UNFOLDING Clinical Reasoning Case Study:
Adrenal Crisis Case Study
1
, Data Collection
History of Present Problem:
A 62-year-old man (60 kg), Thomas Jones, was admitted to the hospital following a motor vehicle accident. He sustained
a concussion, as well as several contusions, and multiple internal injuries. The client arrived in the EDalone, with no
family immediately available. He appeared confused and disoriented and was unable to give any medical history at the
time of admission. Surgery was performed to remove a ruptured spleen and repair an areaof ischemic bowel that resulted
due to a seatbelt injury. The abdomen was unable to be closed during surgery due to swelling. His immediate post-op
course was complicated by the client’s failure to wean from the ventilator, requiring his placement in the ICU for medical
management where he received multiple blood transfusions, prophylactic intravenous antibiotics, intravenous fluids
(0.45% NS @ 75 ml/hr), and aggressive pulmonary hygiene. His vital signs remained within parameters. His vent settings
were as follows: mode-AC; TV-600 ml; Rate-12; FIO2-60%; PEEP-10 cm H2O.
Personal/Social History:
Not available at this time.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Client arrived in ED post motor vehicle When the nurse is unable to obtain a medical history it becomes
accident with concussion, contusions, and important for the nurse to monitor the client closely for post-operative
multiple internal injuries requiring immediate complications and look for causes that may contribute to a lack of
surgery. response to medical/nursing interventions. The nurse must recognize
that trauma and surgery are physiological stressors to the body.
Mineral- and glucocorticoids are produced by the adrenal cortex which
assist the body to cope. Without mineral- and glucocorticoids the client
cannot maintain physiologic stability.
Abdomen was unable to be closed following Third spacing following abdominal surgery results in edema in the
surgery due to swelling. bowel and abdomen. The abdomen must remain open to prevent
abdominal compartmental syndrome.
Unable to be weaned from the ventilator.
Most clients undergoing surgery are able to be weaned off a ventilator
within a few hours after the procedure. A client who is unable to be
weaned should be suspected of having a history of a respiratory
disorder or needs to be assessed for other contributing causes.
RELEVANT Data from Social History: Clinical Significance:
Age 65 years-old. Limited information available because client is unable to provide
personal information. Nurse must use client identification to notify next
of kin of current status.
The client’s age needs to be considered when planning age-specific care.
The client is elderly and the nurse should be aware of the physiologic
changes that occur with aging.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Unable to obtain. Unknown N/A N/A
2
Adrenal Crisis Case Study
1
, Data Collection
History of Present Problem:
A 62-year-old man (60 kg), Thomas Jones, was admitted to the hospital following a motor vehicle accident. He sustained
a concussion, as well as several contusions, and multiple internal injuries. The client arrived in the EDalone, with no
family immediately available. He appeared confused and disoriented and was unable to give any medical history at the
time of admission. Surgery was performed to remove a ruptured spleen and repair an areaof ischemic bowel that resulted
due to a seatbelt injury. The abdomen was unable to be closed during surgery due to swelling. His immediate post-op
course was complicated by the client’s failure to wean from the ventilator, requiring his placement in the ICU for medical
management where he received multiple blood transfusions, prophylactic intravenous antibiotics, intravenous fluids
(0.45% NS @ 75 ml/hr), and aggressive pulmonary hygiene. His vital signs remained within parameters. His vent settings
were as follows: mode-AC; TV-600 ml; Rate-12; FIO2-60%; PEEP-10 cm H2O.
Personal/Social History:
Not available at this time.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Client arrived in ED post motor vehicle When the nurse is unable to obtain a medical history it becomes
accident with concussion, contusions, and important for the nurse to monitor the client closely for post-operative
multiple internal injuries requiring immediate complications and look for causes that may contribute to a lack of
surgery. response to medical/nursing interventions. The nurse must recognize
that trauma and surgery are physiological stressors to the body.
Mineral- and glucocorticoids are produced by the adrenal cortex which
assist the body to cope. Without mineral- and glucocorticoids the client
cannot maintain physiologic stability.
Abdomen was unable to be closed following Third spacing following abdominal surgery results in edema in the
surgery due to swelling. bowel and abdomen. The abdomen must remain open to prevent
abdominal compartmental syndrome.
Unable to be weaned from the ventilator.
Most clients undergoing surgery are able to be weaned off a ventilator
within a few hours after the procedure. A client who is unable to be
weaned should be suspected of having a history of a respiratory
disorder or needs to be assessed for other contributing causes.
RELEVANT Data from Social History: Clinical Significance:
Age 65 years-old. Limited information available because client is unable to provide
personal information. Nurse must use client identification to notify next
of kin of current status.
The client’s age needs to be considered when planning age-specific care.
The client is elderly and the nurse should be aware of the physiologic
changes that occur with aging.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Unable to obtain. Unknown N/A N/A
2
