• Internal Code :
  • Subject Code : NURS5059
  • University : University of Sydney
  • Subject Name : Nursing

Case Study: Joan Deveree


Question. 1.

Question 2.

Question 3.

Question 4.

Question 5.

Question 6.


Question. 1

John is a 72-year-old person who has a history of type 2 diabetes, renal dysfunction, lower abdominal pain and hypertension. So, there is a need to do the following clinical assessment in order to diagnose the actual problems.

  • Abdominal Ultrasound: Patient is complaining the lower abdominal pain while admitting. But no assessment related to the cause of having this done. So, there is a need to do abdominal Ultrasound in order to diagnosing the root of pain.

  • Renal Function Test: It is required as the patient was having a history of renal dysfunction, radial left nephrectomy, right utereric stent. Moreover, patient has history of type 2 diabetes and hypertension. So, there might be the chances of acute kidney damage. Henceforth, by taking samples for RFT, patient actual image can be diagnosed which is mandatory for the patients

  • Lipid Profile Test: Person has a past history of coronary heart disease which needs to assess by doing lipid profile test in order to know the real lipid function. It is mandatory as the patient is having symptoms of hypotension. Patient current blood pressure was diagnosed with 82/48 mmHg which is too low than the normal rate.

  • Liver function Test: Patient is suffering from lower abdominal pain hence; lever function test is mandatory for assessing the actual root of pain.

  • Complete Blood Count (CBC): CBC is required as the patient body temperature is higher than the normal. 38.9 ºC body temperature was assessed recently which is higher than the normal.

  • Chest X-ray: It is done as the patient is diagnosed with 24 per minutes respiratory breath rate which is higher than the normal. With the help of Chest x-ray, patient actual health condition will be diagnosed

All these assessments are necessary for John as he has a severe past medical history. By assessing all the reports, Patients actual health condition will be found out and react accordingly.

Question 2.

From the assessment done, it is evaluated that the patient condition is unstable and continuously decreasing. As he was restless and complaining of severe abdominal pain which is serious issue for the patient health. Along with it, he is suffering from respiratory problems and her respiratory rate per minute was recorded 26 which is too high and comes under severe respiratory problem. However, it can be assessed that the normal breathing problems occurs in the older patients (Reust and Williams, 2016). This is happening due to the structural change in the chest wall or thoracic spine which restrict the chest expansion and limit the respiratory muscle strength. This may due to enhanced physiologic demand.

Joan is the patient suffering the respiratory problems and earlier the patient respiratory rate was 24 breath per minute which was increased to 26 breath per minutes that is severe health emergency (Penner, Fishman and Majumdar, 2017). In this situation, patient need to stabilize by lowering the dosage of cholesterol control medicine such as Simvastatin as it may cause the respiratory problems in the patient (Lee, 2016). While Arterial blood gas analysis, it was found that the patient pCO2 was imbalanced and come to 32mmHg which is lower than the normal range due to which the patient is suffering respiratory problems. Apart from it, the pO2 level of the patient is too high which increased oxygen level in the blood and inhaled air which is also a bad sign of the respiratory issue with Joan (Flenady, Dwyer and Applegarth, 2017).

HCO3 and BE are considerably low which totally said that the entire ABG is not to the normal range which is the main reason of unstabling in the health condition. Although in the routine blood test, Serum Creatinine is considerably high which is the sounding alarm of the detoriating health. This all found while doing clinical assessment findings.

Question 3

John blood samples were taken, and her blood results related to routine blood and arterial blood gas were taken. By examining the results, it is said that in the routine blood report only serum creatinine and Global filtration rate were abnormal which indicates that the patient is facing renal problem. As the patient has a medical history of type 2 diabetes and hypertension, these might be the cause of imbalance the creatinine and GFR rate (Inker, et.al., 2016). As John already had operation of radial left nephrectomy which might also the reason of such imbalance. The patient condition is not stable and decreasing day by day due to the high in lactate in the blood as this makes the health condition worst.

While on the other hand, in the ABG report, pCO2 in the blood vessel was 32mmHg which is considered to be the lower level than the normal. The imbalance of the pCO2 in the blood vessel creates respiratory problem while, pO2 level showing higher than the report which simply means that the patient’s blood vessels has more oxygen in the blood which is also not the good sign for John. HCO3 and BE in the ABG test shown low that makes the entire ABG not ideal for the patient.

These reports are the sign of John abnormality. Hence, there is a need to balance of these tests by under observation and give treatment to make her health condition better and stable.

Question 4

Physiological changes occur with ageing people in all organ system. It mainly involves cardiac output decreases, increase in blood pressure and arteriosclerosis development. This problem mainly starts when any person crosses age of 60 or more and their organ system develops in habitual activities. In this phase, lungs show impaired gas exchange, down in the vital capacity and slower expiratory flow rates (Physiological Changes Associated with Aging and Immobility, 2019). Such changes with age have imperative practical implication for a clinical management of aging patients: where metabolism is altered, changes in response to common habit of using drugs make different drug dosages necessary and there is need for rational preventive programs of diet and exercise in an effort to delay or reverse some of these changes.

Ageing is the natural process and everyone will undergo this stage of life at his or her own time. According to the World health organisation, ageing is the course of biological reality which proactively starts at conception and ends with death. It is determined by genetics and influenced by the wide range of environmental factors such as diet exercise, exposure to micro-organism, pollutants and ionising radiation (Ageing process and physiological changes, 2018). Joan, a high critical patient suffered with diseases and almost 72 year of age, is under old ageing stage. During the ageing, if a person is having diabetes, it would create critical situation and enable frequent administration and medication of them. During the ageing phase, person may experience issue in proper utilisation of the oxygen. There are various alteration related to the physiological, even talk in context of Joan are as discussed below:

Alternation in pulmonary physiological features: Normal aging occur in change in pulmonary mechanics, respiratory muscle strength, gas exchange, and ventilator control. Augmented rigidity of the chest wall and a down in respiratory muscle strength with aging result in an increased closing capacity and a decreased forced expiratory volume in 1 second (FEV1). The partial pressure of oxygen, arterial, decreases progressively with age because of the age-induced ventilation-perfusion mismatch, diffusion block, and anatomical shunt. Also, elderly patients have a diminished ventilator response to hypercapnia and hypoxia. In context of Joan, such alteration may impact upon their regular assessment at the clinical or force clinic worker to increase doze of the medication. Joan is currently facing issue of hypertension, ischemic heart dieaseae, hypercholesterolemia etc. in this Clinic would face problem of focus and it may create problem of tension, while treating her injury.

Changes in musculoskeletal system: Aging is being characterized by a decrease in bone, muscle mass and increment of adiposity. A decline in muscle mass and also reduction into muscle strength lead to risk of major fractures, frailty and reduction in the quality of life (Nyman, et. al., 2017). Such kind of changes may create problem for Joan to take time in her recovery after the collapse. Hence, in this condition, effective care and treatment for Joan is pre-requisite.

It was noted that Joan was collapsed in the house and her age is 72 years old, as a result change in musculoskeletal system would lead to problem in moving her body parts such as legs, waist, hands etc. Also, she requires support from the clinical staff to move her body. Her past medical report shows many health issues and physiological alteration will build problem to manage treatment from the collapse. Such physiological alteration would create hurdles for clinical staff to examine performance and management of the Joan. The result will be more time, while doing treatment of the Joan and late medical recovery after identification of capacity to give medication.

Question 5

Joan is given supplementary oxygen (FiO2 0.60 proportion of inspired oxygen) and her SpO2 rises to 96%. In spite of these changes in arterial oxygenation, Joan remains hypotensive. Joan is given a 250ml Hartmann's injectable bolus with only a temporary rise to systolic 105mmHg, subsequently her blood pressure decreases to 78/48mmHg. Through the biochemical reaction essential for the cellular respiration Narrowing of metabolic function within membranes results in carbon dioxide (CO2) output as a metabolic waste product. This change in PCO2 tissue contributes to rise in concentration of hydrogen ion (H+), which is expressed as a decrease in pH as the atmosphere undergoes acidosis (Chavez, et. al., 2018).

This will impact the organ function tries to work better so that kidney could work efficiently and improves GFR and creatinine level (Hughson, Yee, and Greaves, 2016). Apart from that, due to the appropriate oxygen in the blood vessels, heart rate will try to become normal and works normally. However, from the recent test, Urinary Tract Infection occurred which is due to Escherichia coli that impacts on the renal function and could create severe problems for the patients as Joan is already renal dysfunction.

Question 6

Medical management is an umbrella term which comprises of use of IT for health, disease, care and case management function. It’s a strategy that is designed to modify consumer and provider behavior to improve the quality and outcomes of a health delivery. Medical management comes under the nursing care part and consists of various procedures for specifically a disease (Hashemian, Samadi, and Mohajerani, 2017). In context of Joan, this patient is suffering with problem of diabetes and hypertension which in reality are two serious diseases to be cured. Nursing care planning goals for patients with diabetes involves effective treatment to normalize blood glucose and decrease complication using insulin replacement, balanced diet and exercise (Standards of Medical Care, 2020). Nurse must give importance of comply with prescribed treatment program. In context with Joan, rationale of medical and nursing care management is as follows:

Type 2 diabetes mellitus: It has major problem of insulin resistance and impaired insulin secretion. This uncontrolled type of diabetes would lead to hyperglycemic, hyperosmolar nonketotic syndrome. Causes are excessive weight or obesity and inactive (lack of exercise and sedentary lifestyle may cause insulin resistance and impaired insulin secretion.

Symptoms of the diabetes: Always tired, frequent urination, sudden weight loss, always hurry, blurry vision and vaginal infection.

Medical management: Some of the necessary medical intervention that are performed to manage diabetes mellitus are as given under:

Normalize insulin activity

The purpose is to normalize blood glucose to reduce development of the vascular and neuropathic complications

Intensive treatment

It covers three to four insulin injection per day, insulin pump therapy with frequent blood glucose monitoring and weekly contact with diabetes educators.

Exercise caution with intensive treatment

This therapy involves caution and must be accompanied by thorough education of the patient, family and by responsible behavior of a patient.

Diabetes management

It has five components and involves constant assessment and modification of the treatment plan by healthcare professionals and daily adjustments in therapy by the patient

Nursing care assessment:

Assess the patient’s history

To determine presence of diabetes, assessment of history of symptoms related to diagnosis of diabetes, blood glucose monitoring and exercise regimen

Assess physical condition

Check patient’s blood pressure, while sitting and standing to detect orthostatic changes


body mass index and visual acuity of the patient

Perform examination

foot, skin, nervous system and mouth

Laboratory examination

HgbA1C, fasting blood glucose, lipid profile, microalbuminuria test, serum creatinine level, urinalysis and ECG used to be performed

Hypertension: It is a significant and costliest public health problem. It is one of the major, but modified developers for a development of the cardiovascular disease. Hypertension is also known as high blood pressure. Joan has past record of suffering with the Hypertension, so rationale of medical management and nurse care will be discussed further.

Symptoms: Fainting, dizziness, chest pain, increased thirst, nausea etc.

Medical management of the Hypertension:

Thiazide diuretics

Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume.

Angiotensin-converting enzyme (ACE) inhibitors

These medications - such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others - help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.

Angiotensin II receptor blockers (ARBs)

These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels

Calcium channel blockers

These medications - including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others - help relax the muscles of your blood vessels. Some slow your heart rate

Nurse care assessment:

Nurse intervention


Measure current limitation/degree of deficit of light usual status

Provides baseline information on interventions needed to improve the quality of life.

Mention what level of hypertension is and how it affects heart, kidney, brain and blood vessels

Let know the patient to realize that high blood pressure can happen without any specific symptoms.

Motivate patient to keep a record of food intake

Heavy weight loss can put pressure on a heart and also helps find out emotional condition that can affect eating


Chavez, F. P., Sevadjian, J., Wahl, C., Friederich, J., & Friederich, G. E. (2018). Measurements of pCO2 and pH from an autonomous surface vehicle in a coastal upwelling system. Deep Sea Research Part II: Topical Studies in Oceanography, 151, 137-146.

Flenady, T., Dwyer, T., & Applegarth, J. (2017). Accurate respiratory rates count: So should you!. Australasian Emergency Nursing Journal, 20(1), 45-47.

Hashemian, M., Samadi, S., & Mohajerani, S. A. (2017). Role of Regional Blocks in Awake Intubation in Emergency Airway Managements in Mandibular Hypoplasia or Ankylosis. Archives of Anesthesiology and Critical Care, 3(1), 297-299.

Hughson, R. L., Yee, N. J., & Greaves, D. K. (2016). Elevated end-tidal PCO2 during long-duration spaceflight. Aerospace medicine and human performance, 87(10), 894-897.

Inker, L. A., Tighiouart, H., Coresh, J., Foster, M. C., Anderson, A. H., Beck, G. J., ... & Lash, J. (2016). GFR estimation using β-trace protein and β2-microglobulin in CKD. American Journal of Kidney Diseases, 67(1), 40-48.

Lee, P. J. (2016). Clinical evaluation of a novel respiratory rate monitor. Journal of clinical monitoring and computing, 30(2), 175-183.

Nyman, U., Grubb, A., Lindström, V., & Björk, J. (2017). Accuracy of GFR estimating equations in a large Swedish cohort: implications for radiologists in daily routine and research. Acta Radiologica, 58(3), 367-375.

Penner, R., Fishman, M. B., & Majumdar, S. (2017). Evaluation of the adult with abdominal pain. Retrieved septiembre, 10, 2018.

Reust, C. E., & Williams, A. (2016). Acute abdominal pain in children. American family physician, 93(10), 830-836.

Standards of Medical Care, 2020. [Online]. Available through:< https://care.diabetesjournals.org/content/26/suppl_1/s33 >.

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