clinical presentation

The case study requires the followin" rel="nofollow">ing: • discuss the pathophysiology related to the clin" rel="nofollow">inical presentation • relate the patient’s clin" rel="nofollow">inical assessment fin" rel="nofollow">indin" rel="nofollow">ings to physiological alterations • in" rel="nofollow">interpret selected clin" rel="nofollow">inical in" rel="nofollow">investigations (i.e. ECG, laboratory results) • explore appropriate management options determin" rel="nofollow">ined by evidence based literature CASE STUDY - James James Newton is a 62-year-old admitted to the orthopaedic ward 2/7 ago after fallin" rel="nofollow">ing 8 steps from a ladder, whilst cleanin" rel="nofollow">ing gutters at home. He sustain" rel="nofollow">ined 6 right sided rib fractures, a large chest wall abrasion and some underlyin" rel="nofollow">ing pulmonary contusion. James also sustain" rel="nofollow">ined an in" rel="nofollow">inferior/superior pubic rami fracture on right. He is currently on patient controlled analgesia (PCA) for pain" rel="nofollow">in management. James’ medical history in" rel="nofollow">includes chronic obstructive pulmonary disease (COPD), hypertension, ischaemic heart disease - coronary artery bypass graft x3 2011, GORD, Type 2 DM, current smoker. Medications in" rel="nofollow">include: Clopidogrel 75mg daily, Pantoprazole 40mg daily, Simvastatin" rel="nofollow">in 80mg daily, Spiriva 18mcg daily, Salbutamol PRN. Durin" rel="nofollow">ing the night he experienced in" rel="nofollow">intermittent chest pain" rel="nofollow">in, difficulty breathin" rel="nofollow">ing, and complain" rel="nofollow">ined about a persistent cough. James also developed a temperature of 38.3ºC. An ECG showed sin" rel="nofollow">inus tachycardia. Investigations in" rel="nofollow">included a sputum sample and a chest x-ray which identified worsenin" rel="nofollow">ing consolidation in" rel="nofollow">in the right middle/lower lobes. You are the ward nurse carin" rel="nofollow">ing for James, you perform your clin" rel="nofollow">inical assessment on your mornin" rel="nofollow">ing round. On examin" rel="nofollow">ination James is pale and peripherally cool, and his clin" rel="nofollow">inical assessment revealed: HR 118 beats per min" rel="nofollow">inute RR 24 breaths per min" rel="nofollow">inute BP 170/85 mmHg GCS 15/15, PEARL 3+ Temp 38.3 ºC SpO2 90% on 2L of oxygen via nasal prongs Question 1 (5%) What further nursin" rel="nofollow">ing assessment is required? Provide a rationale for each. (300 words) Question 2 (25%) Discuss James’ clin" rel="nofollow">inical assessment fin" rel="nofollow">indin" rel="nofollow">ings based on the underlyin" rel="nofollow">ing physiological response (in" rel="nofollow">in details). (700 words) While talkin" rel="nofollow">ing to James, his clin" rel="nofollow">inical condition deteriorates. He has severe right sided chest and back pan and is fin" rel="nofollow">indin" rel="nofollow">ing it in" rel="nofollow">increasin" rel="nofollow">ingly difficult to breathe. His respiratory rate is 30 breaths per min" rel="nofollow">inute and shallow. James is only able to speak in" rel="nofollow">in short sentences. His SpO2 is 87%. Arterial blood gases and routin" rel="nofollow">ine bloods were taken. The results are now available and are as follows: Result Reference K 4.8 mmol/L (3.5-5.0) Na 140 mmol /L (135-145) Creat 148 µmol/L (80-120) Glucose 10 mmol/L (4-8) WCC 15.3x 109gL (8-12) Hb 10.5 g/L (13.0-17.0) INR 1.2 (0.9-1.2) APTT 37 sec (25-37) ABG pH 7.30 (7.35-7.45) pCO2 58 mmHg (35-45) pO2 55 mmHg (80-100) HCO3 20 mmol (22-26) BE -3 (-2 to 2) SaO2 88% (95-100) Question 3 (20%) Interpret the above blood results and provide a physiological rationale for any abnormality (in" rel="nofollow">in details). (600 words) James is put on supplemental oxygen (Fraction of Inspired Oxygen FiO2 0.40) and his SpO2 improves to 93%. Despite these improvements in" rel="nofollow">in arterial oxygenation, he has become agitated. Question 4 (20%) Based on the change in" rel="nofollow">in James’ clin" rel="nofollow">inical presentation, discuss how alterations to normal physiology will in" rel="nofollow">influence tissue oxygen delivery and how this will impact on end-organ function (in" rel="nofollow">in details). (600 marks) Question 5 (5%) As the registered nurse lookin" rel="nofollow">ing after this patient, describe how you would escalate management of the patient (200 words) Question 6 Focusin" rel="nofollow">ing on priorities of care, provide a rationale for ongoin" rel="nofollow">ing medical management and subsequent nursin" rel="nofollow">ing care of this patient. (700 words)