(Solved) Clinical Case Study

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Running Head: CLINICAL CASE STUDY
Clinical case study
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CLINICAL CASE STUDY
Contents
Introduction.................................................................................................................... 2
First clinical review..................................................................................................... 3
Nursing intervention................................................................................................ 5
Second clinical review................................................................................................ 6
Nursing interventions.............................................................................................. 7
Third clinical review.................................................................................................... 7
Nursing interventions.............................................................................................. 9
Conclusion.................................................................................................................. 9
Bibliography............................................................................................................. 11

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CLINICAL CASE STUDY
Introduction
This is a case study analyzing the condition of our client John who is an 81 year
old retired farmer. John is married to Jean and together they live a happy life. They are involved
in the community and they are fit both physically and socially. John has a history of transient
ischemic attack and gastro esophageal reflux. He takes clopidigrel for the transient ischemic
attack and zantac for the gastro esophageal reflux (Kletzl, 2015). John wears reading glasses
and he is a non-smoker. He goes for regular medical check-ups and he weighs 104 kilograms
with a height of 180 centimeters. On calculating his basal mass index our client John has a basal
mass index of 57.7 which indicates that he is obese.
At the scene of the accident John was given morphine 2miligrams stat for the
sharp pain he was experiencing on the left upper thigh into and into the hip region, and on route
he was given a repeat dose of 2milligrams morphine, he was also given 250 milliliters of normal
saline stat before arrival to the emergency department (Hadzic, 2017). On arrival to the

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CLINICAL CASE STUDY
emergency department John was started on oxygen(fraction of inspired oxygen at 6litres per
minute) and he was hydrated with normal saline at 200mililitres per hour in the right cubital
fossa.
This case study focuses on the day John was found unconscious in his farm. He had
abrasions on his chest, extensive bruising to the left hip, he was unable to bear weight and his
legs were not shortening (Stenhagen, 2014). John reported sharp pain on the upper thigh and
left hip region, he also reported chest discomfort. He was taken to the hospital in a fairly stable
condition with a Glasgow coma scale of 15 an elevated heart rate of 94 and a slightly elevated
respiratory rate of 28 breaths per min. His condition later deteriorated to an extent he was
resuscitated. John responded to the resuscitation which involved the use of adrenaline and
defibrillation.
In this case study I will analyze the care provided to John and the events which
might have led to the deterioration of his condition. I will analyze the factors that may have
predisposed john to the complications he acquired while in the hospital and the drug interaction
between zantac and clopidigrel (Naidoo, 2016).
First clinical review
On arrival to the emergency department the patient was fairly stable and he was started
on oxygen therapy and hydration with normal saline. On the first nursing assessment that was
conducted John had a shallow breathing with a symmetrical rise and fall of the chest. He could
speak in small sentences. On auscultation the breath sounds were heard and they normal but his
chest was tender to touch, which could have resulted from the abrasions on the chest. There was