Case Study Analysis: Deteriorating Patient - NSG3TCN/NSG3TCC

This document presents a comprehensive case study analysis of four different patient scenarios, each detailing key issues, nursing interventions, and ethical considerations. The first case examines a patient experiencing arterial fibrillation, heart failure, and pulmonary edema, emphasizing the importance of oxygen supply and medication administration. The second case focuses on a patient in hypovolemic and septic shock, highlighting the need for fluid resuscitation, blood transfusions, and vital sign monitoring. The third case explores a patient with tension pneumothorax and hypoxia, discussing pain management, blood thinners, and the ethical dilemma of a patient's desire to leave the hospital. The final case involves an eight-year-old child with bleeding and pain, and the ethical complexities surrounding parental consent and patient assessment. Each case study adheres to nursing standards and professional guidelines, offering insights into effective patient care and ethical decision-making in various clinical situations.

Running head: CASE STUDY ANALYSIS
CASE STUDY ANALYSIS
Name of the Student
Name of the University
Author’s Note:

1CASE STUDY ANALYSIS
Case Study 1
Answer to the question number 1(a):
From the case study three identified key issues are arterial fibrillation, sudden heart failure,
and pulmonary oedema.
The primary risk William is in for arterial fibrillation. The reason behind is that the patient’s
tachycardiac pulse. Tachycardiac pulse occurs due to the irregular and chaotic impulses in the
chambers of the heart. This phenomenon in turn leads to the irregular contraction of the atria.
This irregular contraction leads to the improper working of the heart and as a direct result
heart become unable pump enough blood to the brain (Andrade, Khairy, Dobrev, & Nattel,
2014). Hence the primary issue is arterial fibrillation.
The next key issue for the patient is the sudden heart failure. Heart failure occurs when there
is lack of adequate blood supply in the brain. From the above discussion, it can be seen that
the patient has tachycardiac pulse which might happen due to blocked or narrowed artery
which in turn will prevent adequate blood supply to brain (January et al., 2014). Therefore,
the patient is in a risk for sudden heart failure.
Another issue that has been identified for the patient is pulmonary oedema. From the case
study, it can be seen that the patient has laboured breathing. Laboured breathing happens
when the pulmonary veins are filled with extracellular body fluid which leads to lack of
oxygen in the body. Studies have also reported that the irregular heart beat might happen due
to the pulmonary oedema (Nicholson, 2014). Therefore, it can be stated that the patient’s
another issue might be pulmonary oedema.
Answer to the question number 1(b):

2CASE STUDY ANALYSIS
From the laboured breathing, it is evident that the patient has lack of adequate oxygen supply
in his body. Thus, the first nursing intervention will be to supply the patient with external
oxygen source which can be administered by the nasal route. The reason behind this is to
maintain the patient’s oxygen saturation level in his body.
The next step of action for the nurse will be to address the patient’s comfort level. Patient is
having laboured breathing which might be happening due to the pulmonary oedema. Hence,
Angiotensin II receptor blocker or ACE inhibitor drug can be administered to the patient
(Braunwald, 2015). In addition to that, plasminogen activator drugs for tissues can also be
administered for the patient as a precaution for sudden heart attack. This drug should be
administered to the patient through the intravenous route.
From the discussion in 1(a) section, it has been established that the patient is in a risk for
arterial fibrillation. Hence, the patient should administer with the medicine like Amiodarone,
Dofetilide, Sotalol, and Flecainide, for the betterment of the patient (Qin et al., 2016).
Additionally, the nurse should be monitoring the patient condition in a priority basis as the
patient is in a risk for three different kind of critical issue and the patient should be monitored
for the chance of further deterioration.
Answer to the question number 1(c):
In this scenario, the responsible nurse is very young, new to the job and is in under the
supervision of a Registered Nurse. As a result, the nurse has to report to the registered nurse
first instead of a doctor in case of any changes in the patient condition. In this scenario, the
nurse reported the condition about the patient to the registered nurse but was told not to worry
(Safetyandquality.gov.au, 2019). The nurse was in mind that a doctor should be consulted in
this scenario but was told not to worry about his/ her immediate supervisor. This is put the
nurse in an ethical dilemma whether the nurse should listen to his/ her immediate supervisor

3CASE STUDY ANALYSIS
or disobey him to consult a doctor as nursing practice and code of conduct suggest him/ her
to do so (Baykara, Demir &Yaman, 2015).
Case study 2
Answer to the question number 2(a):
In this scenario, three key issues that were identified are hypovolemic shock, septic shock and
pulmonary distress.
Based on the case study, the hypovolemic shock of Carol is seen to have caused the huge
amount of blood loss from the knee. Hence, it would lead lack of blood supply into all the
cells or tissues of the body resulting in seizures. Therefore, the patient can experience
multiplied organ failure and inadequate tissue infusion. These circumstances are going to lead
to a stroke and coma. In the end, the patient must therefore be examined primarily for
hypovolemic shock and low blood pressure (Siddall, Khatri & Radhakrishnan, 2017).
In this scenario, the nurse has found the patient, Carol, in very drowsy condition and she was
unable to speak properly. For drying up the site, Carol's knee replacement surgery also needs
blood suction (Zhou, Li, Xiong, Jiang, Li, & Wu, 2013). Thus her immune system for
microbial attacks can be said to be very much susceptible, as it is more vulnerable than ever
to a blood loss out of her body. There is therefore a high risk of a microbial attack and
septicaemia can be diagnosed in this particular instance. Septic sepsis causes septic shock as
microbial infections can affect the whole body (Gotts & Matthay, 2016).
In this case, Carol also demonstrates a 12 per minute breathing rate as well as low blood
pressure and her blood oxygen content in that condition must be higher (Baratloo et al.,
2014). Therefore, respiratory distress tends to occur and hypovolémic shock, low blood
pressure and septic shock are the causes of this respiratory distress (DiPiro, Talbert, Yee,
Matzke, Wells & Posey, 2014).

4CASE STUDY ANALYSIS
Answer to the question number 2(b):
For her low blood pressure, the nurse ought to be able to administer medications such
as beta blockers, diuretics, and calcium channel blockers. The saline would also be used to
control her body's sodium content. The nurse could also provide the patient with the blood
needed to address the patient's hypovolemic shock. The saline solution (hypotonic) would
assist in tackling the patient's hypovollemic shock. To resolve the patient’s condition, a
routine blood pressure test would be required (Young, Prittie, Fox & Barton, 2014). In order
to prevent her pain, the nurse must also administer clot preserving medication or fibrin
sealants and other medications, like Morphine (Banihashemi et al., 2017). The nurse must
keep an eye the patient's vital sign in a consistent manner and, if needed, also deliver the
patient with additional oxygen (Wallhult & Quinn, 2018).
Answer to the question number 2(c):
In this scenario, the patient's partner doesn't want the patient to wake, and instead of the
patient she insisted that they talk to the nurse. But, the nurse should talk to the patient and
understand whether the patient is worsening or if the patient has any positive changes. For
additional treatment of the patient, this documentation need be provided to the doctor. In the
process of information collection also, however, the dizziness of the patient represents a
threat. The nurse can therefore not critically assess the patient's health, thus delaying the
treatment for Carol (Grace, 2017). The needs of the patient conversation play an important
role in carol’s therapy, and also enable the nurse to evaluate the current situation of the
patient. The NMBA standards call on the patient-focused care provider and establish a
professional partnership with the patient to provide the best possible care for the patient
(Nursingmidwiferyboard.gov.au, 2019). Thus, in the case of Carol, the lack of discussion
with the patient could be described as the business issue. The nurse has to know about the

5CASE STUDY ANALYSIS
patient's past history and therefore the discussion would also be needed to treat and plan the
patient's treatment process properly.
Case study 3
Answer to the question number 3(a):
For this particular case study of the patient Glenn, three key issues identified for the patient
which are Tension pneumothorax, hypoxia and pain.
Tension pneumothorax can be identified due to the damage of the tissue in the right lung by
lacerated bubbles or blebs. Therefore, the air spreads out his lungs and fills the chest cavity.
(White & Eaton, 2017) In addition, he could have ruptured the bullae. This situation means
that air is kept well into the pulmonary thorax; thus there is excruciating pain and there is no
adequate oxygen in the blood vessels. This leads to low blood pressure and hypoxia in
Glenn's body. In Glenn's case, multiple organ failures can be observed. The hypoxia
condition raises the problem of improper tissue infusion (Porpodis et al., 2014). The hypoxia
can be explained by the fact that the inaccurate placement of the underwater seal drainage
which has caused the breathing of oxygen difficult and responsible for the pain of the patient
chest.
Swelling in the operated area induced Glenn's pain and the irregular expansion of the chest
also caused a lot of pain in the breathing period. This leads to the embolism of the pulmonary
system because the failure of the procedure could have broken the blood vessels, leading to
serious pain for Glenn. The blood clot formation in the lungs is causing pain and as a
consequence of a lock that is capable of preventing blood circulation and also cause pain a
serious heart attack or stroke (Semenza, 2014).
Answer to the question number 3(b):

6CASE STUDY ANALYSIS
The health care provider should conduct Glenn medicines to resolve spontaneous
pneumothorax and chest pain, like talc doxycycline, and other chest pain calming drugs.
Besides that, the nurse could administer beta blockers, lower blood pressure
controlling diuretics, and calcium channel blockers. In case of pulmonary embolism, heparin
and warfarin would also be given as a blood thinner (Brown, Ball, Macdonald, Wright &
McD Taylor, 2014). These are the drug measures that the nurse can take. The nurse must also
distract Glenn from his breathing difficulties and make him understand his priorities by
keeping him in the observation and also by helping him carry the situation of chest pain. In
order to control his restlessness, the nurse should also determine whether sedation is
necessary or not (Brown, Ball, Macdonald, Wright & McD Taylor, 2014). In order to
reinforce its emotional aspect, the nurse must be passionate and affectionate and thus
maintain the NMBA standard for nursing and patient focused care
approach (Nursingmidwiferyboard.gov.au, 2019).
Answer to the question number 3(c):
In this case, Glenn desired fresh air outside the hospital as his condition was not as good as
he would go anywhere. His restlessness represents a threat to the nurse, so the nurse must
stop him. The patient's irritability could not even make him aware of his situation correctly as
he told the nurse that he must go out and he's okay, but he felt pain throughout the chest. This
situation also places the nurse in an ethical issue, because the patient intended to leave
(Luauté, Plantier, Wiart & Tell, 2016). The nurse must demonstrate emotional aspect in a
passionate and affectionate behaviour, so the situation can be managed. The nurse thus needs
to prevent the sufferer from heading outside to discuss his condition with him or to reverse
his opinions. This too is a competent problem as patient’s wish could not be followed without
the physician's consent. In this case, presence of mind, technical understanding and how the
nurse can avoid degradation and deter restlessness of the patient will be evaluated (Hessler et

7CASE STUDY ANALYSIS
al., 2018). In addition to the above mentioned intervention that the nurse must take, she/ he
must also follow the Nursing and Midwifery Board of Australia
(Nursingmidwiferyboard.gov.au, 2019) and National Safety and Quality Health Service
standards while handling the situation of the patient (Safetyandquality.gov.au, 2019).
Case study 4
Answer to the question number 4(a):
This case study is related to a patient named Wendy who is an 8 year old children. From the
case study presented, two major key issues can be identified in this scenario. These two key
issues are bleeding and pain.
In this scenario, the patient had just been gone through the tonsillectomy. The surgery of
patient's tonsillectomy results in inner bleeding which places Wendy in an uncomfortable
position. The internal bleeding can also trigger the pain. The internal bleeding can result to
swelling of the throat which could damage the tissue and cause serious infections on the
patient's throat (Uysal, Polat, Uysal & Koç, 2014).
The patient is a child with extreme tonsillitis and was operated by the tonsillectomy process.
The patient is in a post- operative state. After that, the patient was not able to speak and was
crying continuously. Hence, the first identified major issue is severe pain from the surgery
performed on her. From the examination and assessment it could be said that the bacterial
infection causing the tonsillitis and the impact of the procedure could occur the patient severe
throat pain. This situation can cause serious distress in the patient mind, as well as damage of
the tissue of his throat, which can severely interfere with his speech (Wong Chung, van
Benthem & Blom, 2018).
Answer to the question number 4(b):

8CASE STUDY ANALYSIS
Drugs, including painkillers, should be administered by the nurse in this situation. Besides
antibiotics like penicillin, the infection preventative action should also be administered and
the nurse needs to conduct the correct scheduling and dose of the drugs because the patient is
a child and cannot administer their medicines properly (Lam & Fresco, 2015). To prevent the
agony and also, evaluate the condition of the internal bleeding, the canopy should be removed
from the patient's throat. In this context, it has been found that the patient is in emotional
distress which has been evident by the fact that she is lying in her bed while hugging her
teddy bear. The nurse must also reassure the Patient, Wendy, by speaking to her and opening
her up with empathy and companionship (Arora, Saraiya, Niu, Thomas & Kannikeswaran,
2015).
Answer to the question number 4(c):
The patient is a child, but she cannot describe her situation due to severe pain, and in this
situation her mother remained restless about the paper work done and took the patient home
as her siblings were about to leave school. The nurse should discuss her situation with the
patient and examine the worsening or positive changes in her physical conditions. The nurse
thus needs to be able to communicate the patient's pain or any other illness for longer period
of. This is the ethical and technical, dilemma and the nurse has to examine the patient
correctly and plan its medication. Furthermore, on behalf of the patient or the patient's family,
the nurse cannot make any assumptions so the patient's mother has the right to take patient
home with her (Dorkham, Chalkiadis, von Ungern Sternberg & Davidson, 2014). The nurses
should pursue decision making standards in accordance with the NMBA standards and
promote the well-fare in order to regulate the mother's actions and assist the patient with the
compassion. In compliance with patient- centred care policies, the nurse must also assist the
patient (Nursingmidwiferyboard.gov.au, 2019). Even if the nurse might have the doctor's
consent to the patient's condition and the doctor's consent to the assessment method, the

9CASE STUDY ANALYSIS
mother cannot remove the patient from observation. It is therefore clearly apparent that the
nurse needs to be given priority to patient safety to any other element and let the physician
know the situation of the patient in frequent manner (Walther‐Larsen, Aagaard, Friis,
Petersen, Møller‐Sonnergaard & Rømsing, 2016). Additionally, while dealing with the family
of the patient, the nurse must also follow the National Safety and Quality Health Service or
NSQHS standards. (Safetyandquality.gov.au, 2019).

10CASE STUDY ANALYSIS
References:
Andrade, J., Khairy, P., Dobrev, D., &Nattel, S. (2014). The clinical profile and
pathophysiology of atrial fibrillation: relationships among clinical features,
epidemiology, and mechanisms. Circulation research, 114(9), 1453-1468,
https://doi.org/10.1161/CIRCRESAHA.114.303211.
Arora, R., Saraiya, S., Niu, X., Thomas, R. L., & Kannikeswaran, N. (2015). Post
tonsillectomy hemorrhage: who needs intervention?. International journal of
pediatric otorhinolaryngology, 79(2), 165-169,
https://doi.org/10.1016/j.ijporl.2014.11.034.
Banihashemi, M., Safari, A., Nezafat, N., Tahamtan, M., Negahdaripour, M., Azarpira, N., &
Ghasemi, Y. (2017). Effect of Fibrin Packing on Managing Hepatic Hemorrhage and
Liver Wound Healing in a Model of Liver Stab Wound in Rat. Bulletin of Emergency
& Trauma, 5(1), 18, Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316132/.
Baratloo, A., Rahmati, F., Rouhipour, A., Motamedi, M., Gheytanchi, E., Amini, F., & Safari,
S. (2014). Correlation of blood gas parameters with central venous pressure in
patients with septic shock; a pilot study. Bulletin of emergency & trauma, 2(2), 77,
Retrived from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4771297/.
Baykara, Z. G., Demir, S. G., &Yaman, S. (2015). The effect of ethics training on students
recognizing ethical violations and developing moral sensitivity. Nursing Ethics, 22(6),
661-675, https://doi.org/10.1177/0969733014542673.
Braunwald, E. (2015). The path to an angiotensin receptor antagonist-neprilysin inhibitor in
the treatment of heart failure. Journal of the American College of Cardiology, 65(10),
1029-1041, DOI: 10.1016/j.jacc.2015.01.033.

11CASE STUDY ANALYSIS
Brown, S. G. A., Ball, E. L., Macdonald, S. P. J., Wright, C., & McD Taylor, D. (2014).
Spontaneous pneumothorax; a multicentre retrospective analysis of emergency
treatment, complications and outcomes. Internal medicine journal, 44(5), 450-457,
https://doi.org/10.1111/imj.12398.
DiPiro, J. T., Talbert, R. L., Yee, G. C., Matzke, G. R., Wells, B. G., & Posey, L. M. (Eds.).
(2014). Pharmacotherapy: a pathophysiologic approach (Vol. 6). New York:
McGraw-Hill Education.
Dorkham, M. C., Chalkiadis, G. A., von Ungern Sternberg, B. S., & Davidson, A. J. (2014).
Effective postoperative pain management in children after ambulatory surgery, with a
focus on tonsillectomy: barriers and possible solutions. Pediatric Anesthesia, 24(3),
239-248, https://doi.org/10.1111/pan.12327.
Gotts, J. E., & Matthay, M. A. (2016). Sepsis: pathophysiology and clinical
management. Bmj, 353, i1585, doi: https://doi.org/10.1136/bmj.i1585.
Grace, P. J. (Ed.). (2017). Nursing ethics and professional responsibility in advanced
practice. Jones & Bartlett Learning. ISBN: 1284107337, 9781284107333.
Hessler, J. B., Schäufele, M., Hendlmeier, I., Junge, M. N., Leonhardt, S., Weber, J., &
Bickel, H. (2018). Behavioural and psychological symptoms in general hospital
patients with dementia, distress for nursing staff and complications in care: results of
the General Hospital Study. Epidemiology and psychiatric sciences, 27(3), 278-287,
https://doi.org/10.1017/S2045796016001098.
January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., ... &
Murray, K. T. (2014). 2014 AHA/ACC/HRS guideline for the management of
patients with atrial fibrillation: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and the