Weighting: 60% of overall grade
Length: 1500 words
Individual Assignment
NUR2004 Health Assessment Assessment 3: Case Study Report
Due: Sunday 4th December 2023 (Week 5) at 2200hrs
Rationale: The purpose of this case study is to assess the student’s ability to interpret clinical observations, recognise deterioration and link theory to practice in regard to communication, and patient care.
Case Study Scenario:
You are a registered nurse who works in the fracture clinic at your local public hospital. Brian Lawson, of 58 years of age, broke his left foot 7 weeks ago after he tripped at home. It was a complicated fracture requiring surgery to insert pins and after 6 weeks they removed his cast and discovered a small pressure injury on his left heel. They have given Brian an orthopaedic ‘moon boot’ and begun light weight bearing activity, but Brian must visit the clinic every 2 days to check and dress his pressure injury.
The wound healing is progressing well, but on the last visit 2 days ago you noticed that Brian said he was not ‘feeling 100%’ and hadn’t been able to move around very well as his fractured foot was ‘giving him grief’. Up until now, his pain has been well controlled, and he only needed Paracetamol at night.
When he arrives today, you notice he is slow to walk across the room, is using his crutches again, and he doesn’t seem his friendly self and so you conduct an A-G assessment to see what you can reveal.
PMHx
• Longstanding Type 1 Diabetes
• Arthritis
• Family history:
o Mother Alzheimer’s
o Father: hypertension, myocardial infarction 20 years ago, 2 stents inserted.
Social History and Diet
• Strong family support- lives with wife and has two adult children
• Moderate exercise and socially active.
• Enjoys 1-2 beers a night.
• Doesn’t drink very much water but watches what he eats to keep his diabetes under control
Medications
• Insulin Glargine (Lantus) 100U/mL dose varies according to blood glucose level • Actrapid PRN for intermittent Hyperglycaemia
• Ramipril 5mg in the morning for Hypertension

• Paracetamol 1 Gram when needed.
A-G observations:
Airway and Breathing:
• Respiratory rate: 22pbm
• O2 saturations 98% on room air
Circulation:
• Blood Pressure 129/67
• Heart Rate 89bpm regular
• Temperature 36.6C
• Left foot appears more swollen than 2 days ago.
Disability:
• GCS: 15, orientated to time and place
• Pain:
o 7/10 in left leg.
o Cramping pain in his left calf
o Tells you he needed to take an Endone tablet last night.
Exposure:
• Wound assessment: The pressure area wound is pink and granulating which is the same as the last visit.
• The skin on the left calf looks red, is warm, and Brian complains that it feels like he has a constant cramp in it and it is sore to touch.
Fluids:
• Brian says he has been eating and drinking enough.
• He has not opened his bowels today
Glucose:
• His BGL: 7.1mmol
TASK: Case Study Report
1. Introduction (100 words):
Provide a brief introduction explaining the content of this report and the scope of the
discussion. Introductions are designed to capture the reader’s attention and outline the content of the report succinctly.
2. Consider the Cues (400 words):
After considering the patient scenario, discuss the observations that are of most concern to you, and how they differ from normal. Identify and discuss other types of assessment that you should conduct to provide you with more information and provide your reasons for why you have chosen them.
3. Process information (500 words):
You suspect that Brian may have a Venous Thromboembolism (VTE). Using high-quality evidence from the literature, discuss the pathophysiology of this disease and the potential

outcomes and complications that could occur for this patient if the problem is left
untreated. Review the Australian Clinical Standards for VTE prevention and discuss how VTE risk is assessed and prevented for an inpatient in a QLD or NSW facilities.
4. Nursing Action (400 words):
You are required to report your findings to the orthopaedic surgeon during Brian’s visit. Discuss the importance of both verbal and written communication when escalating patient deterioration, the evidence-based methods you can use to communicate and the QLD or NSW policy guidelines that guide your communication.
5. Conclusion (100 words):
Summarise your report succinctly describing all the main findings to the reader.
6. Reference List (not included in the word count)
Your assignment will also have a reference list at the end. Ensure all references that appear in the Case Study report are listed in your reference list.
The reference list is not included in the word count
The Case Report must include at least 8 reputable references to support your
statements. These only include textbooks, government documents, websites,
guidelines, and policies or peer-reviewed literature sourced through the library
databases.
References will be no more than 5 years old.
Use APA 7th reference style.
Ensure the reference list is on a new page and they are listed in alphabetical order For access to the online APA 7th style of referencing guide use this link:
https://libguides.scu.edu.au/apa
Submitting your Assignment:
Formatting your Work:
o Your assignment must be submitted via Turnitin from the link on the Blackboard
learning site. No assignment will be accepted via email attachment.
o It must consist of 1500 words. The word count provided in the task is a guideline
only. Excessive words will not be marked. A leeway of +/-10% total words will be
acceptable.
o Use these Headings provided above for each article’s annotation
o Your assignments must be submitted as either Word documents (with .doc
extension, or .docx). PDF / Note pad assignments will not be accepted. No
handwritten assignments will be accepted.
o Include either a Header or Footer with your name, student ID number and the
page number
o Use size 12 Calibri font throughout the assignment
o Use either 1.5 line spacing or Double spacing.

HEALTH ASSESSMENT REPORT

 
Executive Summary
This health assessment report discussed the clinical assessment of a patient who undergoes a leg fracture surgery and suffers from “Venous Thromboembolism (VTE)”.The biological and physical abnormalities in the body due to VTE and the potential risks and complications that can arise if the issue remains untreated are also discussed. In the second part of the report, the “Australian Clinical Standards” for VTE prevention and assessment and treatment procedures followed by New South Wales or Queensland clinical facilities are discussed. The real case scenario also mentions how VTE is treated in a local public hospital.
 
Table of Contents
Introduction: 4
Cues consideration: 4
Process information: 5
Outcome and complications, if untreated: 6
“Australian Clinical Standard “for VTE prevention: 7
How QLD or NSW asses and prevent VTE risk for inpatients: 8
Nursing Action: 9
Conclusion: 11
References 12
Appendices 15

 
Introduction:
This health assessment report is about the recovery process of 54 years old Brian Lawson, who underwent surgery for a complicated fracture in his left foot about seven weeks ago due to a trip at home. This report includes his case history, health report patient, community behaviour history and dietary regime, past medications, and the assigned nurse's whole “A-G” evolution. Based on the A-G assessment result, unusual observations and other tests are suggested. Based on the findings, the nurse suspects that Brian suffers from “Venus Thrombo embolism (VTE)”.
Cues consideration:
Brian Lawson broke his left foot and suffered a complicated fracture that requires “Percutaneous pinning” surgery. His cast was taken out following six weeks pass of surgery. A small pressure sore was found in his left heel. An "orthopedic moon boot” was provided to Brian, and the activity of lightweight bearing began. The patient is socially active, with a wife and a father of two. Do moderate exercise and 1-2 beers per day. He is on a controlled diet for his “Diabetes”. The patient takes an "Insulin Glargine (Lantus) 100U/mL” dose, which varies according to the glucose level in the blood. Medication “Actrapid PRN”for irregular “Hyperglycaemia" and “And Ramipril”5milligrams for“Hypertension”, are taken by the patient regularly. The body temperature is 36.6C, but the left foot seems to be more swollen than before. According to, the "Glasgow Coma Scale” and “pain scale”, the patient is responsive and suffers severe pain in the left foot, respectively. The left calf skin looks red and warm, in which the patient feels constant cramps and soreness. As the patient glucose level is normal, the probability of damage is less. “Duplex ultrasound (DUS) with B-mode compression manoeuvres and Doppler evaluation” is suggested as a further assessment to verify.
Process information:
The patient Brian Lawson suffered an injury in his left foot that causes inflammation in his foot. The increase of local blood flow, require “leucocyte” and “chemokines and cytokines” are released there that are contained in Inflammation. This process eliminates the pathogen and increases the rate of healing. In this case, VTE happens due to the reciprocal action of the coagulation and immune system which is called “Immunothrombosis”. It is an immediate response to the introduction of the pathogen which is contagious into the vasculature. Upon recognising the pathogen the process of local thrombosis helps to control the spreading of infection and eliminate the pathogen (Colling, Tourdot & Kanthi, 2021). Uncontrolled and exaggerated activation of the coagulation and immune system can cause “Thromboinflammation” along with macro and micro-vascular thrombosis that can create damage in tissue.
VTE can rise due to the activation of endothelium and dysfunction of the local barrier of blood and vessels. The endothelium is situated at the interface of blood and vessel and maintains the fluidity of blood and homeostasis by introducing anti-inflammatory actions and anticoagulants in the vessels. If an injury happens then the endothelium secret it’s anti-inflammatory and anticoagulant substances and tries to eliminate the effect and initiate the repair. If unchecked, this rapid secretion of anticoagulants can increase the adhesion of leukocytes and the production of cytokine (Colling, Tourdot & Kanthi, 2021). Resulting this, the “antithrombotic endothelial glycocalyx coated with heparan sulfate and chondroitin sulfate are dissolved by matrix metalloproteinases” and this causes the “loss of binding sites for the serine protease inhibitor AT (antithrombin)-III”. The perfect treatment to preclude or prevent VTE will be repressing the surplus coagulation and inflammation without disturbing the process of triggering the deficiency of immunity and hemostasis. Existing research studies describe target interventions of a number of provocative actions in “murine models of DVT”, including the hindrance in the receptors of cell adhesion, activation of platelets, cytokine signaling and thrombosis elimination. As new light is shed due to the discoveries in research of VTE prevention, by focusing upon coagulation and inflammation, there is continued willingness to recognise and create treatments targeting “thromboinflammation” that can be reworded to the hospital for advanced care of patients of VTE.
Outcome and complications, if untreated:
The presence of “venous anastomoses” makes the clinical symptoms caused by the occupation of “thrombus”occur less frequently. If the “thrombus” flows toward the "thigh vein”, it transforms itself into a free-floating “thrombus” that has no critical symptoms, which, left untreated, can cause massive “pulmonary thromboembolism” (Ro, Kageyama and Mukai, 2017).
Patients Brain Lawson's current condition is patient, suffers from blood flow abnormalities. After this operation and 6 weeks of removal patient was cast and saw a left heel injury. The patient's blood pressure rate is “129/67”; patient blood flow is randomly abnormal for a few weeks later. The patient is going for other VTE abnormalities and feeling the charming and raising his left leg heel pain. Based on the pathophysiology treatment “10-20%” of thromboses are advanced proximally and an additional “1-5%” move on to create fatal “pulmonary embolism” and fitting “antithrombotic” actions can decrease VET complications
“Australian Clinical Standard “for VTE prevention:
The clinical care standard is different from a clinical practice guideline. “Australian Clinical Standard”for VTE prevention contains seven steps (Safetyandquality.gov.au, 2022). They are discussed below.
VTE Precaution plan development: A precautionary plan is developed to balance the risk of thrombosis, bleeding consequences, and medication's effects. Inform the patient's relatives: The patient's relatives should be educated and well-informed about the patient's risk and need and their plan for VTE prevention.
Documentation and passing the plan: VTE prevention plan of the patient should be well documented and well shared with the doctors.Application of the right prevention method: VTE prevention plan should include advanced medication and techniques and have guideline which is evidence-based.
Regular monitoring of VTE-related complications: Patients bleeding risk and thrombosis should be monitored regularly at an interval of seven days when the patient is hospitalized. Future care: A discharge and future care plan during the discharge from the hospital.
How QLD or NSW asses and prevent VTE risk for inpatients:
Planning and Implementation are the two main steps for assessing and preventing VTE risk. Planning includes establishing the case, establishing VTE governance locally, engagement of local clinics, and determination of native policy for VTE prevention, to establish a feedback process (Safetyandquality.gov.au, 2022).
NSW obtained an effective prevention strategy for VTE through a complete assessment of factors of risks and the arrangements of the right prophylaxis. The steps include (Health.nsw.gov.au, 2022):
● Identification of patients with VTE risk
● Evaluate the VTE risks.
● Authorize the proper prophylaxis to the patient.
● Revaluate the VTE risks to inpatients.
● Involve the patient
● Monitor practice and performance to estimate conformity and enable step by step recovery.
After this diagnosis patient's pain medication treatment is started, because “thrombophlebitis” can be extremely painful, and holding that pain stands to usually the top priority. This frequently concerns milder drugs, like “acetaminophen” “ibuprofen or naproxen”. Prevents the lumps from the beginning, mostly clots that strength causes a “life-threatening” situation like a “pulmonary embolis”, Doctors and nursing care providers will usually give patients “blood thinners”. Patients' doctors and nurses provide the risks that are most probable with a particular patient and underestimate the risks. Things like warm compress also help reduce the discomfort of this disease and treating the elevation could help to reduce “swelling and pain”. After this treatment patient's condition are better than the previous condition, and the patient feels better (Lyman et al. 2021).
Nursing Action:
Nursing action for VTE prevention in patients should be followed by the regulation of the guide provided by the “Australian Clinical Standard”. From identifying patients with VTE risk to monitoring a step-by-step recovery of the patient, the action of the attending nurse is essential. In Brian's case attending nurse is the first one to evaluate him. Brian Lawson needed “Percutaneous pinning” for his left foot fracture and had undergone surgery. Through the potential indication as shown by the patient's history of surgery, major leg injury, leg cramping, and redness and soreness in the left calf nurse concluded that the patient needs further assessment of potential VTE through “Duplex ultrasound (DUS) with B-mode compression manoeuvres and Doppler evaluation” and informed the patient that he has VTE. There are three categories which properly can define the actions of nursing for the prevention of VTE which are, a) Implementation of the risk assessment of VTE b) Physical and mechanical intervention for prevention of VTE and c) Educate patients about VTE (Barpet al. 2018). The risk assessment of VTE should be conducted on admission to the hospital and during the stay of the patient, mostly every 72 hours, regarding the different stages and transitions that happen during the admission process and the decrease and increase of the factors causing VTE. In this procedure, the use of tools, e.g. “Caprini risks score”, to assess the risk factor of VTE and categories patients as existing at “very low, low, moderate, high or very high risk” of VTE development. Relying on the outcomes, the health team must execute the suggested preventive action (Barp et al. 2018).
Conclusion:
In this case, the study report of health assessment, the detailed clinical observation and assessment of Brian Lawson a patient who undergoes left foot “Percutaneous pinning” implementation surgery, has been discussed. The nurse recognises deterioration during his recovery process from the operation and clinically processed him for further laboratory examination for potential VTE In this report, the nursing actions followed by the regulation of the guide provided by the “Australian Clinical Standard” and the guide provided by NSW or QLD are discussed for the assessment and prevention of VTE for above mention patient.
 
References List
Journals
Barp, M., Carneiro, V. S., Amaral, K. V., Pagotto, V., &Malaquias, S. G. (2018). Nursing care in the prevention of venous thromboembolism: an integrative review. Rev EletronEnf, 20, v20a14.
Cec.health.nsw.gov.au,2022. Available at: www.cec.health.nsw.gov.au [Accessed on: 13/11/2022]
Di Minno, A., Ambrosino, P., Calcaterra, I., & Di Minno, M. N. D. (2020, October). COVID-19 and venous thromboembolism: a meta-analysis of literature studies. In Seminars in thrombosis and hemostasis (Vol. 46, No. 07, pp. 763-771). Thieme Medical Publishers. Retrieved on: 05.12.2022, from: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1715456
Gullick, J., Lin, F., Massey, D., Wilson, L., Greenwood, M., Skylas, K., ... & Gill, F. J. (2019). Structures, processes and outcomes of specialist critical care nurse education: An integrative review. Australian Critical Care, 32(4), 331-345.
Health.nsw.gov.au, 2022. Available at: www.health.nsw.gov.au [Accessed on: 13/11/2022]
Health.qld.gov.au, 2022. Available at: www.health.qld.gov.au [Accessed on: 13/11/2022]
Koutoukidis, G., & Stainton, K. (2020). Essential Enrolled Nursing Skills for Person-Centred Care WorkBook-eBook ePub. Elsevier Health Sciences..
Lyman, G. H., Carrier, M., Ay, C., Di Nisio, M., Hicks, L. K., Khorana, A. A., ... & Alonso-Coello, P. (2021). American Society of Hematology 2021 guidelines for the management of venous thromboembolism: prevention and treatment in patients with cancer. Blood advances, 5(4), 927-974.Retrieved on: 05.12.2022, from: https://ashpublications.org/bloodadvances/article-abstract/5/4/927/475194
Ma, J., Qin, J., Shang, M., Zhou, Y., Zhang, Y., & Zhu, Y. (2020). The incidence and risk factors of preoperative deep venous thrombosis in closed tibial shaft fractures: a prospective cohort study. Archives of Orthopaedic and Trauma Surgery, 1-7. https://doi.org/10.1007/s00402-020-03685-z
Ortel, T. L., Neumann, I., Ageno, W., Beyth, R., Clark, N. P., Cuker, A., ... & Zhang, Y. (2020). American Society of Hematology 2020 guidelines for the management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood advances, 4(19), 4693-4738.Retrieved on: 05.12.2022, from: https://ashpublications.org/bloodadvances/article-abstract/4/19/4693/463998
Piazza, G., Campia, U., Hurwitz, S., Snyder, J. E., Rizzo, S. M., Pfeferman, M. B., ... & Goldhaber, S. Z. (2020). Registry of arterial and venous thromboembolic complications in patients with COVID-19. Journal of the American College of Cardiology, 76(18), 2060-2072.Retrieved on: 05.12.2022, from: https://www.jacc.org/doi/abs/10.1016/j.jacc.2020.08.070
Porfidia, A., Valeriani, E., Pola, R., Porreca, E., Rutjes, A. W., & Di Nisio, M. (2020). Venous thromboembolism in patients with COVID-19: systematic review and meta-analysis. Thrombosis research, 196, 67-74.Retrieved on: 05.12.2022, from: https://www.sciencedirect.com/science/article/pii/S0049384820304588
Ro, A., Kageyama, N., & Mukai, T. (2017). Pathophysiology of venous thromboembolism with respect to the anatomical features of the deep veins of lower limbs: a review. Annals of vascular diseases, a-17. https://doi.org/10.3400/avd.ra.17-00035
Safetyandquality.gov.au, 2022. Available at: www.safetyandquality.gov.au [Accessed on: 09/11/2022]
Silva, J. S. D., Lee, J. A., Grisante, D. L., Lopes, J. D. L., & Lopes, C. T. (2020). Nurses’ knowledge, risk assessment, and self-efficacy regarding venous thromboembolism. Acta Paulista de Enfermagem, 33.
Colling, M.E., Tourdot, B.E. and Kanthi, Y., 2021. Inflammation, infection and venous thromboembolism. Circulation research, 128(12), pp.2017-2036.

 
Appendices
Appendix:Clinical characteristics and classification of deep vein thrombosis

(Source: Ro A et al., 2017)
 
Appendix2: Suspected mechanism of venous thromboembolism due to lethal pulmonary Thromboembolism

(Source: Ro A et al., 2017)

Figure: Activation of Endothelium.
(Source: Colling, Tourdot & Kanthi, 2021)