PRNA 2101-Developing Person Centred Adult Care.
Case study Sian.
Sian is a 20 year old woman who has been admitted to the assessment unit via her GP complaining of difficulty breathing. Sian’s GP made a telephone referral to the medical team without examining her and she has yet to be assessed by the team. She has had 3 days of increasing difficulty breathing and cough (clear sputum), she felt worse last night after attending Hockey training at University. She used her Ventolin inhaler last night with good effect, however today symptoms are increasingly worse.
Presenting complaint:
Sian states she has difficulty breathing and a cough.
PMH–Asthma, eczema as a child
•Medication-Beclazone 50 mcg –2 puffs twice a day, Ventolin 200 mcg –as required up to 4 times a day, Microgynon 150mcg –x 1 tablet for 21 days
Family history-Lives in University housing, Mother lives in Cardiff (has asthma), Father (no medical problems) 2 younger brothers (no medical problems)
Social history-Sports degree student (year 1), Enjoys sports; netball, swimming, badminton, tennis and hockey. Sian is a good at hockey –plays for Uni team.Socializes a few times a week, drinks alcohol (unable to say how much) smokes the occasional cigarette (a couple a night)
General health–feeling tired, last ate breakfast today (cereal), is drinking water –has a sports bottle with her. Weight 75kg, height 175cms. An initial ABCDE assessment is completed by the MAU triage Nurse:
A –clear, talking –but only in short sentences stopping frequently to catch breath
B –RR = 26, SpO2 93% on room air, is leaning over a chair, PEFR -200
C-BP 112/60mmHg, HR 112, CRT 2, skin warm and dry, looks pale, dry mouth
D-orientated, blood glucose 4.8. E-temp 36.8
The task:
•Review Sian’s scenario and identify and discuss the relevant altered pathophysiological, psychological or sociological elements
.•Demonstrate knowledge and understanding of the importance of conducting an accurate nursing assessment recognizing the knowledge, skills and attitudes required to conduct a holistic personalized assessment.
•Select and use appropriate evidence to support how the nurse would assess Sian’s identified care needs using a best practice and evidence based approach(LO1, LO2, LO3).
