HLTENN004 Implement Monitor And Evaluate Nursing Care Plans
Question:
Case Study – Mrs Anh Thuy
Mrs Anh Thuy is a 43 year old lady admitted following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. A neighbour found her on the ground unable to move or speak.
She has been diagnosed as having an ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.
Family history –
- Born to Vietnamese parents in Australia
- Buddist & speaks Vietnamese & English
- Lives with husband & 2 children, Grace 4 years old & Ty 13 years old. Also father who is a frail 82 year old.
Medical history -
- Hypertension, Type 2 Diabetes, Asthma
- Depression
- Lactose intolerant
- Hearing aid left ear
- Bi-focal glasses (broken in fall)
- Upper dental partial plate
- Medication – Amlodipine, Metformin, Salbutomole.
Admission observations -
|
BP 170/100
PR 90 regular
RR 24
To 36.4
SpO2 98% on room air
BGL 7.4 mmol
Weight 71 kg
Height 152 cm
|
GCS (Glasgow coma scale) = 14
Eyes open to speech
Oriented to time, place and person (speech slurred, but able to be understood)
Right hemiparesis
PERL (Pupils equal reactive to light)
|
Issues/impacts of the CVA –
- Pain on movement, mainly right hip & shoulder
- Large haematoma right hip
- 5cm skin tear right elbow
- Dysphasia
- Dysphagia
- Right sided facial droop
Doctor’s orders and interventions–
- Rest in bed (RIB)
- 2nd hourly Neurological observations
- Nil by mouth (NBM) until Speech Therapist review
- Physiotherapist review
- Full assistance with hygiene
- IDC insitu
- Intravenous Therapy via cannula in left forearm
Discharge Information –
Mrs Thuy will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.
Part 1
- Using the headings below explain how you would prepare for Mrs Thuy’s arrival to the ward.
a) Preparation of room:
b) List 4 piece of equipment required for a patient assessment:
c) List four (4) types of forms and or risk assessment tools that will be required as part of Mrs Thuy’s admission:
- Identify 4 components of correct nursing documentation?
- Clinical Handover is an important part of continuity of patient care and safety. Nurses use the tool ISBAR when giving clinical handover.
a) What information would you include when doing a verbal clinical handover for Mrs Thuy to your Registered Nurse? Please use the ISBAR format.
Part 2
Answer the following short answer questions in relation to the scenario and assessment documents.
- Explain 3 strategies to ensure Mrs Thuy privacy and confidentiality using a culturally appropriate approach during her hospital stay.
- When should the discharge plan for Mrs Thuy begin? List 4 things that are required for a patient’s successful discharge.
- Consider Mrs Thuy’s discharge home and what might she require assistance with at home. Complete the following table by identifying three (3) issues she may require assistance with at home and the community services that could be arranged assist with her transition home.
- Mrs Thuy has had a cerebro-vascular accident (CVA).
a) Explain a CVA including where it occurs and what causes it.
b) Identify four (4) signs and four (4) symptoms of a CVA.
Symptoms
Signs
c) Patients who have had a CVA can be hospitalised by a long period of time. Identify four (4) risks of long term hospitalisation on patients.
- Mrs Thuy has had her IDC removed but now has urinary incontinence. Define Urinary and faecal incontinence and give three (3) examples of incontinence aids for both men and women.
Definition
Incontinence aids
- What interventions can be done to help patients with incontinence? Provide four (4) examples interventions.
- List two (2) factors each that promote and impede on comfort, sleep and rest.
- Review Mrs Thuy’s vital signs and clinical data on admission. Answer the following questions in relation to this assessment data.
a) Blood pressure 170/100
What is the normal range for Systolic and Diastolic blood pressure in an Adult?
Is Mrs Thuy’s blood pressure reading within normal range?
What is the correct terminology of this condition?
What would you do as a result of this reading?
b) Pulse rate 90 regular
What is the normal range for adult pulse rate?
Is Mrs Thuy’s pulse rate within normal range?
What would you do as a result of this data?
c) Respiratory rate 24
What is the normal range for adult respiratory rate?
Is Mrs Thuy’s respiratory rate within normal range?
What is the correct terminology of this condition?
What would you do as a result of this data?
d) Temperature 36.4
What is the normal range for adult temperature?
Is Mrs Thuy’s temperature within normal range?
What would you do as a result of this data?
e) Oxygen saturation (SpO2) 98% on room air
What is the normal range for oxygen saturation?
Is Mrs Thuy’s SpO2 within normal range?
What would you do as a result of this data?
f) BGL 7.4 mmol
What is the normal range for blood glucose levels?
Is Mrs Thuy’s BGL within normal range?
What would you do as a result of this data?
g) GCS = 14, PERL
Is this normal?
What would you do as a result of this data?
h) Using the following formula calculate Mrs Thuy’s BMI:- BMI = kg/m2
BMI = (please enter your calculation from the nursing assessment form)
Is this normal?
- Owing to the dysphasia suffered following the CVA Mrs Thuy is having difficulties communicating. Outline three (3) strategies that could be used to assist Mrs Thuy with her communication.
- Mrs Thuy identifies strongly with her Vietnamese culture.
Outline two (2) strategies you could implement to support her cultural, spiritual and religious needs.
Where would you document these?
- Mr Thuy is worried about his wife and the impact hospitalisation has had on the family. He is very distressed about the current situation. Identify three (3) potential causes of Mr Thuy’s distress and strategies that could be implemented to support Mr Thuy during this stressful time.
- Part of the nurse’s role is to assess how Mrs Thuy is coping with the changes in her functional status following her CVA. Describe three (3) behaviours that Mrs Thuy might display if she was not adapting to the changes experienced.
- The RN has identified a number of nursing diagnosis’ for Mrs Thuy. Develop a nursing care plan using the following nursing diagnosis. Provide 2 interventions and a rational for each intervention
