Patient complaining of pain. Morphine given as charted with good
effect. Neurovascular obs commenced as charted. Husband has been contacted, as patient
is primary carer for her mother. R Johnstone, RN_________________________________________