CASE STUDT BELOW

Respiratory Distress and Hypoxia Case Analysis

Scenario: Mr Trent Fulton

Background Mr Trent Fulton, was born in Wagga Wagga where his parents and sister still live. At school, Trent excelled academically and in sport, despite having exercise-induced asthma. He moved to Newcastle when he was 18 to undertake an accountancy degree. Ten years later, Trent completed a Certificate IV in fitness and qualified as a master trainer. With Ian, his partner of many years, he is now establishing his own gym. Trent has been working long hours and has also been training for an upcoming marathon. Phase 1: GP assessment Trent, a normally fit and healthy 35-year-old gym instructor, had seen his GP complaining of shortness of breath, fever, headaches and a productive cough over the past week. After checking Trent’s BP (baseline BP of 125/70mmHg), heart rate (62 bpm) and temperature (38.2oC), the GP diagnosed Trent with a respiratory tract infection and prescribed roxithromycin (Rulide) 150 mg BD. After taking the antibiotic for two days, Trent returned to his GP feeling much worse. A chest X-ray showed bilateral pneumonia and Trent was admitted to hospital via the Emergency Department (ED). Trent has a history of mild asthma which he has had since childhood. His symptoms often get worse with exercise and he takes salbutamol (Ventolin) via a metered dose inhaler (MDI) for symptom relief. Over the past few months, Trent and his partner, Ian, have been converting an old warehouse into a gym. During this time, both of them developed ‘flu’-like symptoms, sore throats and chest infections. Trent has not had an influenza or pneumococcal vaccination as he says he ‘doesn’t believe in vaccinations’. He is immunocompetent and has not recently travelled to tropical Australia or overseas. When Trent arrives at the hospital with Ian, he appears anxious and breathless. Phase 2: Admission to the Emergency Department On admission to the ED, Trent is diaphoretic (sweating) and flushed. He is alert and orientated but very breathless, with slight chest pain which he rates as 2 out of 10 on the numerical pain scale. Trent has a productive cough with green and malodorous sputum. The doctor examines Trent and notes decreased air entry and breath sounds and coarse rales (crackles) on the left side. His chest X-ray (CXR) shows consolidation in the middle left lobe but no pleural effusion. Trent says he has never smoked and drinks only socially. He is admitted to the medical ward accompanied by Ian, who helps him settle in and then goes home to look after their two dogs. Admission observations: Temperature 38.8°C. Pulse rate 128 beats/min. Respiratory rate 31 breaths/min. Blood pressure 100/60 mmHg. SpO2 92% on room air. ABGs: PaO2 55, PaCO2 32, pH 7.48, bicarbonate 24 mEq/.L Co-morbidities Asthma. Medical orders Sputum cultures and sensitivities. Blood cultures. Serum for mycoplasma IgM. Influenza PCR nose and throat swab samples. MSU. Oxygen 4 L via nasal prongs. IV benzylpenicillin 1.2 g, every 6 hours. Oral doxycycline 200 μg day 1, then 100 μg daily for 5 days. Salbutamol (ventolin) via nebuliser, 5 mg in 1 mL normal saline (NS). Chest physiotherapy. Phase 3: Morning handover report (medical ward) Trent had a very disturbed evening after his partner left. At 2000 hours, we found him out of bed with his nasal prongs still in place but the tubing detached from the oxygen outlet. He was a bit confused and disorientated and it took us 25 minutes to settle him down. We eventually got him back to bed and put his oxygen on, but he was reluctant to lie down. At 0200 hours, his temperature was 39°C and his respirations were 33 breaths per minute. It was difficult to monitor his oxygen saturations as he kept removing his finger probe but they varied between 80 and 92 per cent in room, so I changed him to a Hudson mask at 6 L/min. After handover, you read through Trent’s admission notes before going to his room. You enter Trent’s room and he appears to be more settled than he was overnight. His oxygen mask is still in place. You do another set of observations, with the following results: Temperature 38.8°C. Pulse rate 110 beats/min. Respiratory rate 33 breaths/min. Blood pressure 100/55 mmHg. SpO2 90%. Trent’s ABGs are repeated. Phase 4: Trent’s condition changes When you check on Trent 15 minutes later, you find him collapsed on the floor with his oxygen disconnected. He is cyanotic and does not answer your questions. You note that he now has stridor. You do another set of observations, with the following results: Respiratory rate irregular and 5 breaths/min Pulse rate 38 beats/min Blood pressure 75/60 mmHg SpO2 85% While waiting for the rapid response team/MET to arrive, a senior nurse comes to help and changes Trent’s Hudson mask to a non-rebreather mask with a flow rate of 12 L/min. The rapid response team/MET quickly respond to your call. Trent is ventilated and transferred to the Intensive Care Unit (ICU) for further care. He remains in ICU for the next few days, until his condition improves and he returns to the ward.

 

As there are four (4) phases in this scenario, you are required to choose only one phase and document a primary and secondary survey for the patient, using the information and data provided in the Case Study,

This assessment task requires you to refer to the Case Study to address each of the following stages in the Clinical Reasoning Cycle:

Describe the person's situation and their context – provide a description of the person's situation and their context in the scenario.200 words 10 marks. Drawing the most important details that you will understand the situation clinically. Do not bring any bias or assumption into retalling this information. Don does not repeat the content of the case study. Write in own words with the context of the case study. You don’t need to be referenced here.

Collect cues and information- Choose one phase of the scenario and document a primary and secondary survey for the patient, using the information and data provided in the Case Study.300 words 10 marks 

As there are 4 phase in the case study you are required to choose only one phase and documents a primary and secondary survey with up to date information data provided in case study. Consider the most important factors in collecting information what assessment finding are important in clinical reasoning cycle process. Specify the principles / practice/ theory that you will apply to case study. After providing explanation / discussion / analysis of primary survey and relating to case study you then progress to secondary survey. Provide the steps logically how nurse would analyse the care.

Process information – identify and compare the abnormal assessment findings with normal data and identify relevant links between assessment findings (clustering cues).300 words

Just confirming as there are a lot of OBS throughout this scenario, are we to use all these abnormal findings or only the one phase that was used for collect cues?

Under this criteria, you want to be using the set of obs 'you' have done for him on your assessment, i.e., the obs taken after handover on your first assessment when you were collecting the cues to create a plan to manage his care.

The phase you have chosen under the question Collect cues and information will be the observations you will need to refer to i.e., if you choose phase 3 then you will discuss the assessment findings under this phase.

Identify problems– identify, describe and prioritise the most clinically relevant patient-centered problems  from processing your information above. 250 words.10 marks

Identifying the problems will depend on the phase you chose to review. Identify, describe and prioritise the most clinically relevant patient-centered problems from processing your information above. Here is an example of a problem-focused nursing diagnosis. Here you can see there are multiple goals we want to achieve:

Deficient fluid volume related to prolonged vomiting as evidenced by increased pulse rate, increased urine concentration and poor skin turgor.

The goals we could look at here are:

lowering the pulse rate

ensuring the patient is adequately hydrated by monitoring urine output etc.

Please be mindful of the word count though. If you can fit this in then by all means do so but make sure you are adequately discussing or exAs per the rubric you are only required to identify, describe and prioritise the most clinically relevant patient-centered problem/s relevant to the findings you have gathered from processing the information. plaining your goal and not just outlining or describing these.

Establish goals - identify two (2) appropriate nursing care goals that are relevant for the patient in the Case Study. These should be SMART (Specific, Measurable, Achievable, Relevant and Time-Limited) goals and should address the identified clinical problems.150 words 10 Marks

Based on the phase you choose in criteria 2 and your current finding in criteria 3 you are now required to make a nursing diagnosis of Trent presenting problems. A nursing diagnosis is developed based on data obtained from the nursing assessment. i.e. during the primary and secondary survey the nursing diagnosis made here will guide the goals you set up in next criteria. Goals and actions tie in together. A goal is set to guide your actions/interventions that will be put in place.Yes, your nursing intervention noted is on the right track. What can you do as a nurse that does not entail medical intervention e.g. reassurance, comfort, using heat/cold packs, diversional therapy etc.Once you refer for a clinical review this then moves away from what you can do autonomously as a nurse. Once we refer, it then means following medical interventions. Your goals should be nursing intervention-focused and not medical intervention focused. What can you do for him as a nurse to prevent further deterioration whilst you are waiting for assistance? but think about what you can do as a nurse that is within your scope of practice that does not need to be ordered by the doctor e.g. positioning, distraction therapy etc. 

Select a course of action – outline two (2) appropriate evidence based nursing interventions that are within the scope of practice of a Registered Nurse that will assist the patient to meet the desired outcomes of the clinical problems identified and optimise patient safety. Support these interventions with evidence-based rationales of how the interventions address the clinical problems identified. 10 marks 300 words

Evidence based nursing intervention within the scope of practice to meet the desired outcome of clinical problems to optimize the patients safety. Support these intervention with evidence based rationales and how the intervention address the clinical problems identified . For the course of action to be taken make and outline what will be done .

Evaluate actions – describe the process for evaluating the desired outcomes of the chosen nursing interventions in this scenario.20 marks 300 words

Evulate the desired outcome of the chosen nursing intervention in the scenario .this section is most weight on rubric. Evulate the effectiveness of outcomes and action

This assessment is to be in the form of an academic paper using appropriate nursing terminology and academic writing. You are to support your work with at least fifteen (15) academic sources (nursing journal articles, professional manuals and documents, textbooks, and module readings). All sources must be correctly referenced in-text and in the reference list in accordance with APA 7th Edition referencing style.

As there are four (4) phases in this scenario, you are required to choose only one phase and document a primary and secondary survey for the patient, using the information and data provided in the Case Study.

Consider the most important factors in collecting information. What assessment findings are important in clinical reasoning?

Specify the principles/practice/theory that you will apply to the case, e.g., The initial primary survey assesses the major organ systems of the body and follows the mnemonic ABCDE (Burton, 2021)

After providing and explanation/discussion/analysis of the primary survey and relating this to the case study, you then want to progress to the secondary survey e.g., The secondary survey is then completed, continuing the mnemonic with FGH (Fong & Bucher, 2020)....

It is important to make clear to your marker that you understand the clinical reasoning process. Provide the steps logically on how a nurse would analyse a case. In addition, provide references to demonstrate that your ideas are based on appropriate evidence based on professional standards.

If you are comparing normal and abnormal findings (as there are quite a few in the scenario) and explaining or analysing this in relation to the case study, adding pathphysiology will take you over the word count. We are assessing how you are interpreting this findings. Are you able to understand what is normal and then put this knowledge together to identify what is abnormal and how this is affecting the person.

When reviewing the case, brainstorm the areas that stood out to you as being the most significant. Check with the abnormal health findings and investigate what these might mean. When writing your synthesis, you will need to prioritise the most important considerations needing to be addressed in treating the patient and address these in turn e.g. When reviewing height and weight measurements, a body mass index (BMI) can be calculated to evaluate body size (Lewis & McPherson, 2020). John’s BMI works out to be 43.4, which puts him in the category of morbidly obese (Lewis & McPherson, 2020)

please do not use a table as this limits your discussion. You can use a table in your planning but do not include this in your paper.

When reviewing the case study, brainstorm the areas that stood out to you as being the most significant. Check with the abnormal health findings and investigate what these might mean. When writing your synthesis, you will need to prioritise the most important considerations needing to be addressed in treating the patient and address these in turn.

If there are multiple concerns in the phase you have chosen, ensure each of your paragraphs include a clear point; evidence to support that point; and analysis bringing it all together. Your analysis will generally explain to the reader how the point you are making is significant to the case.

Collect cues and information- Choose one phase of the scenario and document a primary and secondary survey for the patient, using the information and data provided in the Case Study.

Identifying the problems will depend on the phase you chose to review. Identify, describe and prioritise the most clinically relevant patient-centered problems from processing your information above.

refer to question 2 on collecting the cues. Under this question, you are advised to choose one phase of the scenario. Depending on the phase you have chosen, you will need to establish goals as an RN taking care of the patient.

Describe the person's situation and their context, i.e., provide a description of the person's situation and their context in the scenario. You will need to provide a description of what has occurred to the patient from his initial symptoms experienced and presentation to the GP and the chain of events that has led to his condition deteriorating e.g., Trent is a qualified gym instructor with a history of exercise-induced asthma, who presented to his GP with shortness of breath..... He was provided treatment and... then you would need to describe what happened next. Use research evidence to explain/analyse the care provided throughout his journey within the healthcare system e.g. in his initial presentation, what communication methods were used, was mindful communication used to assess his symptoms prior to him being prescribed treatment? etc.

When writing your evaluation you need to write the process of how you are reviewing if the goals set are working as planned.  Ask: “has the situation improved now?”  e.g. IV therapy as prescribed has been commenced for John. Nausea and vomiting has settled post administration of prescribed antiemetics. John is now able to tolerate clear fluids. 

Nursing action- Just want to confirm that the nursing actions are linked to our smart goals not just the phase we are examining. This question is relevant to the problems identified and the goals set to manage these problems.

Isn't every answer from Q2 onwards only relating to the phase we chose, no other part of the case study?

Nursing actions and goals will be linked to our chosen phase wont they?

Your goals should be relevant to the phase you have chosen and the problems identified in that phase.

Your goals should be nursing intervention-focused and not medical intervention focused. What can you do for him as a nurse to prevent further deterioration whilst you are waiting for assistance? As this is an assessment I can't tell you if you are right or not, but think about what you can do as a nurse that is within your scope of practice that does not need to be ordered by the doctor e.g. positioning, distraction therapy etc. 

When writing your evaluation you need to write the process of how you are reviewing if the goals set are working as planned.  Ask: “has the situation improved now?”  e.g. IV therapy as prescribed has been commenced for John. Nausea and vomiting has settled post administration of prescribed antiemetics. John is now able to tolerate clear fluids.

As per the rubric you are only required to identify, describe and prioritise the most clinically relevant patient-centered problem/s relevant to the findings you have gathered from processing the information. There is no specific number of problems you need to include.

You are not required to reference the case study; however, if you do use any evidence to support your interpretion, then this would need to be referenced.

Yes, you are using the primary and secondary survey here. If there is something missing in the case study, you could add this to your discussion and advise the reader/marker why you think this is important to be assessed. This is the guide I provided in the recording to support you:

As there are four (4) phases in this scenario, you are required to choose only one phase and document a primary and secondary survey for the patient, using the information and data provided in the Case Study.

Consider the most important factors in collecting information. What assessment findings are important in clinical reasoning?

Specify the principles/practice/theory that you will apply to the case, e.g., The initial primary survey assesses the major organ systems of the body and follows the mnemonic ABCDE (Burton, 2021)....

After providing and explanation/discussion/analysis of the primary survey and relating this to the case study, you then want to progress to the secondary survey e.g., The secondary survey is then completed, continuing the mnemonic with FGH (Fong & Bucher, 2020)....

It is important to make clear to your marker that you understand the clinical reasoning process. Provide the steps logically on how a nurse would analyse a case. In addition, provide references to demonstrate that your ideas are based on appropriate evidence based on professional standards.

If you are comparing normal and abnormal findings (as there are quite a few in the scenario) and explaining or analysing this in relation to the case study, adding pathphysiology will take you over the word count. We are assessing how you are interpreting this findings. Are you able to understand what is normal and then put this knowledge together to identify what is abnormal and how this is affecting the person.

When reviewing the case, brainstorm the areas that stood out to you as being the most significant. Check with the abnormal health findings and investigate what these might mean. When writing your synthesis, you will need to prioritise the most important considerations needing to be addressed in treating the patient and address these in turn e.g. When reviewing height and weight measurements, a body mass index (BMI) can be calculated to evaluate body size (Lewis & McPherson, 2020). John’s BMI works out to be 43.4, which puts him in the category of morbidly obese (Lewis & McPherson, 2020).

Tachycardia and sepsis are not a nursing diagnosis. You could say Increased heart rate related to ....as evidenced by...

It does not matter what format you use as long as you are showing the reader/marker that you understand each component of the SMART acronym and you have used this logically to format your goal/s. You will not be marked down if you stated each letter of the acronym as per your second example and then added your rationale to this.

That is a really good attempt at a SMART goal. Below is a written guide to further support you with this criterion.

The SMART goal is a simplified format to direct and drive goal setting. It stands for Specific, Measurable, Achievable, Relevant and Time-bound. 

Specific: Specifically outline your goal. Be as clear as possible with what you want to achieve. This will focus your SMART goal and make it easier for you for the following steps. The more narrow your goal, the more you'll understand the necessary steps to achieve it. Avoid including 2+ more goals as this will create confusion to both the author and the reader e.g., "To be confident and efficient in my ISBAR handover”.

Measurable: How will you know you are achieving your goal? What will be the necessary actions you need to take to know you are on the right track? e.g.,"Utilising peer review feedback, academic feedback, patient feedback by asking informal questions to measure the effectiveness in the ISBAR handover. For example "did you feel adequately informed and safe to accept this patient by the ISBAR handover?" 

Achievable: What actions will you take to ensure you achieve this goal? Make sure you're goal is as achievable as possible to your scope and level of practice e.g., "Practicing ISBAR handover in every Simulation lab class to my Academic teacher and peers, review example ISBARs and practice in self-directed study time".

Relevant: Make sure your goal is relevant/realistic to your values and practice as much as possible. Ask yourself, 'why is this goal important to you, how will achieving it help you and your long term goals' e.g., "Relevant to my scope of practice as a Registered Nurse and creates a safe patient environment when providing direct care by the bedside".

Time-bound: What is your goal time frame? When would you like to have achieved this goal? An end date can keep you motivated and help prioritise your actions to help achieve your goals e.g. "I want to achieve this goal by the end of my Bachelor of Nursing undergraduate degree so I can be confident and efficient in providing an ISBAR handover throughout my Graduate Nurse Program next year". 

Here is an example of a problem-focused nursing diagnosis. Here you can see there are multiple goals we want to achieve:

Deficient fluid volume related to prolonged vomiting as evidenced by increased pulse rate, increased urine concentration and poor skin turgor.

The goals we could look at here are:

lowering the pulse rate

ensuring the patient is adequately hydrated by monitoring urine output etc.

Please be mindful of the word count though. If you can fit this in then by all means do so but make sure you are adequately discussing or explaining your goal and not just outlining or describing these.

This assessment is to be in the form of an academic paper using appropriate nursing terminology and academic writing.

Dot or numbered points should not be used in an academic paper as this does not allow you to apply your knowledge and understanding of the concept being addressed.

I hope this helps you when preparing your assessment.

It is important to make clear to your marker that you understand the clinical reasoning process. Provide the steps logically on how a nurse would analyse a case. In addition, provide references to demonstrate that your ideas are based on appropriate evidence based on professional standards.

Yes, for the secondary survey, if you find that the information required is not available in the phase you are reviewing and it is important to be included, then information from the case study as a whole can be added here.

 Consider the most important factors in collecting information. What assessment findings are important in clinical reasoning? It is important to make clear to your marker that you understand the clinical reasoning process. Provide the steps logically on how a nurse would analyse a case. In addition, provide references to demonstrate that your ideas are based on appropriate evidence based on professional standards.

IDENTIFY PROBLEMS

Please review the task requirement as this question links to question 2:

Collect cues and information- Choose one phase of the scenario and document a primary and secondary survey for the patient, using the information and data provided in the Case Study.

Identifying the problems will depend on the phase you chose to review. Identify, describe and prioritise the most clinically relevant patient-centered problems from processing your information above.

Here is an example of a problem-focused nursing diagnosis. Here you can see there are multiple goals we want to achieve:

Deficient fluid volume related to prolonged vomiting as evidenced by increased pulse rate, increased urine concentration and poor skin turgor.

The goals we could look at here are:

lowering the pulse rate

ensuring the patient is adequately hydrated by monitoring urine output etc.

Please be mindful of the word count though. If you can fit this in then by all means do so but make sure you are adequately discussing or explaining your goal and not just outlining or describing these.

As per the rubric you are only required to identify, describe and prioritise the most clinically relevant patient-centered problem/s relevant to the findings you have gathered from processing the information. There is no specific number of problems you need to include.

Think about your primary and secondary survey here. When we complete these assessments what are our priorities to manage the patient when we are assessing ABC? Will this be a priority over a falls risk/delirium assessment? Think about priorities of care to prevent further deterioration which could possibly lead to respiratory or cardiac arrest.

DESCRIBE THE PERSON / CONTEXT

To answer this question, you need to: Describe the person's situation and their context, i.e., provide a description of the
person's situation and their context in the scenario.

You will need to provide a description of what has occurred to the patient from his initial symptoms experienced and presentation to the GP and the chain of events that has led to his condition deteriorating e.g., Trent is a qualified gym instructor with a history of exercise-induced asthma, who presented to his GP with shortness of breath..... He was provided treatment and... then you would need to describe what happened next. Use research evidence to explain/analyse the care provided throughout his journey within the healthcare system e.g. in his initial presentation, what communication methods were used, was mindful communication used to assess his symptoms prior to him being prescribed treatment? etc.

I hope this helps with answering your question.

Your goals should be relevant to the phase you have chosen and the problems identified in that phase.

The SMART goals do not need to be referenced as you will be expanding on this in Criterion 6 – Select a course of action. This is where your evidence comes in to support your goals.

EVALUATING COURSE OF ACTION

When writing your evaluation you need to write the process of how you are reviewing if the goals set are working as planned. Ask: “has the situation improved now?” e.g. IV therapy as prescribed has been commenced for John. Nausea and vomiting has settled post administration of prescribed antiemetics. John is now able to tolerate clear fluids.

You are required to briefly describe the case study, drawing out the most important details that you will need to understand the situation clinically. Do not bring in any biases or assumptions into retelling this information. Do not repeat the content of the case study. This information should be written in your own words to show the reader/marker that you understand the context of the scenario and then when you progress to collect the cues, you can choose one of the phases to continue with your review and discussion.