Case Study Analysis Assesment

Running head: CASE STUDY ANALYSIS
CASE STUDY ANALYSIS
Name of the Student
Name of the University
Author Note

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CASE STUDY ANALYSIS
Introduction
Nursing is the primary care for a patient and the factors included in the nursing care are
focused on the improvement of the patient’s condition. Thus, the nurse needs to adhere to the
nursing standards and also factors of the evidence based practice as this will help in improving
the situation for the patient. The evidence based practice is focused on the proper assessment of
the patient’s situation considering the present and the past medical history. A nurse needs to
prioritise the health of the patient. Thus, nurse should implement the communication skills and
develop the therapeutic relationship with the patient for better understanding and provide
improved care to the patient as well.
The purpose of this paper is to assess the health issues and the medication compliances of
the provided case study. The case study is based on a fall injury of an elderly person Mrs. Jane.
The paper will be focusing on the factors of the nursing care based on the diagnosis of the
patient, intervention, medication management and also the pharmacokinetics of the medicines,
Pathophysiology and the patient education.
Further investigation
Mrs. Jane admitted to the emergency department with the complaint of the immense pain
due to an unwitnessed fall incident. In this context, the vital signs of the patient are blood
pressure 147/77 mmHg, respiratory rate 24 breaths per minute, heart rate 112 beats per minute,
oxygen saturation 99 per cent and temperature 37.2 degree Celsius. Thus, based on the data it
can be found that the temperature and the heart rate are deviating from the normal range of the
patient. It can be stated that based on the medical history of the patient she has hypothyroidism,
hypertension, atrial fibrillation and ischemic heart disease. Hence, it can be stated that her
cardiovascular condition is affected and causing the heart rate fluctuation. Moreover, the fall

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CASE STUDY ANALYSIS
incident and the situation of neck of femur cause the inflammation which leads to the increase of
temperature in the body. Thus, based on the assessment it can be found that the patient is also
having a high amount pain which is also a deviating factor for the normal condition. Other than
this, the cognition of the patient found to be deviating as the GCS level is 13/15. Hence, the
deviation is found in the heart rate, temperature, pain level and the cognition level. Moreover, the
X-ray report of the patient marked that she is experiencing the neck of femur condition. Hence,
based on the situation and the data the nurse should be able to develop the planned care delivery.
Additional information
A nurse can develop the care plan for a patient based on the proper diagnosis and
assessment of the condition of the patient. Thus, the nurse should consider different aspects
regarding the patient. The different aspects of the patient are included with the doctor prescribed
medication, vital sign assessment, past medical and social history of the patient and also the
health outcome of the patient. Hence, the it can be seen that the medical and social history of the
patient is one of the crucial factors for the nurse to assess the actual situation of the patient. Thus,
the nurse should ask questions to the patient and also the family members of the patient
regarding this context. The questions would focus on the medical complications of the patient,
life style of the patient, genetic history of the patient. The past medical issues and the social
history of the patient would also effective in the process of the assessment of the present
situation of the patient. Hence, it can be stated that the evidence based practice approach would
be dependent on the approach of the nurse and if the nurse effectively implement this strategy, it
would help in the better assessment and subsequently generating the positive outcome (da Costa
et al., 2017). Moreover, the patient has shown that she had no memory of the fall incident and
also the causes of the incident. Hence, the nurse should ask the issues and the possible causes of

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CASE STUDY ANALYSIS
the incident to the family members of the patient for clear understanding and detection of the
possible causes or the pathophysiology of the condition. Hence, the nurse would be able to
develop the proper evidence based care plan with the consideration of the data collected by the
questions and the situation of the patient as well.
Pathophysiology
Based on the question answers the nurse can determine the pathophysiology of the
patient’s condition. It has been seen that the patient could not been able to memories the causes
of the fall or the fall incident accurately. Thus, based on the present health condition and the past
history of the patient would be the key element for the nurse to determine the causes of the fall.
Thus, the pathophysiology of the patient’s issue would be assessed by the nurse in order to
develop the proper care plan for the patient. The nursing knowledge and the skills of the
determination and identification through the critical thinking and the diagnosis are very much
important aspect in the nursing care. Now, as the past medical history of the patient showed that
she has hypothyroidism, hypertension, atrial fibrillation and ischemic health disease, it can be
found that her cardiovascular condition is not properly functioning. On the other hand, it can be
found that the hypothyroidism is the disorder in the thyroid hormone functioning process which
can lead to many negative conditions of the body including the peripheral resistance increase in
the arteries. Hence, based on the views of Messerli, Hofstetter, Victor and Cerny (2017), the
resistance in the arteries can develop the atrial fibrillation and eventually the hypertension would
increase. This condition can effectively develop the irregular heart rate and the increase in the
heart rate leads to the negative situation of the mild ischemic stroke as the patient already has the
ischemic heart disease. Thus, the irregularity in the heart rate and the lose of control over the
body would be the cause of the fall. Moreover, the past history of the patient showed that she