Assessment Task:
Mr Kevin Daniels Case Study Nursing Report Writing Assessment Answer

Mr Kevin Daniels: Post-operative inguinal hernia repair 

Mr Kevin Daniels a 67-year-old man who is admitted to the Surgical ward, following an open mesh inguinal hernia repair. He had presented to ED with a 6-hour history of an R non-reducible tender, inguinal mass, post commencing a new gym/weight lifting regime. 

Past Medical History: Mr Daniels is retired, lives with his wife, ex-smoker and is obese, with a body mass index (BMI) of 30. Incidentally, he is an ex weight lifter. He is on medication for hypertension and hyperlipidaemia, which are both well-controlled, and he also has mild congestive heart failure (CHF). 
Mr Daniels was recovering well, but on Day 2 post-op, he has become a little agitated and confused, complaining of significant left calf pain.


On your assessment:

•    Vital signs: Temp: 39.3oC, RR: 25, HR:106 regular, SpO2 95% on room air (R/A), BP: 165/90, Pain score 7-8/10 (wound site and left calf), GCS 14/15
•    Physical assessment: Mr. Daniels is restless and confused to.. His chest is clear, skin is dry, post-op surgical wound dressing is oozing green purulent discharge and tender to touch. His left calf appears larger than the right and it is red, and warm to touch. 


Case study instructions:

Utilise the Clinical Reasoning Cycle (Levett-Jones, 2018) (a clinical decision-making framework) to plan and evaluate person-centred care:

•    Considering the person’s situation, collect, process and present related health information;
•    Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care;
•    Establish goals for the priority of nursing care as related to the nursing problem/issues identified;
•    Discuss the nursing care of the person, link it to assessment data and history;
•    Evaluate your nursing care strategies to justify the nursing care provided;
•    Reflect on the person’s outcomes.

 

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  • Uploaded By : Mitchell Lee
  • Posted on : December 26th, 2018

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