holmesglen- HLTENN037 -Case Study Tutorial 3: STUDENT VERSION

HLTENN037 Case Study for Neurovascular Assessment.

Patient: Mr Arthur McKenzie.

Age: 79 years of age.
(DOB 11/06/1945)
Address: 25 Elms Ave, Doncaster 3108.
UR 123456
Admitting Doctor: Dr Tom Thompson
Admission Diagnosis: bronchitis & investigation of fall.
Past History: Asthma. Bronchitis. gastric ulcer. Hypertension. Osteo Arthritis.
A series of falls over the past few weeks with increase in frequency in recent months.
Lethargic, short of breath and fever.
Medication: Antihypertensive (i daily). Pantoprazole (i mane). Celebrex 200 mg (i daily)
Panadol osteo (ii 6/24). Ventolin puffer (PRN).
NOK: Daughter, as his wife- deceased 6 months ago.
Primary Carer: Daughter (Joanne McKenzie) visits twice a week.
ADL’s: Frequent Voiding.
Reduced mobility due to pain associated with OA.
Ambulate with assistance. Reduced ability to perform ADL’s.
Social: Mr McKenzie lives in his own home.
He is finding it increasingly difficult to manage at home. He has a care-assistance alarm at
home in case he needs medical assistance.
Previous admission, six months ago for gastroscopy. You note there are a set of vital
signs in the previous history.
Previous admission vital signs (T 36.9. P 74. R 18, SaO2 97%, BP 126/86).

Vital Signs On admission:- Temp 37.6 deg Pulse. 90, Resps 22,
SaO2= 94% (on room air), BP 100/70.

Mr McKenzie is suffering from urine frequency. He forgets that you have left a urinal by his
bedside and decides to get out of the chair to find the bathroom.
In the rush to get himself to the bathroom, Mr McKenzie scrapes his left lower leg on the
door of the bathroom.
You are walking past his room just as this happens.
You assist him to the toilet and then escort him back to bed for an assessment.
On close inspection of Mr McKenzie’s left leg, it appears he may have an ulcer or skin
abrasion on left lower leg.
You escalate his care and report the incident to RN.
You are asked to perform a neurovascular assessment & pain assessment on his left
lower leg, whilst the RN writes up the hospital incident report.

Q. Why would you perform a neurovascular assessment?

Q. In your opinion is Mr McKenzie at risk of pressure injury?

Q. Why?

Holmesglen: fc 14-Dec-2023 U:\HSB\Programs - Courses\NURSING\Course Delivery & assessment\2023 - HLT54121\HLTENN037- Perform clinical Assessment\Sessions\J23\Tut No 3\Explore\Case
Study.Neurovascular Student .HLTENN037.V2.docx
 holmesglen- HLTENN037 -Case Study Tutorial 3: STUDENT VERSION

Q. What assessment would you indicate is required to prevent any pressure issues for Mr
McKenzie?

Q. If Mr McKenzie’s pain scores increased what might this indicate?

You re-educate Mr McKenzie on the use of the urinal (which is beside his bed) & remind
him of how to use call bell for assistance, if he needs to get up from chair or out of bed. Mr
McKenzie states he forgot it was there.

You inform RN and agree that you will document in patient progress notes and NCP -
that frequent reminders re using bottle to void and having call bell within reach.
This will form part of nursing intervention to prevent further episodes of pressure risk, or
potential falls, whilst Mr McKenzie is moving unaided around his hospital room.

Please complete a Progress Note with the above information. Include your
interventions.

End of case study.

HLTENN037

Holmesglen: fc 14-Dec-2023 U:\HSB\Programs - Courses\NURSING\Course Delivery & assessment\2023 - HLT54121\HLTENN037- Perform clinical Assessment\Sessions\J23\Tut No 3\Explore\Case
Study.Neurovascular Student .HLTENN037.V2.docx