Health risk assessment on a patient
Assessment 1 Case study report Guidelines PATIENT NAME:
Ben Marshall DOB: 05/03/1993 25 Years Male PRINCIPAL DIAGNOSIS: Severe Asthma SUMMARY OF EVENTS: Ben was out for a jog, where approximately 20 minutes into the run he developed severe shortness of breath and tightness in the chest. An ambulance was called and transported him to hospital. SOCIAL: Ben, a university graduate, lives with parents and two younger siblings. He is a very fit, young adult male who plays competition football. PRESENTATION: Patient Complaints: Severe dyspnoea No Loss of consciousness Meds Salbutamol inhaler Health History Diagnosed with asthma as a child (age 7) He has presented to hospital on two previous occasions for asthma related symptoms. Following his last admission 2 years ago he had Pulmonary Function Tests: FEV1/PEFR 80% of predicted, PEFR variability 30% On Examination A – Patient talking in single words, pursed lips B – Spontaneous, resting RR 34, severe dyspnoea Short shallow breathes, with use of accessory muscles Tightness in chest Dry cough Peak expiratory flow rate ?140 ml Auscultation – ?BS, with diffuse wheezes, auditory inspiratory and expiratory wheeze Percussion: hyperresonant SpO2 93% on 4L O2 C – Resting PR128, BP 90/60, centrally warm and perfused Elevated JVP +5 cm D – GCS 15, PERL 3+, E – Temp 36.7, no complaints of chest pain 2 F – RR 34, BP 90/60, resting PR128, Patient catheterized urine output low 40mls/hour BSL 5.9 I – Pulmonary function tests – see above ECG – Normal, no signs of ST elevation Bloods – ABG: Ph7.35, PaCO2 45mmHg, PaO2 70mmHg, HCO3 24mmol, BE +4 Chest X-ray – Normal, hyper-inflated with flattening of diaphragm Bloods – NAD Glossary of terms and abbreviations NAD No abnormality detected ABG Arterial Blood Gas BP Blood pressure ET End Tidal CO2 is the amount of CO2 in exhaled gas GCS Glasgow comma scale LOS Loss of consciousness RR Respiratory rate PERL Pupils equal and reacting to light PMH Past or previous medical history PR Pulse Rate RR Respiratory Rate SOB Short of breath SpO2 Saturation of oxygen onto haemoglobin in arterial blood # Fracture (L) Left (R) Right Case study report Assessment 1: Case Study Report This assessment requires you to apply the Framework of Practice Thinking, particularly the questions of “What’s going on here?” and “What does this mean?” to clinical data related to a specific health condition. You will identify and describe different health patterns and link these to patient assessment data. The assessment will be in the form of a written report of 2000 words on an asthma case study. You will be required to examine and interpret the data in relation to the physiological changes occurring in the patient and answer the two questions: “What’s going on here?” and “What 3 does this mean?” You will also be required to support your answer with evidence from the nursing literature. In addition, you are required to submit a 250 word reflection on your understanding of the University’s policy on Academic Honesty and how you have met the policy requirements in this assignment. This component is a compulsory requirement of the assessment, that is, you must complete this component in order to meet the requirements of the assessment, but it will not contribute to the academic value (grade) for the assessment. In your tutorial in week 5 you will be introduced to a case study and the assignment guidelines will be discussed. Format: Written report Submission: Turnitin submission Drop Box on the eLearning site. Length: 2000 words maximum Due: Monday May 7 2018 (week 9) by 0900 hours Value: 50% Students should note that this assessment will be submitted to similarity detecting software. SDS programmes provide the subject co-ordinator with an estimation of the extent of similarity between the students work and a broad range of academic literature. This estimate of similarity is brought to the attention of academic staff who will be required to undertake a comprehensive assessment of plagiarism prior to any action being taken. Note: Writing in excess of 2000 words will not be marked. A detailed marking rubric for this assessment is available on the Canvas site in the assessment section. Turnitin The Case Study Report will be submitted to similarity detecting software. SDS programmes provide the subject coordinator with an estimation of the extent of similarity between the students work and a broad range of academic literature. This estimate of similarity is brought to the attention of academic staff who will be required to undertake a comprehensive assessment of plagiarism prior to any action being taken. Guidelines This case study report requires you to apply theory and concepts to the case study. You will need to combine the theoretical approach of an essay with the practical nature of a report. This report should contain factual, current, well referenced information from the texts and literature. 4 Presentation This report should combine descriptive and explanatory writing using the subheadings given below and supported by the literature. Tables and graphics may be included and are not counted in the word count. Ensure each page is numbered and includes a header and/or footer. Use consistent formatting and appropriate academic and medical language. Writing should be clear and succinct. Please make sure you edit and proof read your work to avoid lost marks form spelling and grammatical errors or poor presentation. Make sure the font size and style is easily read. It is recommended that you use Arial font, with the minimum font size 10 point. Stay within the word count to prevent penalties. The word count should include all words in the body of the case study. Do not count the reference list. Referencing For this case study report 8-10 references are adequate. You can include relevant readings from the unit of study core readings. Ensure resources are acknowledged appropriately and systematically using APA 6th referencing – Formatting and structure as per a case study report – Correct use of abbreviations – In alphabetical order on a new page – Sticks to word count – Page numbers header/footer Structure and organisation The structure of report writing means headings are allowed. This report is divided into four parts. Make sure each part of the report is clearly identified and meets the specific requirements of the assessment. 5 Use the following subheadings to structure your case study report: Part 1. Introduction to the patient (approx. 250 words) Under this heading you should introduce the framework of practice thinking and provide an introduction to the patient. You should also provide holistic overview of the patient’s situation and past history drawing links to the patient’s social and past history. Part 2. Altered physiology due to principal diagnosis (approx. 750 words) Under this heading you provide a definition and description of the principal diagnosis of the case study. Discuss the altered physiology as a result of the disease process that is, how the disease/injury impacts on normal physiology, for example, how does the disease impact on the patient’s ventilation and oxygenation thus lifestyle. Part 3. Health Assessment (approx. 750 words) Under this heading you discuss your interpretations of the assessment data presented in the case study. Use the SOA of the SOAPIE format (see below) and the A-G assessment tool to document your findings. In your interpretation you are required to analyse the data and link the patient’s assessment findings to the altered physiology related to the diagnosis. You are also required to describe your response based upon your assessment of this clinical situation. To support your findings, use relevant nursing literature and evidence. S Subjective O Objective A Assessment Part 4. Conclusion (approx. 250 words) A short conclusion to summarise the key points covered in the case study Part 5. Academic Honesty Policy (approx. 250 words but not counted in the overall word count) Under this heading you are to write how you have met the University’s Academic Honesty in Coursework Policy 2015 requirements for this assignment. You are required to submit a 250 word reflection on your understanding of the University’s policy on Academic Honesty and how you have met the policy requirements in this assignment. This component is a compulsory requirement of the assessment, that is, you must complete this component in order to meet the requirements of the assessment, but it will not contribute to the academic value (grade) for the assessment. 6 Writing in excess of the 2000 word count will not be marked. The file size must not exceed 2mb. Please refer to the library resources provided and plan early and speak with your tutor if you are having difficulties.