Banu Clinical Nursing Case Study
Key components of the assignment: Utilising the Clinical Reasoning Cycle:1. Describe the patient situation.
2. Collect the cues/information: Identify the specific assessment data you would need to gather from a patient presenting with this condition. Focus on history, physical examination and investigations . Note the results that are not normal.
3. Process information: Discuss the underlying pathophysiology of Pulmonary Embolism and the relationship between the disease process & the patient’s signs & symptoms. Include any risk factors and/or precipitating causes. The pathophysiology MUST be referenced. Using a table (provided)
4. Identify 2 priority Nursing Problems. These must include the related factors & evidence of such.
5. Establish a short & long term goal that is SMART6. Identify 5 priority nursing interventions supported by referenced evidence based rationales (et.al will be accepted in the table) for each intervention.
7. Formulate the expected outcome for your each of your nursing problems.
8. Reflection: Write your reflection on your learning during this assignment & how it enables you to enhance your critical thinking. This will not be marked.
Banu is a 28-year-old female who presented to the Emergency Department with pain in her left calf after tripping over a tree root on her daily run yesterday. She did not hit her head. Banu is a fit healthy female. Her only medication is the contraceptive pill (Drospirenone & Ethinyl Estradiol 3/.02) which she takes daily. Banu lives with her family and has 3 siblings, one older brother, 30 and two younger sisters, 26 and 24. She rides to Holmesglen Institute most days where she is studying Allied Health. This equates to about 10 km/day. She has just returned from a trip to London this week where she visited her aunt and uncle. Her father has a history of Hypertension and GORD and her mother has a history on TIAs. Both are treated symptomatically. Banu enjoys reading books and partying with her friends. She claims she had not been drinking when she fell. Her siblings are all well. Banu’s mother is 54 and her father is 56. Both immigrated to Australia from Asia 36 years ago.At handover you are informed that Banu’s observations are: T37.3 P. 94 & regular BP.120/70 R.18 & O2 sats 98% RA. Pain Score 5/10. Banu’s left calf is swollen and painful. The right calf is normal. Her peripheral pulses and sensation are equal on both legs. A diagnosis of L) DVT is made. Banu is kept overnight for review by the medical team in the morning. She has been ordered Morphine 5mg IV for pain as required.
When you go to the bedside to say good morning, Banu is very distressed. T.37.6, P.128 & regular, R.32, BP.140/90,O2 sats 92% RA and is holding her chest complaining of pain when she breathes 9/10. She is also a little vague as to where she is and is gasping when talking.
A diagnosis of Pulmonary Embolism is made after a VQ scan. Heparin is commenced 5000 units IV stat & 30,000 units in Normal Saline at 42 ml/hour. An aPTT is ordered for 6 hours’ time. Protamine Sulphate is ordered if required.
Using the Clinical Reasoning Cycle, formulate a plan of care for Banu.