Case Study 6 Online Case Study Nursing Assessment

Case Study 6

Assignment one- case study

Jim is a 77-year-old male who originally presented with R) hip pain and difficulty mobilising. This was on the background of a dynamic hip screw for a fractured neck of femur eight weeks prior.  His history includes Parkinson’s disease which is relatively well managed with medication, hypertension, COPD, ischemic heart disease, osteoporosis, and gout. Jim’s hip pain was investigated with x-rays and orthopedic input which showed no bony pathology. His main goals while an inpatient was to improve mobility and pain management.

While under my care, Jim started to deteriorate rapidly. On inspection of Jim, he was pale in colour, he complained of dyspnoea which was evident with his increased work of breathing and became diaphoretic with an intermittent productive cough with yellow sputum. He was not showing coryzal symptoms. I undertook a full assessment to understand the broader picture of what was happening, which did not relate to the reason he was admitted five days prior. Jim was febrile at 38.2 degrees. He was tachypnoeic at 28 breaths per minute with oxygen saturation of 93% on room air. He was hypertensive and tachycardic also. On auscultation, Jim had widespread expiratory wheezes bilaterally. His abdomen was distended with sluggish bowel sounds also. There were no signs of heart failure or fluid overload. Jim was also disorientated to time and place. Jim stated he had no pain, but it was noted from previous shifts that Jim was experiencing some urinary frequency but no dysuria.

After collecting the above cues, I needed to process and interpret the information as well as escalate his level of care with his medical team. At this point, I undertook a bladder scan on the patient, to make sure he was not in urinary retention. He had 250mls in his bladder which I would continue to monitor. Identifying the problems and issues at this point had me thinking about a few possibilities as to why Jim had deteriorated so quickly. Was this an exacerbation of his COPD? Or possibly a urinary tract infection (UTI)? A UTI is one of the most commonly diagnosed infections in older adults. As the population ages, the burden of UTI in older adults is expected to grow, making the need for improvement in diagnostic, management and prevention strategies critical to improving the health of older adults (Rowe & Mehta 2013). My main goal at this point for Jim was to provide him with the medical care he required, starting with practitioner input and medical interventions. My action commenced with obtaining a urine specimen for pathology. Jim was sent for a chest x-ray which showed no pneumonia or consolidation and viral swabs were collected which came back negative. He was found to have an infective exacerbation of his COPD which was managed with bronchodilators, oral antibiotics, and prednisolone for five days. Jim’s urine specimen came back positive for Klebsiella pneumonia. This was managed initially with intravenous fluids, gentamicin, and amoxicillin and was then de-escalated to oral antibiotics with clinical and biochemical improvement. A UTI can easily go unnoticed in an older adult. Elderly patients more commonly present with atypical or nonspecific symptoms and this may contribute to delayed diagnosis and treatment. They may still present with the usual symptoms of dysuria, frequency, and fever as seen in younger people, but they may have a more vague presentation such as an acute confusional state, decreased mobility and newly developed urinary incontinence (Cove-Smith & Almond 2015).

Two days later I returned to looking after Jim. I could evaluate the effectiveness of my actions and outcomes by physically looking at how well Jim now presented. He was orientated to time, place and person and his vital signs were stable. His situation had improved immensely and was back into physiotherapy. Reflecting on this patient care episode, from the cues I collected from my nursing assessment, I had a lot of information I was able to process and pass onto the appropriate medical staff. It is important to note that collecting this information is extremely important in nursing, but most of all knowing what is normal vs. what is abnormal and escalating it to the appropriate team (Massey & Anderson 2017). These clinical reasoning skills have a positive impact on patient outcomes. Conversely, those with poor clinical reasoning skills often fail to detect impending patient deterioration which therefore results in a ‘failure to rescue’(Aiken et al. 2003). This could have happened to Jim. The top three reasons for adverse patient outcomes include failure to diagnose properly, failure to institute appropriate treatment and inappropriate management of complications (Levett-Jones et al. 2010). Each of these mentioned above relate to poor clinical reasoning skills. My assessment and escalation meant that Jim could return to his baseline health with further physiotherapy input to get him home once again.

 References:

Aiken, LH, Clarke, SP, Cheung, RB, Sloane, DM & Silber, JH 2003, ‘Educational levels of hospital nurses and surgical patient mortality,’ JAMA, vol. 290, no. 12, pp. 1617-1620.

Cove-Smith, A & Almond, M 2015, Management of Urinary Tract Infections in The Elderly, Essex.

Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, SY, Noble, D, Norton, CA, Roche, J & Hickey, N 2010, 'The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients', Nurse Education Today, vol. 30, no. 6, pp. 515-520.

Massey, D & Anderson V 2017, ‘What factors influence ward nurses’ recognition of and response to patient deterioration?’, Nursing Open, vol. 4, no. 1, pp. 6-23.

Rowe, TA & Mehta 2013, ‘Urinary tract infections in older adults,’ Ageing Health, vol. 9, no. 5, pp. 13-23.