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AUSTRALIAN CATHOLIC UNIVERSITY 2024 1 NRSG378 NRSG378 Assessment 3 – Case study Shaun Morely is a 35 year-old male who was taken by ambulance to the emergency department (ED) this evening due to worsening cough, shortness of breath, fever, and general weakness, and was accompanied by his husband George. Shaun is only able to speak a few words at a time, before becoming fatigued. George stated that they both tested positive for SARS-CoV-2 virus (tested on PCR) 4 weeks ago, but Shaun has been struggling to recover from his symptoms since then. George noticed that his symptoms were progressively getting worse over the last two (2) days, but they have not been able to make an appointment with their local GP due to a lack of availability. Shaun states that he has not had an appetite for weeks now, and feels he has lost weight since being unwell (although he hasn’t weighed himself). A CT scan was ordered which showed bilateral consolidation most likely due to pneumonia, secondary to his initial SARS-CoV-2 infection. On assessment: • Shaun appears pale, cool and clammy. His lips appear dry and his tongue is cracked • He appears lethargic and George states he “just wants to sleep all the time” • He is lying in a semi-Fowler’s position but keeps pushing himself upright, while holding his chest • He has a frequent productive cough, with purulent green phlegm • Bilateral crackles in the lower and middle lobes are audible on auscultation. Occasional expiratory wheeze noted across all lung fields • His last urine output was this morning at 9am Health assessment findings and laboratory results at presentation: • HR 124 bpm, regular pulse • BP 95/56 mmHg • RR 30 bpm, moderate WOB with use of accessory muscles • Temp 38.7C • SpO2 91% on RA • Alert and orientated to time, place, and person • CRT 2 seconds • Weight – 92kg, Height – 1.65m Result Normal Values Haemoglobin (Hb) 143 g/L 140-180 g/L (males) WCC 11.8 x 109/L 4-11 x 109/L Sodium 132 mmol/L 135 to 145 mmol/L Potassium 3.5 mmol/L 3.5 to 5.2 mmol/L Lactate 2.4 mmol/L <1.0 mmol/l="" australian="" catholic="" university="" 2024="" 2="" nrsg378="" c-reactive="" protein="" (crp)="" 22="" mg/l=""><5 mg/l creatinine 115 umol/l 60-110 umol/l sputum culture pending negative blood cultures pending negative patient history: shaun lives with his husband in an outer suburb in sydney. he is currently studying civil engineering at university full-time, while working at his local café as a barista on the weekends. shaun does not smoke and only drinks alcohol on special occasions, but uses a vape daily, although he has stopped since becoming unwell with covid-19. family history: • parents live overseas and are both well with no medical concerns medical history: • asthma, diagnosed as a child although now well controlled medications: • salbutamol 4-6 puffs via mdi prn management • administer iv bolus nacl 0.9% 500ml over less than 15 minutes • commence iv nacl 0.9% at 100ml/hr • administer iv ceftriaxone 1g bd • 30/60 vital obs and 1/24 respiratory assessment • administer high flow oxygen you are the registered nurse looking after shaun, and you are required to plan his care guided by a clinical reasoning framework and the provided case study information. you will be required to respond to the following sections: 1. patient assessment (250 words): · provide an initial impression of the patient and identify relevant and significant features from the patient presentation. ensure you identify what the presenting condition/issue/concern is; · identify further elements of a comprehensive nursing assessment (this is addition to what has been done already, and can be presented as a list. if you repeat assessments, provide a rationale) 2. disease pathophysiology and complications (750 words): · discuss in detail, the pathophysiology of the presenting condition/issue/concern and how the patient’s presenting signs and symptoms reflect the underlying pathophysiology; · based on the patient’s history and presenting condition, he is at risk for complications. choose two (2) possible complications from the list below, and explain why he is at risk of developing these. you need to refer back to the patient details to support your answer · · septic shock · fluid overload · respiratory failure · acute kidney injury 3. identify nursing issues (400 words): · identify and prioritise 3 nursing issues you must address for the patient for their current admission, and justify why they are priorities and support your discussion with evidence and data from the case study. these can be actual or at-risk issues, and need to written using the “issue, cause, evidence” format. 4. nursing interventions (600 words): · identify, rationalise and explain, in order of priority, the nursing care strategies you should use or plan for within the first 24 hours of admission for the patient. mg/l="" creatinine="" 115="" umol/l="" 60-110="" umol/l="" sputum="" culture="" pending="" negative="" blood="" cultures="" pending="" negative="" patient="" history:="" shaun="" lives="" with="" his="" husband="" in="" an="" outer="" suburb="" in="" sydney.="" he="" is="" currently="" studying="" civil="" engineering="" at="" university="" full-time,="" while="" working="" at="" his="" local="" café="" as="" a="" barista="" on="" the="" weekends.="" shaun="" does="" not="" smoke="" and="" only="" drinks="" alcohol="" on="" special="" occasions,="" but="" uses="" a="" vape="" daily,="" although="" he="" has="" stopped="" since="" becoming="" unwell="" with="" covid-19.="" family="" history:="" •="" parents="" live="" overseas="" and="" are="" both="" well="" with="" no="" medical="" concerns="" medical="" history:="" •="" asthma,="" diagnosed="" as="" a="" child="" although="" now="" well="" controlled="" medications:="" •="" salbutamol="" 4-6="" puffs="" via="" mdi="" prn="" management="" •="" administer="" iv="" bolus="" nacl="" 0.9%="" 500ml="" over="" less="" than="" 15="" minutes="" •="" commence="" iv="" nacl="" 0.9%="" at="" 100ml/hr="" •="" administer="" iv="" ceftriaxone="" 1g="" bd="" •="" 30/60="" vital="" obs="" and="" 1/24="" respiratory="" assessment="" •="" administer="" high="" flow="" oxygen="" you="" are="" the="" registered="" nurse="" looking="" after="" shaun,="" and="" you="" are="" required="" to="" plan="" his="" care="" guided="" by="" a="" clinical="" reasoning="" framework="" and="" the="" provided="" case="" study="" information.="" you="" will="" be="" required="" to="" respond="" to="" the="" following="" sections:="" 1.="" patient="" assessment="" (250="" words):="" ·="" provide="" an="" initial="" impression="" of="" the="" patient="" and="" identify="" relevant="" and="" significant="" features="" from="" the="" patient="" presentation.="" ensure="" you="" identify="" what="" the="" presenting="" condition/issue/concern="" is;="" ·="" identify="" further="" elements="" of="" a="" comprehensive="" nursing="" assessment="" (this="" is="" addition="" to="" what="" has="" been="" done="" already,="" and="" can="" be="" presented="" as="" a="" list.="" if="" you="" repeat="" assessments,="" provide="" a="" rationale)="" 2.="" disease="" pathophysiology="" and="" complications="" (750="" words):="" ·="" discuss="" in="" detail,="" the="" pathophysiology="" of="" the="" presenting="" condition/issue/concern="" and="" how="" the="" patient’s="" presenting="" signs="" and="" symptoms="" reflect="" the="" underlying="" pathophysiology;="" ·="" based="" on="" the="" patient’s="" history="" and="" presenting="" condition,="" he="" is="" at="" risk="" for="" complications.="" choose="" two="" (2)="" possible="" complications="" from="" the="" list="" below,="" and="" explain="" why="" he="" is="" at="" risk="" of="" developing="" these.="" you="" need="" to="" refer="" back="" to="" the="" patient="" details="" to="" support="" your="" answer="" ·="" ·="" septic="" shock="" ·="" fluid="" overload="" ·="" respiratory="" failure="" ·="" acute="" kidney="" injury="" 3.="" identify="" nursing="" issues="" (400="" words):="" ·="" identify="" and="" prioritise="" 3="" nursing="" issues="" you="" must="" address="" for the="" patient="" for="" their current admission,="" and="" justify="" why="" they="" are="" priorities="" and="" support="" your="" discussion="" with="" evidence="" and="" data="" from="" the="" case="" study.="" these="" can="" be="" actual="" or="" at-risk="" issues,="" and="" need="" to="" written="" using="" the="" “issue,="" cause,="" evidence”="" format.="" 4.="" nursing="" interventions="" (600="" words):="" ·="" identify,="" rationalise="" and="" explain,="" in="" order="" of="" priority,="" the="" nursing="" care="" strategies="" you="" should="" use="" or="" plan="" for="" within="" the="" first="" 24="" hours="" of="" admission="" for="" the="">
Answered 6 days AfterMay 13, 2024

Answer To: 15 refrences please

Dr. Saloni answered on May 19 2024
4 Votes
14
Case Study
Patient Assessment
Shaun have been suffering from major respiratory distress as well as systemic indications of infection, indicating sepsis following pneumonia (Bruse et al., 2022). Patients who have sepsis initially in the presentation period typically exhibit the following change in vital signs:
· A fever, or a temperature more than 38 C
· Increased Heart Rate (Tachycardia): HR 124 bpm
· A High Respiratory Rate, also known as Tachypnea: RR 30 bpm
· A Low Blood Pressure (Shaun has Hypotension): BP 95/56 mmHg
· Inadequate Perfusion as well as Hypoxia: Shaun also has Pallor, cold, clammy s
kin, and a SpO2 of 91% on room air.
· Nutritional Inadequacies: Shaun may have loss of weight and appetite, which led him to be weak.
· Dehydration and Renal dysfunction: Shaun also has cracked tongue, dryness of lips, and reduced urine production since 9 am (Marques et al., 2023).
Comprehensive Nursing Assessment
In the case of Shaun, nurse should thoroughly assess end-organ function and peripheral perfusion to ascertain their area in the pathophysiologic progress of sepsis. The assessment should include:
· Urine output analysis
· Mixed venous saturation evaluation
· Glasgow Coma Scale (GCS)
· Psychological assessment.
Urinalysis, source cultures (blood, urine), and a complete blood count should also be assessed in case of Shaun including differential (CBC-d) (Shappell et al., 2023). Additional laboratory investigations can also reveal crucial information on the sepsis severity in Shaun, which include an arterial blood gas, a disseminated intravascular coagulation screen, chemistry profile, and liver function tests. It is advised to perform at least 2 rounds of blood cultures before giving antibiotics. An x-ray of the chest may show evidence of ARDS or pneumonia. If Shaun develops necrotizing fasciitis, simple X-rays of the limbs could show gas in the tissues. The gallbladder can be evaluated with ultrasound. To check for ischemia, intestinal perforation, or abscess in the belly, a CT scan is performed (Unterberg et al., 2022).
Disease Pathophysiology and Complications
A potentially fatal medical emergency, sepsis is often referred to as blood poisoning or septicemia. It develops when the body's immune system responds inappropriately to an infection, causing injury to its own cells and tissues. The extensive pathophysiology of sepsis is triggered by the consequences of persistent bacteremia-induced circulating bacterial products, which are regulated by cytokine release. The host's clinically noticeable symptoms of bacteremia are caused by cytokines. The initial signal is the identification of endogenous host-generated danger signals and molecular patterns caused by pathogens (Schiavello et al., 2023).
In Shaun’s case, he has been suffering from hypotension; the patient is now classified as having severe sepsis when tissue oxygenation is unable to sufficiently meet tissue demands due to the onset of hypotension. Cellular and metabolic abnormalities result from a decrease in peripheral vascular perfusion as well as oxygenation. Most prominently, this causes a change in respiration from aerobic to anaerobic, which causes lactic acidosis (Herminghaus & Osuchowski, 2022).
Identification of endogenous host-derived danger signals or pathogen-derived molecular patterns serves as the initial signal. Through the genes transcription that regulate inflammation, adaptive immunity, and cell metabolism these chemicals activate specific receptors on the outer layers of antigen-presenting cells and monocytes, consequently initiating the clinical syndrome underlying sepsis. Despite the upregulation of both pro- and anti-inflammatory channels, the inflammation that results eventually causes multi-organ dysfunction by producing progressive damage to tissues. Concomitant immunosuppression, resulting from diminished activating cell surface molecules, elevated immune cell apoptosis, and T cell exhaustion, causes "immunoparalysis" in the the later phases of the condition's course and leaves affected patients vulnerable to opportunistic pathogens, viral reactivation, and nosocomial infections in many patients (Ahlström et al., 2022). As a consequence of signal transduction driven by DAMPs and PAMPs binding to TLRs on monocytes and APCs, nuclear factor-kappa-light-chain activator of activated B cells is translocated into the cell nuclei. Interferons, tumor necrosis factor alpha, pro-inflammatory interleukins such as IL-12, IL-1, IL-18, and others are among the "early activated genes" that are expressed as a result. These then trigger the activation of other cytokines (including IFN-y, IL-8, and IL-6), complement, including coagulation pathways. Additionally, through negative feedback, they cause a diminution of adaptive immune system molecules (Nishibori, 2022). Raised levels of cytokines that are both pro- and anti-inflammatory are indicative of these mechanisms in the initial phases of septic illness. Overall, the immunological phenotype (hyper- vs. hypo-responsiveness) is still very individualized, which makes diagnosis extremely challenging (Batra et al., 2022). Neutrophils are an important component of the body's initial stage of protection against pathogens since they are a part of the immune system that is innate. Through acute granulocyte maturation, significant bacterial infections cause the bone marrow to discharge both immature and mature neutrophil types. Immature neutrophils exhibit decreased phagocytosis along with oxidative burst capacity while stimulated by DAMPs or PAMPs (Baghela et al., 2023).
Additionally, Shaun is at risk of developing septic shock. Septic shock develops when sepsis-induced hypotension is not responsive to early fluid resuscitation therapy. Being a distributive kind of shock, septic shock differs from other types of shock states. Histamine, super-radicals, lysosomal enzymes, and serotonin are among the inflammatory mediators that are produced in reaction to bacterial endotoxins. These mediators cause a significant decrease in peripheral vascular resistance and a rise in capillary permeability. This results in a decrease in venous...
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