Health Assessment in Respiratory Rate

Question

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).

Scenario Information

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.

Step 1/3

Health Assessment Findings for Casey Skinner:

Patient History:

– Casey is a 20-year-old indigenous woman living in a small rural town in New England.

– She lives with her mother, siblings, grandfather, and 2-year-old nephew.

– Casey works part-time at a child care center with 37 enrolled children.

– She woke up with stomach pains and nausea, followed by vomiting and diarrhea.

– She has been unable to tolerate food and has only been able to sip small amounts of water.

– Casey reports feeling increasingly lethargic and dizzy.

– She has not been urinating as frequently as normal.

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Explanation:

– The patient history provides a summary of Casey Skinner’s personal and medical background, including her age, ethnicity, living arrangements, and occupation.

– It also includes a description of her presenting problem, which in this case is gastrointestinal symptoms such as stomach pains, nausea, vomiting, and diarrhea.

– Additional information is provided about Casey’s inability to tolerate food, decreased urine output, and feelings of lethargy and dizziness.

Step 2/3

Physical Assessment:

– Upon arrival at the emergency department, Casey is alert and oriented but reports feeling dizzy and lethargic with abdominal cramping.

– She is still vomiting and has had one episode in the last hour, which was less than 100 mls and streaked with green, and one episode of diarrhea in the last 2 hours, which was extremely watery.

– Casey’s lips and mouth are dry, and her tongue is cracked.

– Her observations show a respiratory rate of 26, oxygen saturation of 97% on room air, heart rate of 110 beats per minute, temperature of 36.6 degrees Celsius, blood pressure of 90/57, and pain level of 5 out of 10.

Explanation:

– The physical assessment is a systematic examination of Casey’s body to identify any abnormalities or potential problems.

– It includes observations of her vital signs, such as respiratory rate, oxygen saturation, heart rate, blood pressure, and temperature.

– The physical assessment also includes an examination of Casey’s mouth and tongue, which are dry and cracked, and her abdomen, which is experiencing cramping.

– The observations and symptoms identified in the physical assessment suggest that Casey is experiencing dehydration and other complications related to her gastrointestinal illness.

Step 3/3

Based on the health assessment findings, Casey appears to be experiencing symptoms of a gastrointestinal illness, likely caused by the recent gastro bug outbreak at her workplace. She is showing signs of dehydration, with decreased urine output and dry mucous membranes. Casey’s rapid heart rate and low blood pressure may also be related to her dehydration. Further assessment and treatment, such as IV fluids and antiemetic medication, may be necessary to manage her symptoms and prevent further complications.

Final answer

Casey Skinner’s vital signs show a respiratory rate of 26, oxygen saturation of 97% on room air, heart rate of 110 beats per minute, temperature of 36.6 degrees Celsius, blood pressure of 90/57, and pain level of 5 out of 10. Further assessment and treatment, such as IV fluids and antiemetic medication, may be necessary to manage Casey’s symptoms and prevent further complications. Health Assessment in Respiratory Rate