The case study requires the following:
discuss the pathophysiology related to the clinical presentation
relate the patients clinical assessment findings to physiological alterations
interpret selected clinical investigations (i.e. ECG laboratory results)
explore appropriate management options determined by evidence based literature
CASE STUDY James
James Newton is a 62-year-old admitted to the orthopaedic ward 2/7 ago after falling 8 steps from a ladder whilst cleaning gutters at home. He sustained 6 right sided rib fractures a large chest
wall abrasion and some underlying pulmonary contusion. James also sustained an inferior/superior pubic rami fracture on right. He is currently on patient controlled analgesia (PCA) for pain
management.
James medical history includes chronic obstructive pulmonary disease (COPD) hypertension ischaemic heart disease coronary artery bypass graft x3 2011 GORD Type 2 DM current smoker.
Medications include: Clopidogrel 75mg daily Pantoprazole 40mg daily Simvastatin 80mg daily Spiriva 18mcg daily Salbutamol PRN.
During the night he experienced intermittent chest pain difficulty breathing and complained about a persistent cough. James also developed a temperature of 38.3C. An ECG showed sinus
tachycardia. Investigations included a sputum sample and a chest x-ray which identified worsening consolidation in the right middle/lower lobes.
You are the ward nurse caring for James you perform your clinical assessment on your morning round.
On examination James is pale and peripherally cool and his clinical assessment revealed:
HR 118 beats per minute
RR 24 breaths per minute
BP 170/85 mmHg
GCS 15/15 PEARL 3+
Temp 38.3 C
SpO2 90% on 2L of oxygen via nasal prongs
Question 1 (5%)
What further nursing assessment is required? Provide a rationale for each.
(300 words)
Question 2 (25%)
Discuss James clinical assessment findings based on the underlying physiological response (in details).
(700 words)
While talking to James his clinical condition deteriorates. He has severe right sided chest and back pan and is finding it increasingly difficult to breathe. His respiratory rate is 30 breaths per
minute and shallow. James is only able to speak in short sentences. His SpO2 is 87%. Arterial blood gases and routine bloods were taken. The results are now available and are as follows:
Result Reference
K 4.8 mmol/L (3.5-5.0)
Na 140 mmol /L (135-145)
Creat 148 mol/L (80-120)
Glucose 10 mmol/L (4-8)
WCC 15.3x 109gL (8-12)
Hb 10.5 g/L (13.0-17.0)
INR 1.2 (0.9-1.2)
APTT 37 sec (25-37)
ABG
pH 7.30 (7.35-7.45)
pCO2 58 mmHg (35-45)
pO2 55 mmHg (80-100)
HCO3 20 mmol (22-26)
BE -3 (-2 to 2)
SaO2 88% (95-100)
Question 3 (20%)
Interpret the above blood results and provide a physiological rationale for any abnormality (in details).
(600 words)
James is put on supplemental oxygen (Fraction of Inspired Oxygen FiO2 0.40) and his SpO2 improves to 93%. Despite these improvements in arterial oxygenation he has become agitated.
Question 4 (20%)
Based on the change in James clinical presentation discuss how alterations to normal physiology will influence tissue oxygen delivery and how this will impact on end-organ function (in details).
(600 marks)
Question 5 (5%)
As the registered nurse looking after this patient describe how you would escalate management of the
patient
(200 words)
Question 6
Focusing on priorities of care provide a rationale for ongoing medical management and subsequent nursing care of this patient.
(700 words)