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  • Subject Name : Nursing

Case Study: Mr. John Smith

Table of Contents

Task 1.

Part A..

Part B..

Progress note.

Task 2.

Introduction.

Situation.

Background Assessment

Recommendation.

Reference list

Task 1

Part A

Mr. John Smith is an elderly patient admitted to the medical ward of the hospital. The documentation describing his health assessment provided by the attending nurse lacks clarity and depth. Nothing much of the information has been provided and the descriptions are mostly vague (Asghari et al., 2016). The reason for this can be attributed to the fact that most diagnostic tests are scheduled later on from the time of this documentation. Whatever be the reason but there seems to exist a complete empathy from the part of the attending nurse too while documenting the details. The nurse’s assessment should have been much more thorough describing all the necessary health parameters relevant to the patient’s clinical condition.

This has rendered it to be mostly unreliable as a form of predictive assessment (Asghari et al., 2016). The documentation should provide the results of all the tests performed and the health risk or assessment for each organ system like cardiovascular, gastrointestinal, neurovascular, etc. Though the patient was suffering from severe pain no documentation of the pain ratio was found anywhere. A description of the exact location of the pain and whether or how it is radiating provides a better picture of health analysis. Data on the psychological and stress analysis of the patient could also provide some valuable input (Saravi et al., 2016). Overall the nurse's documentation seems to be incomplete and ill-prepared.

Part B

Ms. Sharon Mills is a 65-year-old woman who had a severe accident and was admitted to the medical ward with a mid-shaft fracture of the right femur. The nurse's documentation regarding her health assessment was well prepared and attentively written (De Groot et al., 2019). The patient had immediate surgery and was carefully monitored during and after the process. The whole assessment as documented by the nurse on duty provides a detailed picture of the health diagnostic of the patient from the time of admission until now. The documentation could have been better if the details of her clinical assessments were also added. A detailed statement entertaining the cardiovascular, neurological, muscular, and gastrointestinal systems might have made the patient's assessment easier. Overall the documentation is written well but a more detailed and descriptive approach would have made it better (Turley, 2016).

Progress Note

Date/Time

Progress details

26.05.2020

10:00 A.M

Mr. John Smith and an 80-year-old patient were admitted with consistent back and shoulder pain. He had a past medical history of hypertension and diabetes mellitus. He was totally conscious and interacted normally at the time of admission. He complained about the radiating pain and discomfort.

26.05.2020

11.00 A.M

The continuous pain perception rendered him to be irritable and he was unable to provide justified answers. He explained that due to the continuous pain he was unable to live a normal life and has lost interest in most things. His systolic blood pressure was high. BP 210/90, and 180/70. P 72, R 18.

26.05.2020

12.00 P.M

Owing to the excruciating pain he refused lunch and avoided any further conversations with the health professionals.

26.05.2020

1.00 P.M

He endowed severe mobility issues and a lack of coordination in his legs. While moving in the ward he fell. Though he did not show any signs of external injuries and internal examination was scheduled.

26.05.2020

2.00 P.M

To assess the neurovascular role of his condition an immediate MRI scan was scheduled for the next day.

Task 2

Introduction

Ms. Mary Sinner Snr., a 56-year-old woman was admitted to the surgical ward. She had accidental tripping on the road, fell and fractured her right hip. She was fast-tracked to the emergency department of the hospital and scheduled for immediate surgery. During admission, she complained about a severe stabbing pain in her right hip.

Situation

The patient had a severe injury on her right hip and was admitted to the surgical ward for immediate hip surgery. Her vitals were mostly normal and no external injury or wound visible. She had a swelling at a localized region of the right hip from where a sharp, stabbing pain emancipated. The pain started immediately after the fall and remains even when the patient lies in rest. On any kind of movement the pain increases reaching a pain ratio of 8/10. The pain mostly radiates downwards through the right leg starting from the right hip junction. The patient had a previous history of type 2 diabetes mellitus and was taking a prescribed dose of metformin for the last one year. Her blood pressure, heart rate, eyesight, respiratory rate, and temperature were quite normal at the time of admission to the surgical ward. She was conscious at the time and responded to all the questions.

Background Assessment

The patient admitted to the surgical ward on an emergency basis was going to have immediate hip surgery. She had an accident and fractured her hip in the process. She had a previous history of type 2 diabetes mellitus and is currently on a prescribed dose of metformin for a year. At the time of admission, her vitals were normal. Both systolic and diastolic blood pressures were high, eyesight was perfect and she was conscious. She was having severe, stabbing pain on her right hip which eventually radiated downwards through the right leg. She was given a prescribed dose of paracetamol as a pain reliever which was not of much use. Even at rest, she had a pain score of 5/10 which increased considerably upon movement to a score of 8/10. No muscular or neurological complications were observed in the patient and her temperature, respiratory rate was normal. 

  • Cardiovascular assessment: She did not complain of any cardiovascular problems; neither had she had any previous history.

  • Gastrointestinal assessment: She did not have any gastrointestinal problems previously. Her bowel movements were normal.

  • Psychological assessment: She did not show any signs of depression or anxiety.

  • Skeleto-muscular assessment: Her left hip was fractured. The swelling was observed at a corresponding site. Severe stabbing pain was radiating down through the right leg. Upon movement, the pain was increasing.

Recommendation

After surgery, the patient will need complete bed rest for a long time. A dedicated physiotherapy regime should be organized for the patient to slowly regain locomotion. Continuous assessment needs to be done post-surgery for assessment of any complications or infections at the site of injury. The patient will need continuous help from others for her daily needs. Under no circumstances, the patient should be left alone. In case the pain persists or increases, a prescribed dose of any Paracetamol can be given to the patient.

Reference list

Asghari, Z., Mardanshahi, A., Farahabadi, E., Siamian, H., Gorji, A., & Saravi, B. et al. (2016). The Quantitative Study of the Faculty Members Performance in Documentation of the Medical Records in Teaching Hospitals of Mazandaran University of Medical Sciences. Materia Socio Medica, 28(4), 292. https://doi.org/10.5455/msm.2016.28.292-297

De Groot, K., Triemstra, M., Paans, W., & Francke, A. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal Of Advanced Nursing, 75(7), 1379-1393. https://doi.org/10.1111/jan.13919

Saravi, B., Asgari, Z., Siamian, H., Farahabadi, E., Gorji, A., & Motamed, N. et al. (2016). Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study. Acta Informatica Medica, 24(3), 202. https://doi.org/10.5455/aim.2016.24.202-206

Turley, M. (2016). Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning. The Permanente Journal. https://doi.org/10.7812/tpp/15-103

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