MSc Adult Nursing

MSc Adult Nursing

NURS 70771 Summative Assessment

Joan Smith is a 77 year old lady who has been bought in by ambulance to ED after her husband Tom has been concerned about her deteriorating condition following a recent cold.

The ambulance crew during handover explain that over the last few days Joan has developed a productive cough, shortness of breath and is feeling progressively unwell showing signs of slight drowsiness and confusion today. Joan is negative for Covid 19 virus.

Clinical Findings

A drowsy, talking in short sentences

B RR 24, Sa02 94% on air, productive rattling cough, rapid shallow breathing

C HR 115, BP 100/60, CRT 4 seconds, looks pale

D Slightly drowsiness and confusion, blood glucose 7.2 mmols/L, PEARL, Temp 38 C

E nil significant

Joan has a history of type 2 diabetes which is controlled with diet and medication from her GP and had a hip replacement 3 years ago for osteoarthritis. Joan is normally independent and quite active enjoying cooking, walking and looking after her grandchildren.

Medication

Metformin 500mgs 2 tablets twice daily

You are working with your Practice Supervisor in ED and have been asked to assess Joan using an ABCDE approach and record your findings on her NEWS 2 observation Chart.

Identify what actions you would take following ABCDE assessment and explain why you would do these.

Using SBAR communicate your findings and action to the appropriate healthcare professionals.