Nursing Assignment Evaluating Medical Case Scenarios

Question

Task: Prepare a nursing assignment answering the following questions based on the given case studies.

Case Study 1.0
Mrs Edna Clough is 87-year-old women who has been admitted to your ward for management of her congestive heart failure. Edna buzzes and you walk into find the following:

A Patent
B RR 34, SaO2 90% course crackles auscultated, increased work of breathing, productive cough with blood stained sputum
C Pink, centrally warm with cool peripheries, HR 105 reg, BP 112/89, no signs of oedema
D Alert and orientated, mild pain in her chest 3/10, moving all limbs,
E Skin intact no evidence of rash, swelling or bleeding

1. What acute condition is Edna likely to have? Provide rationale for your answer.
2. What nursing interventions can you put in place to support Edna with her acute health concerns. Please provide 4 interventions.
3. Enda will be commenced on Bipap.

Explain the nursing management when looking after a patient on BiPAP. Your answer should include 3 nursing management strategies with rationale.

Edna’s condition worsens and she becomes unresponsive.
4. Please use the additional information from the case study to answer the following questions.
What is the emergency protocol you need to follow in this situation with rationale for each?

5. Discuss why teamwork and communication are so important between the emergency responders and provide strategies on how this is achieved.
6. The team leader has asked you to prepare amiodarone. Why is amiodarone given and what is the dose that is given during a cardiac arrest?
7. The resus trolley needs to be checked after Edna is transferred to ICU.

a) Whose responsibility is it to check the trolley?
b) Why is it important to check the emergency trolley?

Case Study 2.
Mr Keith Hanney is an 4 year old male who has presented with thermal burns to his abdomen and upper left thigh after a bowl of hot soup accidently fell on him.

1. What is the assessment tool used to assess Keith’s burns and why is it important to use this tool?

2. Explain the difference between superficial, partial and full thickness burns and symptoms Keith may present with for each.
3. What nursing interventions would you put in place to support Keith’s burns. Provide rationale for your answers in relation to Keith’s injuries. (Your answer should include six (6) interventions).

Case Study 3.
Mr Pham Wang is a 82-year-old male who was admitted to your ward after a motor vehicle accident (MVA). He sustained a fractured femur for which he required an ORIF and a pneumothorax. He has a had plaster of paris (POP) applied to his leg and an underwater sealed drain (UWSD) inserted into his left chest.

1. Explain the pathophysiology of a pneumothorax and how insertion of a chest drain will support this acute condition.
2. Explain to Pham what nursing interventions and assessments you will be doing while he has the chest drain insitu.
3. This question has 2 parts:
a) Explain to Pham the purpose of is POP and assessments that you will be undertaking to ensure there is no complications.
b) Name one complication that is associated with POP and a symptom Pham may experience if this complication was occurring.

4. Identify two (2) actual health issues and two (2) potential health issues for Pham and provide a rationale for your answer.
5. How do you ensure effective pain management in patients with acute health conditions? Please provide 4 points.
6. On assessment of Pham’s UWSD you notice that the bubbling has suddenly ceased. What does this indicate and would you do?
7. What type of shock is Pham at risk of developing?

Answer

Nursing AssignmentCase study 1
What acute condition is Edna likely to have? Provide rationale for your answer.
Acute conditions that might have led to a congestive heart failure in Edna would include:

• Coronary artery disease: building up of fatty acids in arteries reduces the flow of blood causing an attack. Especially the compounds are composed of cholesterol that get deposited in the coronary arteries and swelling occurs that ultimately lead to coronary-associated diseases. A problem is only detected after a decade long development when heart attack or a significant amount of blockage is observed.
• Hypertension: Blood pressure being high, the muscles in the heart needs to be pressurized in order to ensure flow of blood. With the passage of time the muscles become stiff leading to an attack. There are two types- primary and secondary. The risk factors include family history, absence of physical activity, age, increase in salt intake, smoking and so on.
• Heart valve problem: a fault in a valve which helps in the flow of blood leads to artery diseases or heart infections, which with time can cause an attack.
• Cardiomyopathy: Heart muscles can get damaged with time due to genetically related problems, drug abuse, heart infections and much more. The reasons that usually lead to this problem- diabetes, thyroid disease, hypertension, excessive drinking and so on.
• Congenital heart defects: Sometimes it so happens that a child is born with incomplete heart structure leading to an extra pressure on the muscles to keep the work growing. As one grows, risks increase. It can be diagnosed with the help of chest X-ray, an echocardiogram or an electrocardiogram.
• Heart arrhythmias: Abnormal rhythms in the heart (either too fast or too slow) can cause heart attack. Atrial fibrillation is one of the most common types of arrythmia leads to blood clot formation. These clots can travel and result in a stroke or lead to blockage within the arteries. It can be identified in the urine. Arrythmias may cause bradycardia or tachycardia.
• Diseases: Chronic diseases (HIV, Diabetes, Hypertension) and built up of iron or protein can cause heart attacks.

What nursing interventions can you put in place to support Edna with her acute health concerns. Please provide 4 interventions.

• Vital statistics must be regularly monitored. These include a patient’s patterns of the pulse, blood pressure, saturation, body temperature and respiration.
• A nurse must provide an alternative to a patient’s lifestyle in order to ensure positive outcome. A caring environment must be created by a nurse. • Diet must be modified by a nurse with low level of salt and absolutely fat free. Fat free diets helps ensure the minimization of the risk for ischemic heart disease. And low sugar diets help reducing the risk for fluid retention.
• Health education must be provided to the patient as well as his or her family. Proper counselling will help them accept the severity of their health so that they can modify their ways of living in order to live a healthy life. It also helps ensure a patient to take care of oneself by self- examining on a regular basis. The family must be provided with proper education on the disease so that the surrounding of a patient can be supportive in such a delicate case.

Enda will be commenced on Bipap. Explain the nursing management when looking after a patient on BiPAP. Your answer should include 3 nursing management strategies with rationale.Bipap or bilevel positive airways pressure is a device that works as ventilation for patients who are unable to breathe properly.

The strategies for nursing management to be implied during dealing with Bipap would include-
• Nurses and other technical staffs must be well prepared and adequate equipment’s required for the process needs to be ready. Ventilation systems must be checked. The oxygen supply must be accurately connected. Oral hygiene must be ensured.
• A safe environment must be ensured as equipment run on electricity and any accidents must be avoided by prior supervisions. The presence of carbon dioxide in the exhalation port must be ensured. Any sort of electric failure can cause a very misfortunate accident. It is the duty of the nurse to ensure proper safety of the machinery and the electricity.
• Nurse- patient communication must be ensured so as to help the patients relax. Heart attacks occur due to hypertensions and the effects remain until the patient is brought to a certain level of relaxation. It is the responsibility of a nurse to take care of the patients and bring in them a certain level of relaxation so that they can cope up with the current health scenario and progress towards the betterment of their health.

What is the emergency protocol you need to follow in this situation with rationale for each?
Immediate CPR (cardiopulmonary respiration) must be performed when a patient with a cardiac arrest becomes unresponsive. This happens due to the blockage of oxygen in the heart, thus artificial respiration must be ensured in such cases so as to avoid high risk in patients. Bipap must be ensured or the drug amiodarone can be applied. The main motive behind this is, since the heart attack can cause the blockage in the supply of the blood, these methods can help ensure the working of the heart thus reducing the risk in a patient and increasing efficiency.

Discuss why teamwork and communication are so important between the emergency responders and provide strategies on how this is achieved.
Teamwork and communication go hand- in- hand in medical professions and there must be the co- operation of both these among emergency responders so as to prevent any medical errors, increase efficiency and increase patient satisfaction. It can be achieved by the clear division of the roles each has to play and ensuring to inform the other of the action taken by one. In case there is any sort of confusion it might incur the risk of delay while working on an emergency situation. However, the clear understanding of one’s role and working in accordance to that role ensures a proper functioning of the emergency responders. With divided roles, each plays their own part while informing the other, and this helps in efficient performance.

The team leader has asked you to prepare amiodarone. Why is amiodarone given andwhat is the dose that is given during a cardiac arrest?
Amiodarone is an antiarrhythmic agent used to treat arterial fibrillation and ventricular arrhythmias.This drug is used to prevent deaths among high risk patients of ventricular arrhythmias. Though it has a complex effect on heart, it slows down the metabolism in cardiac tissue. The drug amiodarone blocks the hormones that speed up the heart, thus slowing the heart rateHence this drug is applied in case of cardiac arrest in order to maintain a normal circulation.

In case of cardiac arrest in adults, amiodarone is given as a 300 mg rapid bolus which is followed by a 150 mg bolus. The resus trolley needs to be checked after Edna is transferred to ICU.

A. Whose responsibility is it to check the trolley?
B. Why is it important to check the emergency trolley?

a) The resus trolley is to be checked by a registered nurse or an anaesthetic technician on a weekly basis. The person involved in checking the trolley must sign and keep a record on the trolley itself.
b) It is essential to check the emergency trolley on a regular basis as it ensures that all the functioning equipment’s are present, and if not, restock can be done. Regular checking also maximises efficiency by avoiding any delays during critical cases. In larger terms it helps reduces mortality rate in a health care institute. While in case of an emergency case, the absence of any equipment can cause a situation of high risk in a patient. To avoid such situations the trolley must be under regular supervision.

Case Study 2.
Name the assessment tool used to assess Keith’s burns and why is it important to use this tool?
The tool that will be used to assess Keith’s burn would be the Rule of Nines.
In the case provided, this tool can be applied but is imprecise for evaluating the burns of a child. It is because a child’s head or lower extremities indicate various percentages of the burnt region compared to an adult. It is considered that more than 15 per cent burns and more than 10 per cent burns in a child as well as any specific burn occurring in a young child is dangerous. Moreover, Wallace Rules of Nine useful in estimating the burn percentage. In the process, a portion of the Body surface Area is smeared continuously in multiple of nine for several body parts:

1. 9% Complete left arm
2. 9% Complete right arm
3. 9% Entire head
4. 18% Complete back
5. 9% Entire chest
6. 9% Entire abdomen
7. 1% Groin
8. 18% Complete right leg
9. 18% Complete left leg.

This tool helps in assessing the percentage of burns thus helps in guiding treatment decisions. The estimate of the burnt body surface area can be calculated by using multiples of 9. Burn injuries are open injuries on the body surface and are in direct contact with the environment. The number and size of the wounds are vital determinants that help understand the colonization and infection inflicted by any microorganism. It has been estimated that 70 per cent of the deaths in burn patients is a result of the shock that they undergo due to their injuriesMoreover, infection of burn is a general complication. After the total burn has been calculated by applying the rules of Nine, the condition of the patient can be assessed. Significant burn wounds can lead to immunosuppression comprising of suppression of specific immunity as well as non-specific immunity.

Describe the difference between superficial, partial and full thickness burns and symptoms Keith may present with for each. The severity of burns can be classified depending on the number of skin layers that has been affected. The skin is comprised of three layers:
1. The epidermis
2. The dermis, and,
3. The subcutaneous tissue.

Superficial burns are first degree burns and are painful and red. At first there is swelling and then turns white on being pressed. The burnt skin peels off in a day or two. It only affects the outer layer of skin, that is epidermis. This is caused by excessive sunburn. It takes 3- 6 days to heal.

Second degree burns or partial burns are deeper burns. They cause blisters and there is a lot of pain involved. The epidermis and some of the dermis layer of the skin is harmed. It is usually caused by hot fluids. It takes almost 2 weeks to heal a second-degree burn. Full burns are the third degree burns where the skin is completely charred and all the layers of skin gets affected. The nerve ends get damaged hence there is no sensation of pain. It takes almost 3 weeks to heal. Also, depending on the injury it may so happen that the skin might need to be grafted.

Thermal burns are the burns caused by excessive heat, especially contact with hot liquids, hot surfaces and steam or flame. These kinds of burns are most observed in children due to unexpected accidents.

Keith’s damage can be considered as the second degree burn because it has been caused by the falling of hot liquid on the surface of the body. It would take 3 weeks to heal completely.

Identify nursing interventions would you put in place to support Keith’s burns. Provide rationale for your answers in relation to Keith’s injuries. (Your answer should include six (6) interventions).

At the initial stages of a patients’ arrival, a nurse has to first cool off the burnt area as a first aid. The loosened tissue must be gently scrubbed off and an antibiotic must be applied. The cause of the injury and where it occurred and under which circumstances must be assessed keenly. The history of the case must be obtained. Pre- burn weight, temperature of the body and much more, must be noted down.

• Vital statistics must be monitored frequently to avoid any traumatic effects on the patient. If indicated, cardiac monitor must begin immediately. Peripheral pulses must be checked hourly. Amount of urine must be calculated continuously on the insertion of a catheter.
• The dressing on the wound must be changed on a regular basis. The wounds must be thoroughly inspected for any infections. Topical antibiotic chemotherapy must be administered.
• Rich in protein diet must be provided to a patient suffering from burns.
• Proper body alignment must be maintained providing support to the injured areas. This prevents contractures.
• Encourage the patient to do some physical exercises but prior medication for pain is required to be applied. Exercising will reduce muscle tension and stiffness enabling more activeness in the patient.

Case Study 3
Explain the pathophysiology of a pneumothorax and how insertion of a chest drain will support this acute condition.
Pneumothorax is referred to as the condition where the pleural cavity gets occupied with air, which hampers the ventilation and oxygen intake. Pleural cavity is the area between chest wall and lungs and when filled with air it can create an external pressure outside thus destroying the negative pressure. This may result in lungs collapsing. Traumatic pneumothorax is usually caused during a severe accident when the pleura gets ripped and the air is able to enter inside the pleural cavity. The major clinical indications are the sharp pains that arises around the chest which generally exaggerates during coughing and inhalation.

Intercostal drain or chest drain or underwater sealed drains is a process where a flexible tube of plastic is put inside through the chest wall so that it reaches the pleural cavity. The equipment consists of three chambers- a water seal, drainage collecting chamber and the suction control. It is applied when effusions or pneumothoraxes need to be extracted out from the intrathoracic space. It is an extremely essential process that needs to be carried out when there is complicated pneumothorax larger than 2 centimeters after two chances of aspiration. The insertion location is determined using ultrasound. A written consent is advisory before initiating intercostal drain.

Explain to Pham what nursing interventions and assessments you will be doing while he has the chest drain insitu. 200 Firstly, the nursing staff must keep in mind that the chest drain should not be clamped unless ordered by the doctor. The patient should be assessed thoroughly- vital signs including heart rate, oxygen saturation, blood pressure and relative risks must be checked. While the chest drain is being done, continuous evaluation of the above factors in an interval of 15 minutes for an hour or in an interval of one hour for 4 hours. Another important point in this case would be documenting the progress in the Electronic Medical Records. In this way mistakes can be eliminated and a brief history of patient can be kept for a long-term.

It is also vital that inflammation or infection regions are checked properly followed by sterile and intact dressing of the insertion site. Furthermore, the UWSD unit must not be lifted above chest level and the tube must not possess any obstacles or kinks that may stop the drainage.

The nurse should check that the water seal stays at 2 centimetres all the time. The tubing must be attached to the skin of the patient to avoid pulling of the drain.Also, all the connections between drainage unit and tubes are safe and tight at all areas.

This question has 2 parts:
A. Explain to Pham the purpose of is POP and assessments that you will be undertaking to ensure there is no complications.
The most critical purpose of Plaster of Paris is to provide support to the body, fasten the healing process and helps the realigned bone to recover, in this case being the femur. The assessments that must be done are presented below within this nursing assignment-

• Knowledge regarding the injury mechanism
• Social background
• Allergic history
• Medical history

The physical evaluation would comprise of the following-

• Skin integrity
• Presence of any injury or drainage or local infection
• Position and alignment
• Abdominal, respiratory and urological condition
• Neurovascular status.

Complications are a part of any medical process and certain number of them are associated with casting such as- anxiety, compartment syndrome, neurovascular dysfunction, increased thickness of POP and so on. Techniques in which complications can be dealt with are listed as follows:

• Compromised skin must be treated with extra care.
• A thick casting must be avoided and pillow support must be sought when the POP settles
• POP must be soaked gently in the water and optimum soaking is very important.
• The water temperature must be brought in the range of 20°-24°C.
• Fresh water must be applied that is any kind of residue must be absent.

A. Name one complication that is associated with POP and a symptom Pham may experience if this complication was occurring.

In case of peripheral neurovascular dysfunction (A complication associated with casting), the patient must report to the concerned health staff. It can be assessed through numbness, high amount of pain and tingling sensation which is recognised as abnormality during the casting process.

Identify two (2) actual health issues and two (2) potential health issues for Pham and provide a rationale for your answer. Actual health issues that may persist are listed below:

Heart diseases are common within the elderly population. It has been found in recent studies that almost 50 per cent of people aged 80 and above suffer from cardiovascular diseases which may be untreated.

1. Pneumothorax is a serious condition that has been identified in the patient and men are more prone to suffer from this condition. The condition can worsen due to habits like smoking and drinking.

Potential issues that can occur are mentioned below:
1. Bacterial infection that may be caused from the equipment or incision if the wound is not properly sterilised during the ORIF process. Hence, it is required to disinfect the tools using alcohol-based compounds and then use them in the required technique.

Frothing of fluid can occur possibly due to a large pleural leak during the intercostal drain process. Therefore, the draining process and equipment must be monitored in case disconnection, loose connection or dislodgment issues rises.

How do you ensure effective pain management in patients with acute health conditions? Please provide 4 points.
Pain can be reduced using opiods in case of emergency conditions for patients with acute health illnesses. It has been observed that opiods are provided in most of the cases for people who are undergoing dental or orthopaedic issues.

• Rating scale can be applied to measure the amount of pain for patients undergoing acute illnesses.
• Fluid balance needs to be supervised at regular intervals so that if any abnormality occurs, it can be reported rapidly.
• In order to ensure effective management, accurate documentation must be recorded so that there is adequate knowledge regarding the drug activities of the patient.
• Emotion is also an important criterion when the elderly is treated. On assessment of Pham’s UWSD you notice that the bubbling has suddenly ceased. What does this indicate and would you do?

In the presence of an air leak, bubbling is witnessed in the water seal chamber of the system. Whenever the patient coughs or exhales, bubbling occurs. If the bubbling suddenly elevates, it is clear indication that a substantial amount of leak is present between the patient and the drain and needs to be addressed soon.The medical staff should be informed in case it is not solved immediately.

What type of shock is Pham at risk of developing?
The shock can be caused due to heart problems that are bradycardia, tachycardia, minimised chest movements, lowered breath sounds and hypotensio