Mr John Douglas is a 70 year old man who has been admitted to the emergency department after feeling unwell for 4 days at home with nausea and vomiting. His current observations are: T39, HR 120, RR 24, BP 90/60, and his oxygen sats are 92%. GCS is 15. He has generalized abdominal pain which is 7/10. He has not opened his bowels for 4 days and has abdominal distention. He weights 88kgs. He still works as a factory worker. He admits to drinking 6 stubbies of beer a night. He smokes a packet of cigarettes a day and has done this for 30 years. He does little exercise, but his job involves being on his feet all day. On assessment of John’s knowledge of his condition, he admits that he only did Grade 5 of primary school, and really cannot read well. He is divorced and has no children. Allergies- nil Current meds- nil Past illnesses- diverticulitis, right carpel tunnel repair 6 years ago
The goal of this case study is for you to present a response to a clinical scenario in which you demonstrate evidenced based principles for care assessment and the management of the chosen case.
Step 1: Understand the case
Step 2: Conduct a comprehensive secondary assessment of this patient and outline the systems assessments using the systems framework. CNS/ CVS/ RESP/ ABDO/ RENAL/ Other. Not all information for the case will be provided. You need to research what assessments might be important here and include these. For example blood tests or other diagnostic tests and present what these tests may show. You may add data as needed. Eg chest inspection showed decreased air entry in left chest. This section may not need extensive referencing as it is the assessments needed.
Step 3: Identify the main priorities of treatment for this case. Usually only 3-4 priorities will be needed and these need to be explained with appropriate references and evidenced based practice. In this section you will identify the RN responsibilities for care and how these will support the management of this case. If you choose the sepsis case there will be more priorities to cover.
Step 4: Outline and discuss appropriate discharge planning for this patient that aligns with the social justice framework and the principles of equity, rights and access for the case.