Assessment : Case scenario
Shift handover:
Identify: Miss Grace Orun, HRN: 123567, DOB: 07/05/2005
Situation: Grace is a 16-year-old caucasian female. She has been admitted to the medical ward due to Diabetic Ketoacidosis.
She has a 2/7 history of feeling unwell, fatigue, and a fever. Her Mum was worried as Grace has been complaining of increased thirst and passing large amounts of urine frequently. Her Mum brought her to the emergency department (ED). She was treated for DKA in ED. She has been reviewed by the
Endocrinology team and has been diagnosed with Type 1 Diabetes Mellitus (T1DM) and subsequently developed DKA. She has been transferred to the CDU Medical ward for continuing care.
Background:
Grace lives with her parents and younger brother Tommy. She is independent with her cares and plays Netball at state level 3 times a week after school.
She has never been admitted to hospital before.
Her past medical history:
Previously ankle sprain in 2020 – resolved.
Tonsilitis.
She is allergic to Penicillin.
Assessment:
Airway: Own, patent
Breathing: RR 26, Sats 98% on RA.
Circulation: HR 115 bpm, BP 90/55 mmHg.
Disability: GCS 15/15
Exposure: Temp 37.8 oC
Grace feels tired and anxious.
Grace has 2 x IVC’s inserted to both ACF’s.
She is refusing to eat, feels sad and tells you ‘Leave me alone, my life is ruined, I’ll never play sport again’
Venous Blood Gas attended shows Potassium 3mmol/L
BGL 25mmol/L
Ketones – 1mmol/L
Recommendations/Read back:
Medical orders
Routine ward assessments and observations
Strict fluid monitoring
Administer Intravenous fluids as prescribed
Commence Insulin sliding scale
MSU for MC & S
Diabetic diet and fluids as tolerated
TED stockings and DVT prophylaxis
IV Fluid orders
Intravenous compound sodium lactate (CSL) 500mls over 2 hours followed by:
Intravenous Potassium Chloride 40mmols/1000mls over 8 hours
Medication orders
Actrapid insulin (sliding scale) S/C
Insulin Glargine 10 Units S/C OD
Tazocin 4.5g IV TDS (allergic to Penicillin)
Nursing orders
Devise a plan of care for your patient.
Assessment Tasks:
Using the template provided on the separate document and, based on the handover and information above, other information included below and current reliable evidence for practice, address the following tasks.
Do not make up or assume information in relation to or about your chosen patient. Only use what you know from the information you received today.
Task 1: Assessment
Based on your chosen case scenario and in grammatically correct sentences identify:
Three (3) priority nursing assessments you would conduct at the commencement of your shift.
AND
For each assessment you have identified explain:
Why it is necessary for the patient’s condition and nursing care?
What consequences can occur if this assessment is not completed accurately?
What chart or document could you use to assist with/record your assessments?
(Approximately 400-500 words)
Task 2:
Based solely on the handover you have received and using the template provided on the separate document, complete a nursing care plan for your patient. Your plan must address the physical, functional, and psychosocial aspects of care.
Three (3) nursing problems have been provided for you on the separate document. For each nursing problem on your care plan you need to identify;
What it is related to?
Goal of care
Interventions
Rationales for interventions
Evaluation
Notes for Task 2 only
Dot points may be used in the care plan template.
Appropriate professional language must be used – legally recognised abbreviations may be used in this task (care plan) but a KEY with full terminology must be provided after the assignment references – key will be excluded from word count tally.
Rationales must be appropriately referenced (Only rationales need referencing in the care plan)
(Approximately 400 words)
Task 3: Patient education
Discharge planning
An important aspect of nursing practice is to effectively and succinctly communicate relevant information related to ongoing disease management or prevention of reinfection or deterioration on discharge.
Patient education and discharge planning starts on admission and you need to provide your patient with education during your shift in preparation for discharge home.
Explain two (2) important points/topics you will need to include in your patient’s preparation for discharge to aid healing and prevent further illness. For each education point identified provide:
One (1) strategy to assist your patient to implement the education into their daily routine.
(Approximately 400 words)
Task 4: Medication
Calculate the hourly rate of the compound sodium lactate and the sodium chloride infusions. List the formula that you used.
Choose two (2) medications that your patient has been prescribed (one (1) from their IV fluid order and one (1) from their medication order) and include the following in your discussion:
Describe the pharmacokinetics of the fluid/medication?
Why has your patient been prescribed this fluid/medication?
Discuss any side effects that could affect the patient.
Please keep in mind that Grace is Alergic to Penicillin however is prescribed – Tazocin 4.5g IV TDS – discuss the elements of pharmacokinetics but highlight that this is either a drug error or you would not give, and state why.
