Assessment Notes: Case Study Report
No. Words: 1500
Please note : –
Students are required to comply with word and time limits You are not expected to achieve exactly the required length and a 10% leeway on either side is acceptable The marker will not mark beyond the 10%. Only your work to that point will be marked against the assessment criteria.
HSNS373 Nursing Assessment
Relates to Learning Outcomes: ULO1, ULO2, ULO4, ULO5
Task:
Read the case studies below, choose only one of the following case studies to discuss and answer all 4 of the questions listed below. You do not need an introduction or conclusion and headings are advised. You must use academic writing and reference your work using APA referencing. Your ISBAR may be presented in table format. Please do not use bullet points, instead use well structured paragraphs.
Case Study 1 (Community)
Angela Thapa is a 72 year old woman who lives with her husband Arnold also 72 years old in their own home. Angela is a hospital in the home patient with nursing visits since she broke her hip after a fall while she was out in the garden. She had a fractured right Neck of Femur (NOF) and was taken for repair. The surgery went well however she developed a wound infection in the distal end of the suture line. Nurses visit to dress the wound and she takes oral Amoxil 500 mg B D twice daily for the infection. Over the past 3 days Angela has noticed an uncomfortable pain in the centre of her chest it is worse when she breathes and has also noticed a dry annoying cough. She has not mentioned it to Arnold as she did not want to worry him. Today she decides to mention it to you as her visiting nurse as the pain is more frequent and increasing and she feels quite short of breath.
HSNS373 Nursing Assessment
You ask some more questions regarding the pain and you have discovered she hasn’t been up and about as much with the pain in her hip and she has lost confidence in mobilsing since her fall. You look at her medical history she has a history of HT and take anti hypertensives Osteo Arthritis and has no allergies. She is not a smoker and does not drink any alcohol. You see she is short of breath while talking to you but you can not see any use of accessory muscles for work of breathing.
You do a set of vital observations and the following is found:
You are very concerned about her observations and wonder if she has developed a Pul monay Embolism (PE).
Questions:
1.Discuss your assessments on this patient, identify signs of deterioration and clearly state if the patient requires a clinical review or rapid response as per Between the Flags (BTF).Justify your decision with data from the case and relevant support.
HSNS373 Nursing Assessment
2.Document a succinct and accurate ISBAR handover in verbal script format (eg. Hello my name is…)
3.Considering the assessment findings prioritise and discuss the immediate nursing management of the patient including who you would call and why
4.Succinctly discuss the ongoing management of this case and integrate the relevant members of the interdisciplinary team
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