Evaluation in Adult Nursing Case Study 2022

Running Head: CASE STUDY EVALUATION IN ADULT NURSING 1
CASE STUDY AT REMOTE CLINIC EVALUATION IN ADULT NURSING
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CASE STUDY EVALUATION IN ADULT NURSING 2
Patient Assessment
In this case study analysis, Ashanti, an indigenous girl 3-year-old is brought into the
remote clinic at Wilcannia. I as the RN was present for my fortnight visit. The case
presentation of the girl showed she had the runs and whatever she is given passes straight
through. Diagnosing the patient reveals she is unable to walk and is lethargic. On further
physical examination, it is seen that she has cracked lips, sunken eyes, dry tongue and looks
quite unwell. She had bowels in the last few days but has not passed urine. Her vital signs
have been monitored, which revealed her RR levels at 56, SpO2 at 93%, BP 68/32, HR at
182, AVPU at V, slightly high temperature 37.5 and pain score 3/10. A discussion regarding
early signs of deterioration with a clear statement if the patient requires clinical review. An
ISBAR has been documented with immediate nursing management of the patient.
Patient assessment is integral to understand signs of deterioration. Evaluating patient data
from the case reveals Ashanti is in a state of extreme dehydration due to diarrhea. Monitoring
her vital signs shows clear signs of deterioration as she has cracked lips, sunken eyes, which
is a clear sign of dehydration, dry tongue, RR 56. A normal RR is 12 to 20 breaths per minute
whereas 25 breaths per minute while resting is considered to be abnormal (Tallon et al,
2015). Ashanti's health shows clear signs of abnormality with such a high RR rate. Her SpO2
is normal with 93% saturation, as anything between 90 and 100% is considered to be normal.
Monitoring her BP shows a clear sign of abnormality at 68/32, which normally should have
been 120/80. Her blood pressure has dropped significantly showing signs of being not well.
Normal HR is between 60 and 100 beats per minute. Her HR shows 182, which is abnormal
and it can be fatal. Normal body temperature is 37 and she has a mild fever with 37.5. Her
AVPU sign shows she is not fully awake and only responds to verbal stimuli. She is unable to
respond fully to whatever she is being asked. Her pain score reveals 3/10, this indicates she is
experiencing moderate pain (Beasley et al, 2015).

CASE STUDY EVALUATION IN ADULT NURSING 3
The patient clearly requires rapid response between the flags (BTF) approach for
lifesaving. As the patient’s vital signs are seen to be rapidly deteriorating in a systematic
manner, providing her emergency response might enable restore her health. High heart rate
and high RR can be fatal and can lead to cardiac arrest for increased cardiac activity
(Ziebarth, 2015). Her low BP is also a matter of concern, hence she needs to be immediately
provided with an emergency medical response. There need to be her vital signs monitoring
such that her palpitations can be reduced.
ISBAR for the patient
ISBAR is a mnemonic developed for enhancing safety while transferring critical
information (Kitney, & Bennett, 2016). The full form of ISBAR is identified, situation,
background, assessment, and recommendation (Pang, 20170).
Identify (I)-
 Hello, my name is ................
 I am the RN visiting the remote clinic at Wilcannia for my fortnightly
visit.
 The patient's name is Ashanti and she is an indigenous 3-year-old girl
child.
 She needs to be rereferred to the gastroenterological department.
Situation (S)-
 I am calling because I have identified that Ashanti to be acutely dehydrated.
 Her vital signs show clear signs of fatality.
 I have observed major changes in her urine passing frequency, bowel movements,
RR, HR, BP and body temperature with signs of moderate pain.