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Adult Emergency Department Chart: includes the Vital Signs and admission screening assessments

Vital Signs:

Resp 22

02 Sats 98%

BP 120/70 normal

HR 98 and 102

Temp: 38.2 and 38.4

Pain: 7/10 with movement and 6/10 with rest

Urinalysis: Nil findings

Process Information:

Resp. 22 elevated due to pain

HR 98: normal parameters, but heading towards abnormal.

HR 102 is above normal. This could be due to pain, anxiety and infection

Temp febrile

Pain is moderate at rest and increases to severe with movement.

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Home Meds:

No medications

Takes a herbal supplement - Ginseng 200 mg once a day

Emergency Dept. Meds

PRN Meds:

IV Morphine 1-2mgs every 15mins max dose 20mg/24hrs - PRN for pain

IV Metoclopramide 10mins 8hrly - PRN for nausea

Scheduled Meds:

IV Ceftriaxone 1gram BD for Appendicitis

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Admission Screening:

Falls Risk Screen: 0 = Low Risk (> or equal to 9 = high risk)

Water Pressure Ulcer Screening Assessment: Score 6 (low risk) - charted as 8

Malnutrition Screening Tool (MST): Score 8 (low risk)

Admission checklist

Valuables: phone and clothes

Process Information:

Waterlow score identified he is smoker

Falls Risk: 0 - not at risk and independent mobilising

Waterlow score: 6 - Low risk of pressure injury, even though below-average BMI (17.9), healthy skin

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After finishing the case studies please reflect on the what you have learnt from the process.

These questions may assist in your reflection:
- How did you feel about the case study & the application clinical reasoning cycle?

- What did you do well?

-What could you have done better?

-What did you learn from this exercise?

How will today's experience help you in your professional practice?

Click on the + link above to upload a word document

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Please see Joshua's assessment data from his admission to the Emergency Department

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D.0.B: 7/11/94
UR: 100654

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Findings consistent with appendicitis

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Elevated WCC indicative of acute infection

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Please upload your completed table from the case study identifying patient problems, SMART goals, interventions and evaluation date below.

Click on the + link and you can attach a Word document

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CAP203 Case Study 2: Joshua Nguyen: Collect Information

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CAP203 Case Study 2: Joshua Nguyen: Collect Information

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Introduction: Joshua NGUYEN (DOB 7/11/94)

Nil Known Allergies

32-year-old male

Situation

0900 Joshua Nguyen is admitted to the Emergency Department with persistent, periumbilical pain, nausea and vomiting over the past 12 hours.

Background: Nil Medical/Surgical history

Assessment:

GCS 15: alert and orientated, PEARL, normal ROM.

Vitals signs completed - see Obs. chart

A FBC count and CT scan have been performed, and a diagnosis of acute appendicitis has been made.

Objective data:

Pain 7/10 with movement and 6/10 with rest

Nausea and vomiting over the past 12 hours

Subjective data:

Pain: Joshua complains of persistent periumbilical pain, stating, "The pain in my lower stomach is really bad."

Anxiety: "Being in a hospital for the first time has made me anxious.

Other: "I feel so sick - something is wrong."

Social History: Lives with his partner, Brian, in an inner-city apartment

Psychosocial History: Joshua is very anxious about his upcoming surgery as he has never been in a hospital before.

Admission charting complete

Recommendations:

He is scheduled to undergo a laparoscopic appendicectomy as soon as an Operating Theatre is available.

The surgeon is coming to discuss surgical consent for the procedure.

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CT performed consistent with appendicitis 

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CT performed consistent with appendicitis 

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Full blood count

White blood Cell Count above normal parameters 14.5

Neutrophils above normal parameters 7.0

Lymphocytes above normal parameters 4.6

Process Information:

This would indicate an infection within the body.

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Craft et al. (2023, p. 816): Appendicitis: https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729543910000363#hl0002077

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What other assessments would the RN complete?

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What other assessments would the RN complete?

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What new nursing information must we gather?

What do we already know about Joshua?

Where did we get this information from?

Other Nursing Assessments to Complete:

Complete a focused assessment.

Which one would you conduct based on Joshua's admission history?

Assess the severity of the infection:

Review laboratory results and radiology results.

Why is this important?

Would this change how often you conduct the vital signs and the type of patient assessment, such as changing to a primary survey?

Diabetic Patients: If the patient is diabetic, obtain their blood glucose level (BGL) and ketone levels.