Nursing Case Study and Transition to Practice

Running head: NURSING CASE STUDY AND TRANSITION TO PRACTICE
NURSING CASE STUDY AND TRANSITION TO PRACTICE
Name of the Student:
Name of the University:
Author note:

NURSING CASE STUDY AND TRANSITION TO PRACTICE1
Question 1
It is likely that Ashanti is inflicted with dehydration. Dehydration is condition
characterized by the excessive loss of fluid from the body as compared to the amount of intake.
Environment factors like high surrounding temperatures, pre-existing illness, nausea and
vomiting and diarrhea can trigger loss of excessive amount of fluid and thus the resultant
condition of dehydration (Falszewska, Dziechciarz & Szajewska, 2017). Common symptoms of
dehydration include: decreased urination, lips and mouth which are cracked and dry, sunken
eyes, excessive levels of fatigue and lethargy and decreased levels of activity. These symptoms
have been found to exist in Ashanti, thus evidencing her present predisposing to dehydration.
Her mother’s comment on having ‘the runs for a few days’ – further indicates Ashanti’s previous
condition of diarrhea and liquid stools – a key risk factor associated with dehydration (Levine et
al., 2017). Additionally, one of the most prevalent signs of dehydration is the absence of urine
output – a symptom which is caused due decreased amount of fluids, blood and electrolytes
being circulated to the kidneys. Such a symptom can be well related to Ashanti, whose mother
has claimed that despite diarrheal bowel movements and her intake of 400ml of juice, she has not
passed urine for a few days (Harsh & Devgan, 2018).
To assess the need for clinical review or rapid responses, the nurse must refer to the
Clinical Excellence Commission’s (CEC) ‘Between the Flags’ (BTF) system and assessment
values indicated in the Standard Pediatric Observation Chart (SPOC). Such determinations as per
the BTF system are to be administered via comparing patient assessment results with the
‘Slippery Slope’ graph. Patient assessment conditions marked in yellow are to be followed by
clinical review interventions while those indicated by red are to be rapidly responded to (CEC,
2020).

NURSING CASE STUDY AND TRANSITION TO PRACTICE2
It can be observed that her Heart Rate and blood pressure are well within the rapid
response red range of 170 to 220 beats per minute and 10 to 70 mm/Hg, while her level of
consciousness, respiratory rate and oxygen saturation are within the yellow marked clinical
review ranges of ‘verbal, 50 to 60 breaths per minute and 90 to 95%. Her scores of pain and
body temperature are within the blue zone scores of 1 to 3 and 35.5 to 38.5C. Considering that
two areas of Ashanti’s assessment measures are within the red marked critical range, it is
advisable to administer rapid response based interventions via placemen to a Clinical Emergency
Response System (CERS) specific to pediatric services (CEC, 2020).
Question 2
Table 1: ISBAR Handover Report of Ashanti (Source: CEC, 2020)
Identify “Hello my name is (Name of the Student) and
I assigned as the Registered Nurse in the
remote clinic of Wilcannia. The concerned
patient whom I would like to handover with
respect to my visit is Ashanti – a three year
old girl with an Indigenous background. She
was presented to the clinic today by her
mother and grandmother.”
Situation “As a part of this handover, I need to inform
you about the notable clinical signs and
symptoms presented by Ashanti – which are
indicative of dehydration and diarrhea. The
child has presented to the clinic upon
complaints and observed symptoms of a dry
tongue, sunken eyes, cracked lips and feelings
of being unwell, lethargic and inability to
walk or engage in any form of activity. Her
mother, claimed that Ashanti been suffering
from diarrhea since the last few days as per
her statement of Ashanti having ‘the runs for
a few days’. Additionally, her mother also
shared concerns of her daughter’s decreased
output of urine for several days, even after
feeding her with approximately 400 ml of
juice.”
Background “The background of my concerned patient