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– Case study

Morning shift: Time 8.00am

Demographics: Mr Jones 65 yrs.

Diagnosis: #NOF (Neck of femur fracture) 65yr day 2 post op THR (Total hip replacement). 

Previous History: Myocardial infarct and CABG (Coronary Artery Bypass Grafting) 2012 and CCF (Congestive Cardiac Failure). 

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 (Shortness of breath). 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

 

Questions:

1. Fill in the table.

Abnormal Result Normal or expected range for result Pathophysiology or changing pathology that could be causing abnormal result
1. Respiration Rate is 26 Adults at repose typically breathe between 12 and 18 times per minute.  
2. SaO2 is 90% In order to be deemed normal, an oxygen saturation level (SaO2) should be between 95% and 100%.  
3. Swollen wound    

2. 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
   
   

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING HLTAAP003

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