Patient profile 

Question Patient profile Rebecca Bathchild is a 59 year old women who has been admitted to the gastrointestinal ward with increasing abdominal pain, nausea and vomiting, and anorexia over the past 4 days. Her brother has reported that her alcohol use had been substantial (he had counted 30 bottles of wine in the bin) over the past week. She has a known medical history of pancreatitis, alcohol induced liver disease and ethanol misuse. An abdominal CT scan was performed yesterday and confirmed a suspected diagnosis of necrotising pancreatitis. The nursing notes from the night shift report the following: 22/10/2021 at 06:10 hours – Patient slept well overnight. Diazepam 5mg administered at 23:30 hours for an alcohol withdrawal scale (AWS) of 10, and subcutaneous morphine at 03:00 hours for increased abdominal pain 7/10. Reviewed overnight by the night registrar at 05:00 due to the patient experiencing malena, full blood count taken, with Hb reported at 05:30hours of 88g/L (reduced from 101g/L 21/10/21 at 07:00 hours). Vital signs as documented. Night registrar to follow-up with treating team regarding malena, advised to monitor for further instances, and report if patient heart rate exceeds 100 beats/minute and if blood pressure decreases below 110mmHg systolic. Time Respiratory rate (breaths/min) Oxygenation (%) Temperature (degrees Celsius) Heart rate (beats/minute) Blood pressure(mmHg) Comments 23:30 24 96% on 2L via NP 36.2 97 156/86 Diazepam 5mg oral administered as per AWS 03:00 22 95% on 2L via NP 37.4 101 162/74 Abdominal pain 7/10 administered morphine 5mg S/C 05:00 20 92% on 2L via NP 37.2 105 122/56 Doctor notified – malena, FBC taken, Hb 88g/L, group and hold, and cross match taken. 06:00 21 93 on 2L via NP 36.6 92 118/62 Subjective data: At 08:05 hours Rebecca has pressed the nurse buzzer. She has vomited a large amount (estimated to be 200ml) of dark brown coffee ground like fluid. She appears distressed and is reporting increased abdominal pain. Physical assessment Neurological – orientated to person, place and time. Appears anxious, mildly diaphoretic Cardiovascular – pale, cool clammy skin to touch, blue tinge noted to fingernails, CRT approximately 3 seconds, pulse rapid and weak , HR 118 beats/minute and regular, Blood pressure 104/78mmHg, temperature 36.4 degrees Celsius. IV cannula insitu left cubital fossa – patent. Respiratory – siting up in bed, increased work of breathing, respiratory rate 26 breaths/min, SpO2 89% on 2L via NP. Gastrointestinal – sharp abdominal pain 7/10, decreased bowel sounds, BGL 4.1mmol, no further malena. Renal – last voided 04:00 hours and pass urine in the toilet. You have notified the team leader of your assessment findings and she/he is calling the treating to team to review. 1. From the chosen case study identify and discuss two (2) signs or symptoms of clinical deterioration reported in the case study, making connections between the related pathophysiology and the patient’s reported admission diagnosis. 2. Identify one (1) priority problem associated with the patient’s clinical presentation and signs or symptoms of clinical deterioration (identified in point 1). Justify why the selected problem is a clinical priority within the case. Use contemporary research to support your justification. 3. Discuss one (1) evidence based clinical interventions to address the priority problem and how to evaluate the efficacy of the intervention. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)