Solution
Soumi answered on
Feb 28 2021
Running Head: UNWELL ADULT PATIENT PRESENTING TO ED 1
UNWELL ADULT PATIENT PRESENTING TO ED 2
ASSESSMENT 1
CASE STUDY— WRITTEN ASSIGNMENT
PRACTICAL CLINICAL REALISTIC ASSESSMENT
SCENARIO 2— UNWELL ADULT PATIENT PRESENTING TO ED
Table of Contents
Patient Presentation 3
Collecting Cues 5
Processing the Information 6
Symptoms Cluster 8
Identifying Critical Problems 9
Interventions or Actions 11
Rationale of the Interventions 12
Outcomes and Evaluation 14
References 15
Patient Presentation
ISBAR Tool
I
INTRODUCTION
IDENTIFY
Joy Smith, a 70 years’ old woman was bought to the emergency department by her husband John. She was bought to the hospital because she was agitated, confused and fatigued. In triage, Joy was confused to time and place. At 6 am, she was transfe
ed to acute care bed in red area of emergency department.
S
SITUATION
At 6 am, her situation was that she was placed in a gown and covered with a sheet and one blanket. On examination, her airway was patent. She was talking in full sentences. She appears slightly,
eathless and she used her accessory muscles on inspiration. Her blood glucose and lactate were high.
On auscultation, there was decreased in air entry in both bases. Nil cyanosis is peripherally or centrally. Her heart rate was regular but weak. Her vitals are RR 27, T 38.3℃, SpO2 93%, BP— 90/55 mmHg, HR 116. Joy’s orientation was fluctuating, and she was confused to places.
Her GCS is 14 (Eyes = 4, Ve
al = 4, Motor = 6). She rated her pain score to be 3/10 when passing urine. She has recently had a stinging sensation when passing urine. Skin turgor is decreased and skin is intact.
B
BACKGROUND
She was under triage category 3. Although she previously had been suffering from hypertension, osteoarthritis and atherosclerosis and had even been projected under percutaneous coronary intervention in her left anterior descending artery, along with undergoing cholecystectomy as well as left total knee replacement; nevertheless, cu
ently, she is being assessed based on her recent readings.
Here vital signs, at 6 am, were RR 27, SpO2 93%, BP was 90/55 mmHg, HR 116 weak and regular, T 38.3 ℃. Her medications are Carvedilol 50mg BD, Aspirin 100mg daily in the morning, Lipitor 40mg daily in the evening, and Panadol Osteo - 2 tablets TDS, NKA.
A
ASSESSMENT
Patient’s condition is deteriorating. When compared with the vital sign at the time of admission to emergency department and cu
ent vital sign show change in her condition. Her blood pressure is reduced; respiration rate has increased in comparison to earlier measurement. Her blood sugar and heart rate have increased. Her oxygen saturation is lowered. The lactate level is higher than normal.
R
RECOMMENDATION
I would like to recommend that the patient be given immediate care as her condition is deteriorating and her symptoms are getting worse. Her blood pressure and blood sugar both needs to be controlled before her symptoms get further worsen. She immediately needs effective treatment to stabilize her condition. She might have risk of getting sepsis. Thus, immediate care is needed.
Collecting Cues
A to D
Framework
Assessment
A
Airway
· Airway patent
· Talking in full sentences
B
Breathing
· Slightly
eathless using accessory muscles on inspiration (normal
eathing rate: 12-20
eath per minute)
· Respiratory rate: 27 (12-25 per minute)
· Peripheral capillary oxygen saturation: 93% on room air (94-100)
· On auscultation, there was decreased air entry in both bases, nil cyanosis peripherally or centrally
C
Circulation
· Blood Pressure: 90/55 mmHg (120/80-140/90)
· Heart Rate: 116 (60-100 beats per minute)
· Temperature: 38.3 ℃ (36.1°C-37.2°C)
D
Disability
· GCS 14 (Eyes=4, Ve
al=4, Motor=6)
· In triage, confused to time and place
· Orientation was fluctuating
E
Exposure to the Environment
· Transfe
ed by wheel chair to the acute care bed (red area in ED)
· Placed in a gown and covered with a sheet and one blanket
F
Fluids
· pH = 7.36 (7.32- 7.42)
· pCO2 = 43 mmHg (41 – 51 mmHg)
· pO2 = 40 mm Hg (30 – 40 mmHg)
· Hb = 115 g/l (121 to 150 g/L)
· K+ = 4.3 mmol/L (3.5 to 5 mmol/L)
· Na+ = 143 mmol/L (135 to 145 mmol/L)
· Glucose = 9.0 mmol/L (4 – 8 mmol/L)
· HCO3 = 25 mmol/L (24 - 28 mmol/L)
· BE = 1.5 mmol/L (-2 to 3 mmol/L)
· Lactate = 3 mmol/L (0 to 2 mmol/L)
G
Give comfort measures
· Triaged ATS category 3
· Pain score of 3/10 when passing urine
Processing the Information
Joy Smith had lost her appetite in the last three days before admitting to the hospital. She was weak showing fatigue, agitation and nervousness. She was confused to time and place and has chills.
Relevant Information
I
elevant Information
· Weakness
· Temperature: 38.3 ℃
· Agitation and nervousness
· Fatigue
· Slightly
eathless using accessory muscles on inspiration
· On auscultation, there was decreased air entry in both bases, nil cyanosis peripherally or centrally
· Stinging sensation while passing urine
· Confused to time and place
· Hypertension
· Osteoarthritis
· Atherosclerosis
· Heart Rate: 116
· Glucose = 9.0 mmol/L (4 – 8 mmol/L)
· Haemoglobin = 115 g/l (121 to 150 g/L)
· Blood Pressure: 90/55 mmHg
· Respiratory rate: 27
· Orientation was fluctuating
· Lactate = 3 mmol/L (0 to 2 mmol/L)
· Airway patent
· Talking in full sentences
· Skin turgor is decreased
· Skin is intact
· Surgical scar on left knee
· Triaged ATS category 3
· Pain score of 3/10 when passing urine
· Peripheral capillary oxygen saturation: 93% on room air (94-100)
· Transfe
ed by wheel chair to the acute care bed (red area in ED)
· Placed in a gown and covered with a sheet and one blanket
· HCO3 = 25 mmol/L (24 - 28 mmol/L)
· BE = 1.5 mmol/L (-2 to 3 mml/L)
· K+ = 4.3 mmol/L (3.5 to 5 mmol/L)
· Na+ = 143 mmol/L (135 to 145 mmol/L)
· pH = 7.36 (7.32- 7.42)
· pCO2 = 43 mmHg (41 – 51 mmHg)
· pO2 = 40 mm Hg (30 – 40 mmHg)
Symptoms...