Case Study on Healthcare Journey

Contextualization of the Case and Setting

• Contextualise the case and setting of the healthcare journey, identifying an appropriate person from practice – maintaining confidentiality at all times

• Describe the case utilising an evidence-based explanation of the person’s condition, their associated health need and the impact it had on them on their family

• Justify and clinically reason the care you planned, how it was coordinated and delivered, referring to any nursing theories, processes or models

• Reference and discuss relevant policies and legislation referred to and detailed in the account

• Appraise, your own role and your influence on care Use the storyboard attached for the patient details. mention biopsychosocial, policies. 20+ UK harvard references inlcuding NMC, World health organisation.. etc.

Please use the storyboard to guide the essay. british english instead of American e.g realise not realize.

In the early hours of the Morning, 75 year old Mr Rogers called the ambulance complaining of shortness of breath. He was transported to A&E and upon arrival the doctors made the decision to put him on Intravenous fluids.

The Medical term for “SOB” is known as Dyspnea

Mr Rogers lives alone as his wife passed away 4 years ago. He used to be independent but ever since being diagnosed with CKD. His feet are normally swollen, and this has led to reduced mobility.

Mr Rogers has 2 Sons and a daughter. His children are actively involved in his care as they are aware his health is rapidly declining

Mr Rogers was transferred to an Emergency Acute Unit for close monitoring.

This is where it was finalised that they are treating him for low respiration tract infection.

The doctors there made the decision to stop his IVF due to fluid overload. This meant that Roger needed to be put on fluid restriction of 1litre and clear updates of input and output charts. Mr Roger was given a short-term catheter

Mr Roger is a type 2 diabetic patient who also suffers from chronic kidney disease stage 4.

Patients that are diabetic are more like to develop CKD especially if their insulin levels are poorly managed. This is because, high sugar levels will eventually lead to kidney failure.

Medication:

Warfarin –

IV Furosemide –

Magnesium -

As a student Nurse my role was to monitor the patient’s:

Urine input and output. -

Check blood sugar levels -

Daily weight –

Nutrition -

Observations – Target saturation levels are 88% - 92% for patients

suffering with SOB

During Mr Roger’s stay in Hospital, he had procedure called dialysis

(Dialysis is a procedure that is used to get rid of excess fluid and waste product in you body.)

After Days of taking medication Mr Roger started to show signs of recovery:

His saturation levels started to improve and needed less oxygen.

Having being assessed by the physio, he started to gain confidence mobilising however need walking frame.

His living situation was assessed, and it was decided that he needed carers to assist him during the day. This was arranged with the help of his children.