Julia Chan Case Study In Nursing

Submitted By brooke0011
Words: 1765
Pages: 8

Name | Julia Chan | Date of Birth | 24 May 1995 | Age | 16 year old | Gender | Female | Height | 160 cm | Weight | 50 kg | Past medical history | Nil | Past surgical history | Nil | Allergies | Nil known | Medications | Pre admission: multi vitamin one daily. Paracetamol prn, morphine 5mg IMI every 3 hours prn, maxolon 10 mg orally TDS prn. On call pre medication- temazepam 10mg orally. | Current Admission | Julia was out partying and drinking for a friend’s 16th birthday when she fell down some stairs and (?)hit her head. Her friends’ when questioned, were unable to determine exactly how long she had LOC for. Her friends found her and they called an ambulance which took her to hospital. On arrival to hospital she was slightly confused and complained of a headache and a very tender left wrist. Julia has been reviewed by the emergency team and had a head CT that showed no obvious abnormality. X-ray revealed a closed fracture of her left wrist (the scaphoid bone). The wrist was swollen and therefore the doctors have decided to put a backslab on her left wrist. Julia is admitted for observation and an ORIF of her fractured left scaphoid bone. Julia has a IVC in her right wrist and has normal saline running 8th hourly. She is ordered 4/24 neuro obs for 24hrs. Julia’s parents have just arrived. | Social history | Lives with her mother. Parents from a low social economic background. Julia works as a shop assistant at the local Coles, casually one day a week after school. She is an only child. Her parents are divorced. Julia is socially active and goes partying every weekend. She admits to binge drinking at parties; states approx 6 glasses of spirits in pm. She says she has taken illicit drugs such as Ecstasy in the past. States she has a boyfriend who 17 years old. Julia admits she is sexually active. | Discharge planning considerations | Does not drive. Relies on mother or friends to drive her. Reluctant to see GP. |

You are a registered nurse working on an orthopaedic ward. You have just accepted a client admission from the emergency department. The client is Julia Chan.

In this admission process you will need to complete a systematic assessment (combination of head to toe assessment and body systems) approach in your admission of Julia. Please follow this as a guide:

1. CNS e.g. GCS, alert & orientated, neurological assessment, drug & alcohol use, drug /alcohol testing 2. Respiratory: e.g. risk of complications, respiratory assessment,? need for oxygen 3. CVS: e.g. cardiovascular assessment, neurovascular assessment, risk and complications, haemostasis 4. Renal: e.g. metabolism of drugs, continence, interpret blood/urine results, history 5. GIT/liver: e.g. nutritional/fluid status, NBM? Pre surgery, abdominal assessment 6. Integument: e.g. appearance, including skin breaks, mobility, wounds 7. Musculoskeletal: e.g. Range of motion, musculoskeletal assessment, mobility, trauma, injury 8. Endocrine: e.g. glycaemic status, ?use of oral contraceptive pill 9. Immune: e.g. risk of infection, allergy status 10. Reproductive: e.g. (female: menstrual disorders, cancer, endometriosis), STIs, (male: prostatitis, cancer, testicular torsion, phimosis). 11. Medication use: e.g. medical history, drug interactions, medications she has received pre op (e.g analgesia) 12. Psychosocial: e.g. cultural issues, language, and family status

Activity 1: Neurological assessment

In pairs, practice taking your partner’s neurological observations and document your findings on a neuro chart.

Why are we doing a neurological assessment for Julia?

Activity 2: Cranial nerve assessment and discussion with facilitator

You note in the admission entry from the doctor that they assessed Julia’s cranial nerves.
List the cranial nerves.

Give a brief description of how you would assess the olfactory and facial cranial nerves?

Why do you think it