Case Analysis (RLE)

To be answered using the Digital Learner’s Worksheet

Case:
You are on 7-3 shift at the ER. While you are on duty, Mrs. T, 70-year-old female, was rushed to
the ER due to body weakness and poor oral intake for 3 days. Mrs. T was diagnosed of CKD5
since 2017 and she is on dialysis treatment as prescribed by her doctor. Upon assessment, vital
signs were as follows: BP 130/80, CR: 80 bpm, RR 16 cpm, SPO2 of 95 %. Lab results
revealed Hgb of 8g/dl, Hct of 0.25, blood type O, creatine of 135 ummol/L BUN 9mmol/L, Xray:
clear. “Nanghihina ako at hindi ako makakain for 3 days na“ as verbalized. With pale nailbeds,
pale conjunctiva, needs partial assistance in doing ADL, consumes approximately 2 table
spoons of food served, with history of CKD in the family, with history of DM, non-smoker, non-
alcoholic. Due to her present condition, the family had decided to bring the client to the hospital,
hence admission.

Doctor’s Order:

Start an IV line of PLNSS 1L x KVO

Transfuse 2 units of PRBC after properly cross matched
Transfuse each blood for 4 hours, regulate PLNSS to KVO while on blood transfusion
Observe transfusion reaction and refer accordingly
Repeat CBC after 6 hours
Monitor VS every 2 hours and refer accordingly
Monitor I and O and record
Limit fluid intake of 1L within 24 hours
Continue the following meds:
Losartan w/ HCTZ 50/12.5 mg 1tab OD
Metformin 500 mg 1-tab OD after dinner
Sitagliptin Metformin 50/500 mg 1tab OD before breakfast
Ferrous Sulfate 1-tab BID
DAT with low protein, limit sodium, phosphorous and potassium

8 AM Mrs. T was handover to Medical Ward

9 AM Her initial vital signs were as follows: BP = 120/70, T = 36.7’C, RR = 19 cpm, PR= 78
bpm. Blood was properly crossmatched with Serial No. PB – 4567 Expiry date: 2020 – 12 - 30
9:10AM 1 unit of PRBC had started, no transfusion reaction

2 PM2nd unit of PRBC had started with Serial No. OA – 1434 Expiry date : 2020-12-30
VS : BP = 130/80, T= 37.1’C, RR=18cpm, PR= 84 bpm
After a while, he complains of a “severe headache”. The nurse leaves the client to obtain some
Tylenol and returns to find the client shaking and complaining of “chills” and pain at the IV site.
While the nurse is examining the IV site, the client vomits all over the bed. The nurse assists the
client to a chair and gets fresh linens for the bed. The client then complains of back and chest
pain and asks for assistance to the toilet. The nurse notices that the client’s urine is almost
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He was then referred to the physician for further evaluation and management. 1
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 Note: Assessment findings of all other areas (under Review of Systems) must be filled-up using
fictional data BUT should be within the scope of the case scenario given. This will be answered
using the digital worksheet.
Digital Learner’s Worksheet (Spreadsheet)
 Fill-up the needed data (yellow-colored boxes) based on the given scenario/case using
black, but please use RED for abnormal findings under Review of Systems (ROS)
 Open the file and explore the content. Using the data in the case presented above, fill-up
the needed data/information in the following worksheets
1. Patient profile
2. Review of systems (Assessment)
3. IVF and I&O (IV fluid computation)
4. Medications (Drug study of all medications included in the case)
5. Vital Signs
6. Laboratory and Imaging data
7. Concept map (instruction and legend in assignment guide)
8. Nursing Care Plan
9. FDAR Charting
10. Critical thinking (Question below)
11. Communication (Question below)
12. Collaboration (Question below)
13. Ethico-moral-legal considerations (Question below)
14. Reflection

Questions:
Critical Thinking:
 What should the nurse suspect as the cause of these symptoms?
 During situations like this, what should be the initial response / intervention of the nurse?

Communication:
 How should the nurse respond to the patient in this situation?

Collaboration:
 In an event like this, who else aside from the doctor, should the nurse collaborate with
for patient care.

Ethico-legal Considerations:
 As a nurse performing blood transfusion, what is your legal responsibility? Discuss your
answer briefly.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any DIGITAL LEARNERS’ WORKSHEET: Module 6
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 Student name: ________________________________ Section/group:
Date: ___________________ Affiliating Institution: _______________ Area:
_________________

Before you start your duty, write a personal prayer for your assigned patient/s, groupmates,
clinical instructor, and the healthcare team.

Patient profile:

Patient’s case Room #/ Bed

Doctor/s Age

Diagnosis Sex

Chief Diet
complaint

Activity Contraptions
restrictions

Special
endorsement

History
Present illness
Past medical-surgical
Family
OB-Gyne
Personal/Social
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 Review of systems (ROS): Use RED pen for abnormal findings
General

Skin

Head, Eyes, Ears, Nose,

Throat (HEENT)
Neck

Breast

Respiratory

Cardiovascular

Gastrointestinal

Urinary

Genital

Peripheral / Vascular

Musculoskeletal

Neurologic

Hematologic

Endocrine

Psychiatric

IVF Computation: Change the time as appropriate for your duty schedule according to the case

IVF # Date hooked Date and time Due

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 Intake: Output: Contraptions:

Intake and Output

Date Intake Oral IVF Gavage TOTAL

AM

PM

Night

Total

Date Output Urine Bowel Drainage Vomitus TOTAL

tube

AM

PM

Night

Total

Medications

Generic name

Brand name

Dosage

Route

Frequency

Indication

MOA

Side effects
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 Nursing
responsibility

Generic name

Brand name

Dosage

Route

Frequency

Indication

MOA

Side effects

Nursing
responsibility

Generic name

Brand name

Dosage

Route

Frequency

Indication

MOA

Side effects

Nursing
responsibility

Generic name

Brand name

Dosage

Route
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 Frequency

Indication

MOA

Side effects

Nursing
responsibility

Treatment (nebulization, hot water bag, etc.)

Type

Dosage if any

Frequency

Significance

Vital signs
Time (Change Temp PR RR BP SP02
as appropriate)

9AM

1PM

4PM

Laboratory and Imaging

Relevant tests Date done Result (if any) Normal values Significance

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 Concept map: You can use separate paper for this of use the back of this paper (follow instructions
and legends stated in assignment guide)

Nursing care Plan:

Identify 3 nursing 1
diagnoses
2
3

Identify the Priority:

PRIORITY nursing
diagnosis

Expected outcome of
priority nursing
diagnosis

Enumerate planned Interventions Rationale

nursing interventions
and rationale

Expected outcomes

References

 Add lines as appropriate

FDAR Charting

Focus

Data

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 Action

Response

Evaluation

Justificatio
n

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