Nursing Case Study Analysis | Report

Running Head: Nursing Case Study
Case Study Analysis
Name of the Student
Name of the University
Authors Note

Patient presentation
The patient for this case study is 58 years old and admitted to the hospital with severe
flu-like symptoms and less appetite. Jeff, the patient produced cough (with green colouration)
with aches and pains in different joints. The nurses checked his vital signs for assessing
whether he has any pain or aching symptoms. The patient was admitted to the hospital at 5.30
AM. The patient was assessed, and the evaluated vital signs are RR 26, SpO2 94% on RA,
BP 95/55 mmHg, HR 100 and T 38.5 . He had no record of surgery for the premedical°C
history. He was on the low-fat diet and did not have the record of flu vaccination. Jeff was
admitted to the acute bed care in the red area of ICU. His words were broken, and his GCS or
Glasgow coma scale reported a normal condition of the patient. His weight is 62 kg and
height is 183 cm tall. The BMI of the patient is 18.5. He had a high fever so that the
temperature was 38.5 C. Jeff was a competitive cyclist and was trained himself for the racing
the cycling.
Collect Cues
Primary
Survey
Patient’s Condition Standard Rate
A(Airways) At 6.00 AM: Abnormality in airways was
present. Any obstruction regarding the
airways was observed.
Normal range: No
obstruction in airways was
found. No tracheal tug or
swelling (Chaparro, Parra &
Upegui,2018).
B(Breathing) At 6.00 AM: Chest wall movement
observed to be equal, use of accessory
muscles on inspiration has been observed.
Normal range: Equal chest
wall movement, nil use of
accessory muscle to breathe.

He was breathless and was facing
shortness of breathing. The trachea was in
the midline position. Respiratory rate is 32.
SpO2 is 92%. Decreased entry of air in
both the bases was observed.
Respiratory rate 20-30
breaths/min. SpO2 >95%.
Trachea should be in
midline position (Chaparro,
Parra & Upegui, 2018).
C
(Circulation)
At 6.00 AM: Pulses were decreased and
weak. The capillary Refill rate was 3
seconds and the peripheries are cool to
touch. BP 90/55. HR is 115. Cyanosis
peripherally was absent or observed
centrally.
18guage cannula was inserted on the Right
posterior forearm. His body temperature
was 38.6 °C.
Normal range: no skin
discolouration, warm
peripheries. Strong and
regular pulses should be
observed 80-120 bpm.
Blood Pressure is 90-110
systolic. CRT < 3 seconds.
Normal temperature is
36.5–37.5 °C.
D
(Disability)
At 6.00 AM: GCS (Glasgow Coma Scale)
(E=4, V=4, M=6) score is 14. His
orientation is fluctuating during the
examination. He seems confuse where he
is now. BGL: 10.0 mmol/L. Listlessness
observed.
Normal Range: GCS or
Glasgow Coma Scale is
15(E= 4, V=5, M=6).
Normal Glucose level is 4-
8mml/L (Chaparro, Parra &
Upegui, 2018).
E
(Exposure)
At 6.00 AM: The pain score is 4/10 when
coughing. Skin was intact. Skin turgor
decreased. His orientation was disrupted.
Normal Range: No pain
should be present in the
patient. Skin should be
intact.

Process Information
The patient had fever with a temperature of 38.3 to 38.9 C. The condition signifies
that the patient was having fever which is mild to severe level fever. The patient was
admitted to the Emergency Department. After half an hour when the nurses checked his
temperature, they found that the temperature was not reduced as it was 38.6 C which is also
higher than normal range which is 36.5–37.5 °C.
The respiratory rate of the patient was recorded as 26 initially. After he was taken to
the red area of the ED, the Respiratory Rate was recorded as 32. Normal respiratory rate is
within 12 to 20 breath per minute. Therefore it can be said that the patient was suffering from
a high respiratory rate. Jeff was suffering from the shortness of breath but the oxygen
saturation rate is normal for the patient. His heart rate was 100 when he was admitted to the
hospital and later it was recorded as 115. The results showed that the patient had tachycardia
and shortness of breath or breathlessness. As the patient had a history of high cholesterol
level, the patient can be suffered from hypertension. The respiratory rate was higher than the
normal range so the patient can suffer from different type of disorders such as lung disease,
COPD and heart disease. The tachycardia was observed after he was taken to the red area of
the ED. On the contrary heart rate and respiratory rate can be increased due to cough and
fever. During fever, respiratory rate and heart rate are increased in a rate of 10 bpm with an
elevation of 1 C.
However, the pulses were regular and weak. Both the systolic and diastolic pressure
were low in nature as per the record. In the red area of ED, his BP was checked and it was
90/55mmHg. During the assessment of blood circulation, it was observed that the refilling
time of capillary was 3 seconds, which is slower than the normal. Therefore, the capillaries
are not refilled in a normal range as the patient had hypotension. The patient was an avid