Scenario – Part 1
John, a 41 year old male, has a severe gram negative bacterial infection to a wound on his left foot.
Ten (10) days ago John cut his foot on an oyster shell whilst out fishing. At the time of the injury minimal first aid was applied, leading to the bacterial infection and cellulitis of the lower leg. John states pain has been managed with OTC “Nurofen and Paracetamol” as recommended by his chemist.
John was admitted to hospital five (5) days ago following unsuccessful oral antibiotics from the GP. He has commenced intravenous antibiotics which the wound is responding well to.
John has a medical history of chronic anxiety which is managed with a mental health plan and diazepam as required.
You are commencing the morning shift on day five (5) of John’s admission, the following are the last set of observations; please refer to the attached bedside charts for more information:
Medical orders
· Foot elevation
· Cellulitis marking
· Daily wound dressings
· Pain management
· Eat and drink as tolerated
Medications orders
· intravenous gentamicin 300mg TDS
· oral paracetamol 1g 4-6 hourly
· oral ibuprofen 400mg TDS
· oral diazepam 5-10mg PRN
Other useful information
Vital Signs (day 5 0600)
Sedation Alert
Blood Pressure
172/92 mmHg
Heart Rate 108 bpm regular
Oxygen saturation100% on RA
Respiratory rate 20 bpm
Pain score 3/10 discomfort
Temperature 36.5oC
Output average 30mls p/hr
Pathology(on admission
)WBC18.0 x 109/L (4.0-11.0)
urea7.8mmol/L (3.0-8.0
serum creatinine 96μmol/L (60-100)
eGFR 75mL/min/1.73 m2 (90-120)
Urinalysis (day 5 0600)
pH 7.0
Specific Gravity 1.005
Protein ++
Glucose nil
Nitrite nil
Leukocyte nil
Blood +
Colour dark yellowish/brown
Task 1
Based on the handover information and in grammatically correct sentences identify:
Three (3) priority nursing assessments you would conduct to determine the nursing care John requires. AND For each assessment you have identified explain:
Why it is necessary for John’s condition and nursing care?
What consequence scan occur if this assessment is not conducted or completed accurately?
(250 words) approx. 83 words for each assessment
These are ideas for nursing assessments
Wound assessment
Urine Output assessment
Urine analysis … ph level and specific gravity
IV Cannula assessment .. (Please see below) and rewrite if necessary, I will reference this .. please edit
An assessment of Johns IV Cannula is a priority at the beginning of the shift, firstly, to determine whether it is still required and will be used as the route of administration of the prescribed antibiotic or whether is its to be removed. Assess for pain by asking John if its uncomfortable, visually inspect for swelling, correct position, dressing integrity and patency. Infection at cannula site, dislodgement and allergies to tape can go unnoticed if there is a failure to complete this assessment this would cause discomfort and result in instant removal and unnecessary repeated insertion elsewhere.
Task 2
In grammatically correct sentences briefly explain why
John has been prescribed the following medications;
O Gentamicin 300mg TDS IV
o Ibuprofen 400mg TDS Oral AND
o The specific nursing responsibilities associated with administering these medications and monitoring John for expected, side and/or adverse effects
(300 Words) 150 words each drug
Task 4 Deterioration
Prior to your lunch break you commence the administration of John’s intravenous gentamicin diluted in 250mls normal saline running over 30mins.
On returning from your lunch break the first person you check on is
John as his IVAB should be finished.
On arrival John states he “can’t breathe” and appears to have increase work of breathing; sitting in the tripod position.
He states he is feeling nauseated, has a headache and feels like he is reacting to the medications. On your visual inspection you observe slight periorbital oedema.
On assessment you find the following, please refer to the attached bedside charts for further details;
Vital signs
Sedation Alert
Blood Pressure184/96 mmHg
Heart Rate 115bpm regular
Oxygen saturation 100% on RA
Respiratory rate 24 bpm coarse crackles in base of lungs bilaterally on auscultation
Pain score 3/10 discomfort
Temperature 36.3oC
Based on your findings above address the following:
Identify any other nursing assessments you would conduct
What conclusion would you make from the signs, symptoms and assessment findings
AND
Explain why you came to this conclusion
Identify your immediate nursing interventions
(you may include expected interventions from the treating medical team in your answer)
Include in your answer if John’s deterioration could be prevented and how
(250 Words) please see file attached – Nephrotoxicity and Acute glomerulonephritis
Patient education
Discharge planning
An important aspect of nursing practice is to effectively and succinctly communicate relevant
information related to the ongoing management of disease management or prevention of reinfection or deterioration on discharge.
John’s condition has improved and he is preparing for discharge home;
Explain three (3) important things (e.g.tips, lifestyle choices or medication instructions) you will need to include in John’s preparation for discharge to aid healing and prevent further illness
AND
Identify resources John can access for more information
(200 Words)
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