Adult Nursing Case Study: Remote Clinic Evaluation Analysis

This case study evaluates the assessment and management of a 3-year-old indigenous girl, Ashanti, presenting at a remote clinic with severe dehydration due to diarrhea. The student, acting as the RN, details the patient's presentation, including lethargy, inability to walk, and concerning vital signs such as a high respiratory rate, low blood pressure, and a rapid heart rate. The assessment highlights the critical need for intervention, emphasizing the severity of the patient's condition and potential for cardiac arrest. The ISBAR (Identify, Situation, Background, Assessment, Recommendation) framework is used to communicate the patient's critical state, including the lack of urine output and frequent stools. The nursing management plan focuses on immediate interventions such as hydration, electrolyte monitoring, and continuous vital sign monitoring. The case underscores the importance of interdisciplinary care, including GP intervention for potential infections and ongoing management involving the patient's grandmother to prevent recurrence of diarrhea. The student emphasizes the need for a rapid response system to address the patient's deteriorating condition and the importance of diligent care and monitoring to improve the patient's health.

Running Head: CASE STUDY EVALUATION IN ADULT NURSING 1
CASE STUDY AT REMOTE CLINIC EVALUATION IN ADULT NURSING
Student Name:
Student Number:
Date:

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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).

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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.

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 I have measured the following values, RR- 56, SpO2 – 93%, BP- 68/32, HR – 182,
AVPU – V, temperature – 37.5 and pain – 3/10.
 I have received the test results to be highly alarming.
 Her physical signs are also negative.
 She is lethargic and unable to walk properly.
 She is also seen to have cracked lips, sunken eyes, dry tongue and looks unwell.
Background (B)-
 It is highly urgent and I am concerned because Ashanti's grandmother revealed that
Ashanti has not been passing urine for quite a few days, though she has had
frequent stools.
Assessment (A)-
 I think the problem with the patient's condition is related to digestive issues.
 I don’t know what exactly is the problem of the patient, but she has deteriorated
significantly.
 The patient is unstable, we need to attend to her to stabilise her.
 I am highly concerned regarding the patient situation.
Recommendation (R)-
 I suggest certain interventions
o Immediate intervention is putting her on saline to maintain her hydration
levels
o Investigative treatment includes checking her infection levels and then starting
her medications
 I will make the next contact every other day to understand the patient's vital signs.

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Nursing Management
Assessing the patient findings reveals there are extreme dehydration and palpitation of the
patient. Nursing interventions need to continuously monitor the vital signs of the patient.
Immediate nursing management for the patient is to put her on hydration levels (Vaismoradi
et al, 2015). Monitoring her weight can reveal dehydration which is a loss of at least 1% of
the bodyweight due to fluid loss. Ashanti needs to be provided with extra fluid with meals,
such as soup, juice, ice cream (if she can tolerate), sherbet, gelatin and water on trays. She
needs to serve beverages at activities. The patient will be encouraged at least 60 ml of fluid.
Ashanti will need to be encouraged to consume at least 180 ml with medications. The juice
and fluid cart needs to be filled twice a day.
Nursing interventions for the patient for reducing palpitation includes performing
relaxation technique. Electrolyte intake and its monitoring is crucial to make sure that the
palpitation of the patient is reduced (Lavoie et al, 2015). The nursing intervention will also
include monitoring of urine output of the patient, with the insertion of the catheter. RN need
to monitor the intake of fluids to the patient that needs to be provided to avoid dehydration.
Oral Rehydration Solution (ORS) will need to be provided such as salted water, salted yogurt
drinks, chicken soups with salt and so on. The child needs to be fed continuously as this will
increase the speed of recovery of normal intestinal functions. Monitoring the vital signs
repeatedly can reveal any signs of improvement or deterioration in the patient.
The nurse assigned to the patient will need to assess the patient report of diarrhea in every
shift. The nurse will assess the patient's stool consistency regularly as per the Bristol stool
chart. The nurse will need to keep track of how many bowel movements the patient daily has.
The nurse will encourage and provide clear liquids every two hours while she is awake. Once

CASE STUDY EVALUATION IN ADULT NURSING 6
the child becomes stable, the nurse will educate the patient on the clear liquids to consume
and which to avoid. The nurse will educate the patient's grandmother regarding ways to treat
diarrhea when it is present and will also educate regarding the contributing factors leading to
diarrhea.
Ongoing Management of the case
The patient requires serious interventions from interdisciplinary team members. Apart
from nursing intervention strategies, there needs to clinician interventions. A GP needs to
monitor signs of infection and other physical symptoms. GP might provide antibiotics in a
certain type of acute diarrhea in the situation (Tobiano et al, 2015). Combined with ORS and
medication, the patient will gradually recover from her current state. She will need to
continue with her medication for longer time periods to stabilize. For the ongoing
management of the patient case, her grandmother needs to be briefed regarding her state and
then also guided regarding the ways she can prevent the recurrence of diarrhea.
The patient signs show clear signs of deterioration requiring immediate and emergency
response system BTF. Ashanti had been reported with clear signs of fatality with an increased
rate of heartbeat and respiration with low BP. 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, at the healthcare center there needs to be intervention given in a
systematic manner providing her emergency response, which might enable restore her health.
High heart rate and high RR can be fatal and can lead to cardiac arrest for increased cardiac
activity. Her low BP is also a matter of concern, hence she needs to be immediately provided
with an emergency medical response with her vital signs monitored such that her palpitations
can be reduced While she had been bought into the clinic by her grandmother, she was

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lethargic and was unable to respond in a clear manner. Though she did not have any signs of
pain yet she shown significant signs of dehydration which can lead to her collapse. Thus,
with proper nursing and clinical intervention strategies, the patient's condition can improve.
However, she needs proper and diligent care with regular monitoring of her crucial signs such
that she can recover fast. She needs to be fed and intake ORS continuously till her vital signs
improve.

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References
Beasley, R., Chien, J., Douglas, J., Eastlake, L., Farah, C., King, G., Moore, R., Pilcher, J.,
Richards, M., Smith, S. and Walters, H. (2015). Thoracic Society of Australia and New
Zealand oxygen guidelines for acute oxygen use in adults: ‘Swimming between the
flags’. Respirology, 20(8), 1182-1191. DOI: 10.1111/resp.12620.
Kitney, P., & Bennett, P. (2016). Handover between anesthetists and post-anaesthetic care
unit nursing staff using 3 ISBAR principles: A quality 3 improvement study.
Lavoie, P., Pepin, J., & Cossette, S. (2015). Development of a post-simulation debriefing
intervention to prepare nurses and nursing students to care for deteriorating
patients. Nurse Education in Practice, 15(3), 181-191. DOI: 10.1016/j.nepr.2015.01.006.
Pang, W. I. (2017). Promoting integrity of shift report by applying ISBAR principles among
nursing students in clinical placement. In SHS Web of Conferences (Vol. 37, p. 01019).
EDP Sciences. DOI: 10.1051/shsconf/20173701019.
Tallon, M., Kendall, G., & Newall, F. (2015). Recognising and responding to deterioration in
paediatric nursing practice: Broadening our perspective. Neonatal, Paediatric & Child
Health Nursing, 18(2), 22.
Tobiano, G., Bucknall, T., Marshall, A., Guinane, J., & Chaboyer, W. (2015). Nurses' views
of patient participation in nursing care. Journal of advanced nursing, 71(12), 2741-2752.
DOI: 10.1111/scs.12237.

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Vaismoradi, M., Jordan, S., & Kangasniemi, M. (2015). Patient participation in patient safety
and nursing input–a systematic review. Journal of clinical nursing, 24(5-6), 627-639.
DOI: 10.1111/jocn.12664.
Ziebarth, D. J. (2015). Factors that lead to hospital readmissions and interventions that reduce
them: Moving toward a faith community nursing intervention. International Journal of
Faith Community Nursing, 1(1), 1.

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