Nsg3Ncr – Nursing: Reflective Clinical Assessment Answer

Internal Code: 1IDJD

Nursing Case Study Assignment

Patient – Background

Ysabel Green is a 33 year old woman who prior to giving birth to her 3rd daughter Ruby, at 37 weeks gestation was diagnosed with Cholelithiasis. Post the birth of Ruby, Ysabel’s LFT results and and bilirubin levels had stabilised and a medical decision was made not to remove the gall stones and/or gall bladder.

About 6 weeks after Ruby’s birth, Ysabel started experiencing some episodes of right upper quadrant pain and nausea. Over a period of 5 weeks, her symptoms intensified and became more frequent. She presented to a hospital Emergency Department on a Tuesday evening experiencing acute right upper quadrant pain which was radiating to her right shoulder. She was nauseous and had vomited twice over the last 24 hours. Ysabel was examined by the medical officer on duty and administered Morphine 2.5mg IV 1-2 hourly prn. Following administration of 5mg of Morphine her pain score decreased from a 9/10 to a 2/10. No further investigations were conducted and 8 hours after admission to ED Ysabel was discharged. She was advised by the discharging medical officer to make an appointment to see her own local doctor over the next week.

Medical History

• Asthma
• Cholelithiasis pre birth of her 3rd child
• Gestational Diabetes

Social Situation

Ysabel lives with her husband and 3 daughters aged 5 years old, 14 months and 3 months. The family recently moved from a rural setting to the city. They currently live in a 2 bed room unit whilst they await the purchase of their own home.

Please answer the following questions, using academic language and format.

Questions:

1. Identify all clinical practice issues in Ysabel’s care during all of her hospitalisation.

2. Identify all National Health and Safety Standards that have been breached in Ysabel’s care and discuss how these standards have been breached.

3. From your list of identified National Health and Safety Standards, choose two standards, review literature and discuss how those 2 standards could have been maintained by health care staff in the care of Ysabel and her family during her hospitalisation. 

4. Based on your 2 chosen standards, what recommendations would you make for changes to health care practice at the ward level? Support your recommendations with rationales supported by evidence-based literature.