Nursing Documentation: Body Systems Approach and Case Study Report

This report presents a nursing case study focusing on a 19-year-old female experiencing acute respiratory distress. The case study details the patient's presentation, including symptoms like shortness of breath and wheezing, and the initial interventions, such as salbutamol administration and oxygen support. It includes assessments of various body systems, such as the respiratory, cardiovascular, and gastrointestinal systems, along with relevant vital signs and examination findings. The report also covers the patient's history, including a childhood diagnosis of asthma, and psychosocial factors. The plan section outlines recommendations for continuous monitoring, medication administration (ipratropium and hydrocortisone), and further investigations. The report emphasizes the importance of the body systems approach in comprehensive patient assessment and documentation, aligning with the guidelines from St. Vincent's Hospital Melbourne.

Running head: NURSING
Rheumatic Heart Disease
Student Name
University Name
Author Note

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Part A
SITUATION/SUMMARY: Janet Doe, 19 year old female brought with acute respiratory
distress by her housemates. After dancing, felt shortness of breath and administered herself
the emergency asthma first aid plan. In ambulance, 5 mg of salbutamol was administered
with the help of a nebuliser and was put on oxygen support. Has a history of childhood
asthma which likely exacerbates due to exercise.
CNS: Alert. Oriented. Restless and Anxious. GCS to be conducted. Difficulty in speaking.
CVS: Temperature and blood pressure value to be taken shortly. Chest pain investigations
and ECG tests are to be conducted in a short while. Electrolyte and troponin levels will be
undertaken by John.
RESPIRATORY SYSTEM: pulse – regular at 110 bpm. Breathing rate – 28-30 breaths per
minute. SpO2 at 88%. Wheeze sound is heard while breathing. Sputum sample to be taken by
John. Unable to take deep breaths. Difficulty in breathing.
GIT: speech pathologist to be called to assess language and talking difficulties. No bowel or
flatus sounds are heard. Only saline IV drip. Abdomen is firm. No signs of nausea and
vomiting. Diabetes to be checked.
RENAL: urine output, bladder irrigation, fluid balance status, and urine frequency to be
taken. Creatinine and urea levels are to be tested by taking samples by evening. Percutaneous
catheter to be attached on immediate basis.
MUSCULOSKELETAL: status of gait of the patient cannot be evaluated. Household repair
reported. Water damage and leaking roof. A fall could be suspected. No aids in walking
required.
INTEGUMENTARY: no external wound observed. Skin is pale and disphoretic. Peripheries
are cool. Conduct waterlow assessment to determine score.
PSYCHOSOCIAL/OTHER: living alone on rent with three other same-aged individuals.
Moved from Brisbane to study in college. Mental health assessment needs to be conducted.
PLAN/RECOMMENDATIONS: continuously monitor cardiac output and report any
changes. Keep the SpO2 above the level of 92% and insert a peripheral intravenous cannula.
Nursing

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Administer ipratropium 250 micro gram every four hours by nebuliser. Administer
hydrocortisone 200 mg via the cannula.
Nursing