Part 2 – Case study Morning shift:

Part 2 – Case study Morning shift: Time 8.00am Demographics: Mr Jones 65 yrs. Diagnosis: #NOF 65yr day 2 post op THR. Previous History: Myocardial infarct and CABG 2012 and CCF. Prescribed Medications: IV Morphine for post-operative pain, Regular medications: Oral Lasix, oral Aspirin. Handover: The mornings report mentioned that he had a bad night with uncontrolled pain and at 7.45am he was pale, restless and fidgeting, SOB. Patient requested to head of bed lowered to relieve hip pain. Based on this information you decided to check on him first before reviewing your other patients. On examination: Patient is lying flat in bed, tachycardia, hypotensive and SOB. A- Pt speaking clearly and in short sentences. B- SOB RR 26, Sa02 90% on RA. C- HR 120, BP 101/50 (Previous BP 130/80) Chest Pain 7/10, Heavy and tight in nature. D-Patient orientated but restless. Complains of Hip pain but also Chest Pain. E- Pale, cool and sweaty, Bellovac drain bag was full. Wound swollen, hard, bruising noted. IDC insitu. F- IV fluids running at 100mls/ hr. Fluid balance: Urine bag emptied 24.00. Now only 100mls of concentrated urine in bag overnight. Bellovac drain last emptied at 06.00. Now full of blood again G-BSL – 6.0 Review the information above, then identify and explain three (3) abnormal results based on the results of tests, observations and physical assessments. must include the normal or expected range and the pathophysiology or changing pathology that is impacting the person’s health status and could be causing the result. Abnormal Result Normal or expected range for result Pathophysiology or changing pathology that could be causing abnormal result 1. RR 26 2. SPO2 90% 3. HR 120 You recognise that Mr Jones’ current health status requires urgent nursing interventions. Review his clinical information above, then identify three (3) current or potential issues. Then develop and document your action plan using the template provided. You must prioritise your actions (e.g. most immediate/important in 1. Then next important in 2.) You must also provide a rationale for why you completed that nursing intervention and your prioritisation. Use side Coronary heart disease – Nursing Management Current / potential issue (findings of your assessment) Nursing Intervention (Action, health teaching, and referral to a member of MDT) Evaluation of Interventions (Why did you complete this nursing intervention, why is it a priority) 1. 2. 3. When patients like Mr Jones have multiple morbidities and complicated history, the nurse must consider any potential contraindications in any action plan otherwise they may put the patient at further risk. Using Mr Jones’ clinical information and your action plan. Consider and note implications of two (2) actual or potential contra-indications in relation to health assessment findings within your action plan. Describe your nursing response, what precautions will you take to manage or prevent the contraindication from impacting Mr Jones’ health status. Potential contraindication of your action plan based on your assessment of Mr Jones’ information Nursing response / Precautions to manage or respond to this contraindication 1. 1. 2. 2. SCIENCE HEALTH SCIENCE NURSING DIPLOMA OF HLTAAP003

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