Objective Structured Clinical Assessment: Lisa Case Study- Diverticulitis- Nursing Assignment Help
Task:
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Guided by the Clinical Reasoning Cycle and patient scenario, students are required to utilise clinical reasoning and demonstrate knowledge regarding the care of Lisa. In this written OSCAstudents will need to clearly identify one problem, presenting sound rationales that supporttheir decision. Students are encouraged to draw on the patient’s story, cues and relatedinformation as they do this. Students are required to outline one goal, nursing care/actionand how evaluation will take place; providing rationales supported by literature. Studentsmust focus their nursing care to address the identified problem.
SCENARIO:
You a third-year nursing student working on a surgical ward allocated to the high dependencyarea. It is 7:30am and you have just received the following handover from night staff. Yourbuddy nurse asks you to care for Lisa today.
Lisa a 38-year-old mother of two who competes in triathlons. Lisa presented to the emergency department 48 hours ago with an acute abdomen and was diagnosed with perforated bowel secondary to suspected diverticulitis. Lisa underwent emergency midlinelaparotomy with division of adhesions and resection of 10 centimetres of bowel. Sincereturning to the ward she has suffered intractable pain that is not well controlled with a PCAand intrawound catheters. Her pain is reduced to a 2/10 for about 2 hours after the localanaesthetic via the intra-wound catheters and then increases to 7-8/10. Lisa attempted to sitout of bed yesterday but was unable to sit due to the pain and discomfort while sitting. Shehad a CT scan which was NAD. Overnight Lisa had a 10 minute period of AF which alteredblood pressure. She was given IV potassium and magnesium by MET Call Team.
On Assessment the following is identified:
CNS: Alert and Orientated rating her pain at a 6/10 and increasing. Lisa has a Fentanyl PCA with 20 mcg background, and 20mcg boluses with a 5 minutes lock out which was increased after review by the pain team yesterday. In the last hour she has had 12 demands and 8deliveries. Lisa has equal limb strength and is able to move herself in bed with assistance. HerGCS is 15 and PEARL. Lisa prefers to lay flat in left lateral position curled up, asking that youdo not sit her up as it hurts too much.
CVS: IVC X 2 insitu, one in right forearm, the other in left forearm, both VIP score 0 IV therapy s running at a 6 hourly rate. She has warm peripheries and is slightly diaphoretic. Her vitalsigns are stable with a heart rate of 80-90 beats per minute in sinus rhythm, blood pressureranges from 100-106/ 56-60, Temperature is 37.2 celcius. Overnight she has had short runsof AF, self-reverting on the monitor, lasting about 10 minutes. During the most recent episodeof AF at 0500hrs today she felt short of breath and her Blood Pressure fell to 85/50. Currentlyshe is in sinus rhythm.
RESP: Respiratory rate of 16-20 shallow breathing, oxygen saturation of 95% on using the AIRVO2 at 50% Flow 40L/min nasal prongs insitu. She has a very weak cough non-productive.On auscultation air entry to bases is quiet but heard in the midzones.
GIT: Abdomen is tender to touch, but soft. Bowel sounds are present throughout allquadrants. Bowels have not been open but she is passing flatus. She remains nil oral at thisstage only having ice for comfort, awaiting surgical review. Currently no nausea and has notvomited overnight.
Renal: IDC remains insitu due to immobility. Over the past 4 hours the urine output has been 110ml. Urine test was NAD.
Metabolic: BSL range between 6.0 and 8.0mmol/L, electrolytes have been stable and morning blood tests of U&E, Mg, K, PO4, LFT, FBE and Coags have been taken at time of MET Call. Forrepeat at 1000hrs.
Wound: Midline dressing intact, minimal ooze on dressing. No heat or redness noted. Intrawound cathethers insitu. No pressure areas but marking from sheets noted on back.
Social: family aware and husband and children will be visiting in the afternoon.
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