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Assignment on Nursing : Case Study

   

Added on  2020-10-04

8 Pages2442 Words57 Views
Nursing Case Study

Table of ContentsOutline of the case.......................................................................................................................1Justification to clinical nursing decisions....................................................................................2ISBAR handover script................................................................................................................4REFERENCES................................................................................................................................5

Outline of the caseThe patient named Kate Ham, who is 79 years old, has visited to the surgery ward of thehospital. She weigh’s 75 kgs. with a height of 153 cm which comes under the category of beingoverweight. Clinical condition: She has undergone under Right Total Knee Replacement (RTKR) surgery.Total blood loss during intra operative practice is 200 ml and Intravenous Therapy (IVT) up to1200 ml. Medical history: She also has a history of Non-Insulin Dependent Diabetes Mellitus (NIDDM).Further, she is also asthma / smoker 50/day.Current situation and sign and symptoms: The case further states that the patient appears to berestless, pale and grimacing in pain with her eyes shut. The dressing of her wound is dry andPatient Controlled Analgesia (PCA) has not been brought into use since past hours. She hasstated that the pain in her knee scores 5 / 10 and feeling lightheaded as well. She has beenallowed light diet by the doctor. However, she does not feel like eating anything and senseconstant nausea. Vital signs: Current BP measures tends to be 105 / 56, Heart Rate (HR) 118, Respiratory rate is20, peripheral capillary oxygen saturation (SpO2) is 92%, Blood Glucose Level (BGL) is -3.5and periphery capillary refill is 3 seconds plus pale cool digits. Other observation criteria arebeing found stable in her. Ongoing medications: Seretide (250/25) which is used to clear out the ways, when patient issuffering from Asthma. Metformin which is given to control the level of glucose in the blood,which is diabetes. The nurse is accompanying the patient after Kate has gone through post-operative periodof 4 hours in RTKR surgery. The immediate nursing actions can be stated that the patient inundergoing low Blood pressure due to which she is constantly feeling nauseated and lightheaded. Moreover, her blood glucose level is also at a decreasing state, that is -3.5. hence, theinitial treatment to be given by the nurse will have high dependence on these two aspects of hercurrent health (Burns and Grove, 2012). Since, she has undergone knee replacement surgery, it isimportant to emphasize on blood glucose level and bring back to normal. Moreover, her lowblood pressure can be the result of anaesthesia being given to her during her surgical operation.1

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