Analyzing a Deteriorating Patient: Clinical Priorities & Care Plan

This case study focuses on an 84-year-old patient, Mr. Orkins, admitted after collapsing at home with a history of type 2 diabetes, hyperlipidemia, and hypertension. The analysis identifies high blood sugar and potential ischemic stroke as clinical priorities, evidenced by elevated blood sugar levels and symptoms like facial drooping and slurred speech. The report details primary and secondary assessments, including neurological evaluations and stroke assessment tools, alongside interventions such as restoring sensory perception, managing blood glucose levels with pharmacological interventions like Metformin and insulin, and providing psychological support, particularly considering the patient's Aboriginal background and preference for a same-gender nurse. The effectiveness of the interventions is evaluated based on the restoration of consciousness, perceptual functioning, and improved strength and functionality. The study concludes that early assessment, neurological evaluation, and holistic care are crucial for the successful rehabilitation of stroke patients, emphasizing the importance of addressing both physical and psychological needs.

Running head: GUIDED CASE ANALYSIS: DETERIORATING PATIENT
GUIDED CASE ANALYSIS: DETERIORATING PATIENT
Name of the Student
Name of the university
Author’s note

1GUIDED CASE ANALYSIS: DETERIORATING PATIENT
CASE STUDY ANALYSIS
INTRODUCTION
This case study is about an 84 years old gentleman Mr. Orkins, who had been admitted to
the unit after she has collapsed at home. Mr. Orkins belongs to an aboriginal family and lives in
Broken hills. He had a past history of type 2 diabetes mellitus, hyperlipidemia and hypertension.
It is evident from the case study that the blood sugar level is 10.4 mmol/mL, which is more than
the standard value to the blood sugar level. Hence, one of the clinical priority that can be
identified for Mr. Orkins is that he might have went in to diabetic shock or coma and the second
identified clinical priority is that the patient might undergone from ischemic stroke, evidenced
from the face drooping, slurred speech and saliva drooling from the mouth. Furthermore, the
patient also had past history of hypertension and obesity which can be a predisposing factor for
stroke.
However, this report will point out the clinical priorities of Mr. Orkins and will discuss in
details, the primary, secondary and specific assessment related to the patient along with a plan of
care guided by some evidence based rationale.
BODY
Primary, secondary and other patient focused assessment
The case study reveals that the patient had high blood sugar level, which might have
caused a diabetic shock in patient, due to which he had collapsed and probably might have
suffered from a traumatic injury.

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The secondary assessment and a significant goal for this assessment is the identification of a
triggering factor for the condition, especially the presence of a reversible cause. Primary
Assessment should include a detailed clinical history evaluation and physical examination of the
patient as well as he venous blood gas measurement, a complete blood count and the basic
metabolic panel of the patient (Nolte & Audebert, 2015).
The patients should be immediately assessed and airways and the hemodynamic status
should be stabilized. Special Stroke assessment tools are useful for assessing 100 areas like LOC,
facial palsy, visual fields and gaze, motor arm, motor leg, sensation, language, limb ataxia,
aphasia and inattention (Fothergill et al., 2016). Immediate evaluation might also include placing
the client on oxygen, measuring the oxygen status and the oxygen saturation of the patients along
with cardiac monitoring as well as the obtaining the vital signs, and 12 lead electrocardiogram
for evaluating the presence of any arrhythmias (Ergul et al., 2013). At the time of assessing the
patient, it is necessary to consider the differential diagnosis like infection, indiscretion (drug use
and insulin lack).
Again, it is evident from the case study that the client had a slurred speech and
disoriented gaze, which can be the sign of a transient ischemic attack. In such a case the patient
can be referred with some tests like CT or MRI scan of the brain or an angiogram and an
echocardiogram (Lang, et al, 2013).
Since, the GCS scale of the patient has been found to be 13 with a slurred speech, a
neurological assessment of the patient is required which involves examination of the sympathetic
and the parasympathetic division by assessing the respiratory rate, heart rate dilation and the
constriction of the pupils, salivation and others (Nolte & Audebert, 2015). The working of the

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peripheral nervous system can be assessed by assessing the temperature, balance and the cranial
nerves. Motor reflexes can be assessed by the muscle tone, movement and muscle. These are
some of the basic part of the nursing assessment.
Interventions and rationale
The initial intervention is to restore the sensory perception of the patient, nurses can call
the patient by the name, reorient as needed to place, person and time, enunciate and speak
clearly. The rationale behind this is that such actions decreases confusion and helps the client in
maintaining contact with the reality (Jauch et al., 2013). It is evident from the case study a facial
drooping can be seen and saliva is drooling from his mouth. A nurse can position the patient with
a slightly elevated head and in the neutral position. This is done because it reduces the arterial
pressure by the promotion of venous drainage, improving cerebral perfusion (Jauch et al., 2013).
Nurses should also document other changes in vision and should report of blurred visions,
modifications in the visual field and the perception of the depth. The rationale behind this is that
alterations in reasoning and speech can be an important indicator of the location and the extent of
the cerebral involvement (Sun, Tan & Yu, 2014).
Again it is necessary to sustain communication with the patient. It is necessary to set up a
normal method of communication based on the basic needs of the patient. This is because, that
even a patient who is unresponsive might be able to hear.
Another intervention is to reduce the blood glucose level to the normal value.
Pharmacological interventions like Metformin, alpha glycosidase inhibitors. Sulfonylureas and
meglitiqnides might increase the insulin secretion in patients. Once the bed side measurement of
glucose confirms hypoglycemia, the patient should be encouraged with oral intake of food or

4GUIDED CASE ANALYSIS: DETERIORATING PATIENT
intramuscular glucagon (Ford, Self, Slovis & McNaughton, 2013). Insulin therapy can be
initiated in case of high blood glucose level.
As a part of holistic care, nurses should provide psychological support to the patient and
involve the patient in the decision making process when possible and encourage the patient to
express feelings, including. Anger, hostility, depression and the denial. The reason behind this
action is that it increases the confidence of the patient and helps in adhering with the treatment
regimen (Morris & Morris, 2012). Again it is also mentioned that the patient belongs to an
aboriginal background and generally seeks for a nurse of the same gender. In case the patient
demands for a nurse of the same gender, special provisions can be made for the patient, to
provide him with a caregiver of the same gender.
Evaluation
The effectiveness of the nursing interventions would be characterized by the restoration
of the normal level of consciousness and perceptual functioning of the patient, acknowledging
changes in the ability and the presence of any residual involvement. On effective treatment, the
client would display an increase in the strength and functionality of the affected body part. The
patient will be able to maintain an optimal position of function as evidence by the absence of the
contractures or facial droop. Other expected outcomes would involve establishment of
communication such that needs can be expressed.
CONCLUSION
In conclusion, it can be said initial assessment and history taking plays an important role
in the rehabilitation of stroke. Neurological assessment and primary assessment such as
obtaining the vital signs, measuring the arterial blood gas volume, helps in avoiding adverse

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condition and helps in the initiation of the treatment early. Some of the effective interventions
involve pharmacological interventions, provision of insulin therapy. A holistic care can be
provided by providing him with psychological support.

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REFERENCES
Ergul, A., Kelly-Cobbs, A., Abdalla, M., & C Fagan, S. (2012). Cerebrovascular complications
of diabetes: focus on stroke. Endocrine, Metabolic & Immune Disorders-Drug Targets
(Formerly Current Drug Targets-Immune, Endocrine & Metabolic Disorders), 12(2),
148-158.
Ford, W., Self, W. H., Slovis, C., & McNaughton, C. D. (2013). Diabetes in the Emergency
Department and Hospital: Acute Care of Diabetes Patients. Current emergency and
hospital medicine reports, 1(1), 1–9. doi:10.1007/s40138-012-0007-x
Fothergill, R. T., Williams, J., Edwards, M. J., Russell, I. T., & Gompertz, P. (2013). Does use of
the recognition of stroke in the emergency room stroke assessment tool enhance stroke
recognition by ambulance clinicians?. Stroke, 44(11), 3007-3012.
Jauch, E. C., Saver, J. L., Adams Jr, H. P., Bruno, A., Connors, J. J., Demaerschalk, B. M., ... &
Scott, P. A. (2013). Guidelines for the early management of patients with acute ischemic
stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke, 44(3), 870-947.
Lang, C. E., Bland, M. D., Bailey, R. R., Schaefer, S. Y., & Birkenmeier, R. L. (2013).
Assessment of upper extremity impairment, function, and activity after stroke:
foundations for clinical decision making. Journal of Hand Therapy, 26(2), 104-115.
Luitse, M. J., Biessels, G. J., Rutten, G. E., & Kappelle, L. J. (2012). Diabetes, hyperglycaemia,
and acute ischaemic stroke. The Lancet Neurology, 11(3), 261-271.

7GUIDED CASE ANALYSIS: DETERIORATING PATIENT
Morris, R., & Morris, P. (2012). Participants’ experiences of hospital-based peer support groups
for stroke patients and carers. Disability and rehabilitation, 34(4), 347-354.
Nolte, C. H., & Audebert, H. J. (2015). Management of acute ischemic stroke. Deutsche
medizinische Wochenschrift (1946), 140(21), 1583-1586.
Sun, J. H., Tan, L., & Yu, J. T. (2014). Post-stroke cognitive impairment: epidemiology,
mechanisms and management. Annals of translational medicine, 2(8).