Health Assessment in Respiratory Rate
Using the information from the scenario below, outline your health assessment findings of Casey. Your response should include the patient history (including history of the presenting problem) and patient physical assessment (include observations and if they are abnormal).
Casey Skinner is an indigenous 20-year-old woman. She is the daughter of Michael and Mary, and has 2 other siblings, aged 22 and 18. Casey has a large, close extended family, many of whom are living with or near her in her small rural town in New England. She currently lives with her mother, and siblings, along with her 2 year old nephew, and grandfather. Her father is living with his new partner in another town. Casey works part-time at a child care centre with an enrolment of 37 children. She has worked the last 3 days, now has 2 days off. It has been a busy week, with 5 children off sick with a gastro bug, and 6 children sent home. The outbreak is significant enough to make the local newspaper.
Casey wakes at 0600 with stomach pains and slight nausea, she tries to go back to sleep but can’t. She decides to get up and have some toast for breakfast and a cup of tea. 30 minutes later Casey started vomiting and has diarrhoea. By now she has vomited six times and had four small episodes of diarrhoea. She calls in sick for work, and goes to bed. She is feeling increasingly lethargic and isn’t tolerating any food. She has only had small sips of fluid (water total 1000mls) so her mum suggested she go to the hospital and get checked out. Casey presents to the Emergency department where she is meet by the triage nurse.
At Triage in ED: Casey is alert and orientated, she reports feeling dizzy and lethargic with abdominal cramping noted. She is still vomiting, and reports one emesis in the last hour which was less than 100 mls and ‘it was streaked with green’ and diarrhoea once in the last 2 hours, minimal amount, ‘extremely watery’.
Casey reports that she has been unable to eat any solid food and is only managing to sip water. She has a water bottle with her which can take 1000 mls, her mum filled it up this morning (0630) and the nurse notes it is half full. The nurse asks Casey about her urine and Casey states she ‘has not been urinating as frequently as normal’, she is given a specimen container to collect a urine sample. The nurse records Casey has dry lips and mouth, and her tongue is cracked.
Observations : RR 26, Oxygen sats 97% R/A, HR 110, temp 36.6, BP 90/57, pain 5/10.