NSG2201 Case Study

Mr Jason Bourne is a 35-year-old man who presented to his GP complaining of nausea, vomiting, dizziness and severe headache. He has no relevant history apart from a very sore throat over the past week. He is normally fit & healthy. He is married to Gwyeneth and they have two sons, Bill and Ben, twins, who are 5 years old. The GP sent him home after giving him an injection of Metoclopramide 10 mg and Morphine 10mg for a migraine headache.

Last night Jason woke his wife complaining that his headache was worse. He vomited all over the bed and collapsed.

An ambulance was called and Jason was taken to the ED.

On admission

 T.39°

 P. 120 & regular

 RR. 28 bpm

 BP. 170/90

 SpO2. 94% on room air

 BGL. 3.5 mmol/L

 Pupil reaction. Slow & PEARL

 Photophobic

 Pupil Size. 3 mm L & R

 GCS. 11 (3,3,5)

 Nuchal Rigidity

Jason was ordered

 blood cultures, FBE, E&U, LFT, Glucose level, platelet count

 Lumbar Puncture – protein, glucose, WBC, Gram Stain & culture

 CT, MRI,

 IV Therapy

 IV Antibiotic therapy

 Dexamethasone

 IV Paracetamol

 IV Mannitol

 Provisional diagnosis is Bacterial Meningitis

No introduction is required.

 Part 1

Your assignment will begin with Process the Information

• Interpret: analyse the cues
• Discriminate: distinguish relevant information
• Relate: discover new relationships or patterns
• Infer: make logical deductions
• Match: NOT REQUIRED
• Predict: outcome
• This MUST be referenced

Part 2

• Formulate a care plan for 2 nursing diagnosis/problems with associated medical factors & supporting clinical evidence

Please follow this format, only rationale must be referenced.

Diagnosis: Impaired gas exchange
Goals:	Short-term– Establish and maintain patent airway, reduce fatigue, effective tissue perfusion and optimum gas exchange with arterial blood gas (ABGs) being in the normal range and oxygen saturation being 95 – 100%.
	Long-term– significantly improved understanding of therapeutic intervention and procedures and displays active participation in respiratory exercises by remaining alert, orientated and proactive.
NURSING INTERVENTION		EVIDENCE BASED RATIONALE
1.    Conducting an assessment of the colour of the nails, skin and mucous membranes.		Pale skin happens as a compensatory mechanism for hypoxemia. Lack in oxygen causes circumoral, tongue and peripheral cyanosis evidenced by capillary refill, blue colour, indicating the hypoxic state of tissues(Adeyinka & Kondamudi, 2019).
2.    Monitor the vital signs for any changes in oxygen saturation using pulse oximeter.		Pulse oximeter consistently monitors oxygen saturation in blood, any significant drop in oxygen saturation in blood can cause ineffective tissue perfusion as evidenced by laboured breathing(dyspnoea), gasping and anxiety(Corrigan et al., 2016). Behavioural changes and reduced cognitive activity are the early signs of hypoxaemia(Sarkar et al., 2017), increased PaCO2 (hypercapnia) in blood stream and decreased PaO2 results in respiratory acidosis therefore causing impaired cognition, inability to follow commands, lethargy, confusion, disorientation and fatigue(Patel & Sharma, 2019) response.
3.    Positioning Banu in a semi-fowler’s position where head and trunk are raised to 45 degrees(Kuhajda et al., 2015). Teaching diaphragmatic breathing.		Positioning encourages and facilitates respiration as it expands thoracic and lung capacity causing diaphragm to augment, stimulating and supporting deep breathing. Semi-fowler’s position conserves lung capacity and improves hypoxemia thereby enhancing performance with less dyspnoea (Morrow, Brink, Grace, Pritchard, & Lupton-Smith, 2016).
4.    Administer humidified oxygen with an aim to establish oxygen saturation at 90% or higher.		Supply of humidified oxygen maintains adequate concentration of oxygen in systemic circulation thus conducting effective tissue perfusion and improves hypercapnia linked with poor ventilation(Roca et al., 2016).
5.    Provide encouragement, reassurance and education in scheduling and managing activities of daily living (ADL’s) at a pace that is less intense.		Overworked muscles and non-essential daily tasks need oxygen for proper functioning. Due to reduced lung capacity, restricted breathing and finite oxygen reserves, Banu with laboured breathing and hypoxia can deteriorate her current state of health (Sanchez et al., 2017).
Expected Outcome/Evaluations: (for each intervention) 1 2 3 4 5

 

 

o 2 priority nursing diagnoses

o Short & long term goals for each nursing diagnosis (SMART)

o 5 priority interventions for each nursing diagnosis

o 1 evidenced-based rationale for each intervention (must be referenced)

o 5 expected outcomes including clinical data

 

Part 3 · Write a short reflection of your learning throughout this assignment. (100 words)