CLINICAL PRESENTATION REPORT
- Word count for this report is 2000.
You are working in an emergency department of a rural hospital as a Registered Nurse. Your nearest base hospital is only 100 km away. At the time of your afternoon shift that is 5P.M, an old lady 66 years old, Doris Evans brought into the emergency department by her husband.
She is short of breath, pale and cyanosed. While holding her chest she is speaking to you in short and most of the time she is coughing.
She is facing problem in the breathing that is dyspnoea, chest pain and the cough. Also she has a general muscle pain. Two - three days ago she has started feeling this type of symptoms. For the pain she is taking a pain killer paracetamol. Through this pill she thought her pain will go ease until she started coughing again and produces the yellowish sputum.
Allergy: She has allergy from penicillin- rash reaction
- Telmisartan 40mg orally daily
- Rosuvastatin 10mg orally nocte
- Temazepam 10mg orally nocte
Past Medical and Surgical History
- Insomnia Doris stopped smoking 2 years ago. Has been a smoker since her teenage years.
- No-one has had COVID19 in the family.
- Positive Family History of heart disease - Father died aged 52
- Hysterectomy four years ago
Lastly, she had taken oral intake as, a bit of soup in lunch when she was not feeling well.
In this task you are required to discuss the clinical assessment as per given in the case study. You have to consider the interpretation of the findings of an assessment and also the subsequent nursing management. Your report must include following points:
- Introduction: Purpose of the report
- Body : Apply the primary survey assessment framework to find out the relevant data. Also identify additional assessment in order to complete the report. Along with the interpretation of abnormal assessment findings.
- Nursing management( 600 words)
- underlying pathophysiology (600 words)
- Conclusion: You are required to summarise your work and end the report.
Explain the findings appropriately and produce the effective report based on the given case study.