Nursing Case Study Assignment

Nursing Case Study Assignment

Introduction

DETECT (Detecting Deterioration, Evaluation, Treatment, Escalation and Communication in Teams) is an education system which was developed on the recommendations by the NSW Health Greater Metropolitan Clinical Taskforce (GMCT) Working Party. The main purpose of this program is to improve management system and to provide better medical facilities for the patients. It deals with the various steps involved in the management and detecting deterioration. It also performs the evaluation of system performance and treatment of the patients. It is a complete educational system for the nurses and physicians. It also has a well developed e-learning program.. This provides the complete case taking and methods of detecting the deterioration signs in the patients. Also provide the guidance for clinical review and the ways to reverse deterioration. It provides complete system of patient assessment in the clinical fundamentals of nursing to assist nurses in taking case (Potter and Peterson 2008).

Thesis Statement

Post operative assessments and nursing interventions play vital role in treating and detecting the deterioration in patients.

Discussion

Case Study and Background

Mrs. Cheryl Brown is a 44 year old female who presents to the emergency department with a 2 day history of Right Iliac Fossa (RIF) pain and vomiting. She was referred by her local GP with a provisional diagnosis of Appendicitis. She is 160 cm tall and weighs 65 kilograms and is allergic to Penicillin. After a surgical review she was admitted to Hospital and transferred to theatre for appendectomy.

History

Temperature: 36.5 degrees

Heart rate (HR): 80 beats per minute (BPM)

Respiratory rate: 12 respirations per minute (RPM)

SaO2: 96 % on room air

Blood Pressure (BP): 105/60 mmHg

The doctor has requested that she be administered Metoclopramide hydrochloride (Maxalon) 10 mg IMI injection as charted and will review her in 1 hour.

Mrs Brown states she has pain (1) on a scale of 1-10 and is complaining of nausea.

PART A

Post Operative Assessment

ABCDE (Airway, Breathing, Circulation, Disability, Expose)

A-Airway

Mrs. Brown's airway can be observed by asking simple question and observations. The most important thing is to notice whether she has any difficulty in breathing or talking. It is very important that if she has any obstruction, it should be cleared as soon as possible. As described by Aghababian, the patient's airway can be assessed by following proper steps, the first step is chin lift or jaw thrust with care that tongue should be attached to jaw. If it does not work then succession, guedel airway, nasopharyngeal airway or ventilator can be tried. Cervical spine should be protected. There is no sign of airway obstruction as gurgling, snoring, stridor, hypoxia or cyanoxis. In case of emergency it might be needed for the use of advanced airway management techniques (Aghababian, 2010).

B- Breathing

In breathing assessment, Greaves and potter provides special care towards the post operative care assessment, in the light of breathing care assessment methods provided by them, Mrs. Brown's airway patency and breathing adequacy needs to be rechecked. Mrs. Brown's Respiratory rate is 12 respirations per minute (RPM) at SaO2: 96 % on room ...