Assessment and Discharge
Case Study : Developing an individualized care plan
Core care plans and care pathways are being used increasingly to plan and deliver patient care. However, patients will inevitably have problems or health needs (nursing diagnoses) for which there is not a core care plan, so it is vitally important that nurses are able to develop comprehensive and individualized care plans for patients no matter what their condition.
Read the following case study:
Anna is a 27 year old woman who was admitted to the ward with abdominal pain via the Emergency Department. She is currently nil by mouth and on intravenous fluids. She is very anxious about her mum, who is wheelchair bound and currently being looked after by a family friend; Anna is her main carer at home.
Develop a care plan for Anna to include the following:
Infection Prevention and Control
Case Study : Source isolation
Read the following case study:
Mr Peters is a 74 year old man who has a history of chronic obstructive pulmonary disease. He lives alone and became unwell 7 days ago, feeling fatigued with a productive cough and elevated temperature. He was diagnosed with a chest infection and admitted to hospital for intravenous antibiotics. Having completed his course of antibiotics yesterday, he has now had five episodes of diarrhoea in the last 12 hours. He is being cared for in a six bedded bay on a male medical ward and is expecting his daughter to visit him later today with his two young grandchildren.
- What precautions should be taken for this patient? For how long?
- What information would you give to Mr Peters and why?
- Would the precautions you take be any different if you were visiting Mr Peters in his own home? If so, how?
Communication
Case Study : Consent
Read the following case study:
Rose is a 79 year old woman with dementia. She is having a pre-operative assessment prior to having a right hip replacement due to severe osteoarthritis. Rose has come to the department with her daughter, who lives with her and is her main carer. Her daughter informs you that Rose is capable of following simple instructions but she is struggling to understand why she is visiting the hospital today.
Elimination
Case Study : Diarrhoea
Read the following case study:
Mrs Stone is a 44 year old woman with Crohn's disease who has been suffering from severe diarrhoea for the last 10 days and has been admitted to your ward with dehydration. She reports having at least 12 episodes of diarrhoea a day (type 7 using the Bristol Stool Chart).
- What precautions should be taken?
- What information would you want to include in your assessment of her diarrhoea?
- What nursing interventions is she likely to require?
Case Study : Constipation
Read the following case study:
Mr Jones, aged 32 years, is recovering from orthopaedic surgery for which he has been on bed rest. While on the ward he has suffered from constipation. He would like to know what he should do to avoid getting constipated when he goes home.
Moving and Positioning
Case Study : What are the risk factors for developing pressure sores?
Read the following case study:
A 86 year old gentleman has just been admitted onto your ward. He had a fall at home last night resulting in a fractured neck of the femur. You have been asked to assess his risk of developing pressure sores.
- What are his main risk factors for developing a pressure sore at this time?
- What tool could you use to assess this risk?
- What manual handling aids might you require to assist this patient with repositioning?
Case Study : Moving the unconscious patient
Read the following case study:
Ms Jones is a 56 year old woman who has been unconscious and intubated in the intensive care unit (ICU) for the last three days following a road traffic collision. You are looking after her today along with one of the members of the ICU nursing team and have been asked to help turn the patient from lying on her right side to a supine position.
- What are the main considerations prior to repositioning Ms Jones?
- How many staff are required to move Ms Jones?
- What equipment is required to assist in moving her safely?
- What should the team be considering during the procedure?
- What should be done after Ms Jones is repositioned?
Nutrition, fluid balance and blood transfusion
Case study: Assessing nutritional status
Read the following case study:
John Goody is a 44 year old man with a history of Crohn's disease. He has just been admitted for bowel surgery following worsening of his GI symptoms and significant weight loss over the last 4 - 5 months. John reports that 6 months ago he weighed 12st 7lb (79.4 kg). He has just been weighed on admission today and he now weighs 68 kg (10st 10lb). His height is 1.88 m (6ft 2in). On examination his clothing appears to be very loose fitting. He tells you that he has lost so much weight that his wedding ring falls off his finger now and he notices some of his bones are sticking out more than they used to. His face appears drawn and he seems to be a little slow in responding to questions.
- Using the formula provided within this section, calculate John's current body mass index (BMI).
- Now calculate his percentage weight loss.
- Based on your calculations, is John malnourished?
- What other signs/symptoms of malnourishment does John have?
Patient comfort and end-of-life care
Case study: Pain
Read the following case study:
James is a 37 year old man who was admitted to your ward having had knee surgery this morning following an injury he sustained playing football a couple of months ago. It is now early evening; he is using patient-controlled analgesia (PCA), containing morphine, in order to control his pain, and is also receiving regular doses of oral paracetamol and diclofenac (a non-steroidal anti-inflammatory).
James has said he has some pain. The nurse you are working with has asked you to assess James's pain.
- What tool would you use to do this?
- What else would you want to find out about his pain?
- What pharmacological interventions may be appropriate?
- What non-pharmacological interventions may be appropriate?
Respiratory Care
Case study: Respiratory assessment and smoking cessation
Read the following case study:
Ella Smith is a 29 year old woman who was admitted to your unit overnight for observation following an acute exacerbation of her asthma. This is the second time in 6 weeks she has been admitted for this reason.
- You need to assess her respiratory status; what else should you be observing for?
- What would be your first step in encouraging her to stop smoking?
- What other forms of support may she benefit from?
She is a smoker and on her previous admission was advised that she should try to stop smoking as this was a likely trigger for her asthma. She managed to stop for 4 weeks but started again one week ago when she was on a girls' night out and all her friends were smoking. She tells you that she usually smokes 5 - 10 cigarettes a day.
Case study: Cardiac arrest
Read the following case study:
Mrs Grange is a 69 year old woman who has had recent extensive gynaecological surgery. During the shift handover this morning, you were told that she had not been feeling herself overnight and that she was slightly tachycardic with lower than normal blood pressure. You have been asked to keep a close eye on her with regular hourly observations. You go to her bed to carry out your next set of observations and as you approach her you find her on her bed and she appears pale and slightly slumped to one side on her pillows. You go up to Mrs Grange and touch her arm but she does not respond.
- What should you do next?
- One of the healthcare assistants comes to help you. What should you ask him to do?
- You now know that Mrs Grange is not breathing and has no pulse. One of the qualified nurses comes to help you and the healthcare assistant brings the cardiac arrest trolley. What do you do next?
- What should you be prepared to do once the cardiac arrest team arrive?
- What may be the possible causes for her cardiac arrest?
Interpreting diagnostic tests
Case study: Swab sampling
Read the following case study:
Mr Wills is a 68 year old man who has been admitted to hospital for IV antibiotics via his GP. Following surgery to his abdomen 3 weeks ago, he now has a dehisced laparotomy wound which is showing signs of infection (red, inflamed, producing pus). He has been admitted to your unit and, as part of his risk assessment, requires an MRSA screen.
- Before carrying out the MRSA screen, what should you do to prepare Mr Wills?
- Which is the most important area of the body to take a swab sample from when screening for MRSA?
- What other areas of Mr Wills' body would you need to take swab samples from?
- Once you have taken the swabs, what should you do with them in order to ensure they are ready for collection?
Observations
Case study: Breathing Assessment
Read the following case study:
Mr Lyle is a 74 year old man who has been admitted with exacerbation of his chronic obstructive pulmonary disease (COPD). He is finding it hard to catch his breath, particularly after walking short distances around the ward. He usually finds that sitting in certain positions makes it more comfortable to breathe. He is having regular nebulizers and is finding these are helping to ease his breathing.
- You wish to assess Mr Lyle's breathing, how might you prepare him?
- In carrying out an assessment of his breathing, what observations should you be making?
- What additional parameters will help you to determine his respiratory status?
Medicines management
Case study: Complications of IV infusions
Read the following case study:
Mrs Kyle is a 48 year old woman who had abdominal surgery yesterday. She has a peripheral cannula in situ in her left forearm, through which she is having continuous intravenous fluids, as well as intravenous antibiotics, three times a day. Her observations are stable, but she is complaining of some discomfort around the cannula site.
- What may be causing this discomfort?
- In consultation with your supervising nurse, what actions would you suggest taking?
Perioperative care
Case study: Safe discharge from the post-anaesthetic care unit
Read the following case study:
Jane Ward, 38 years old, is being discharged back to the ward from the post-anaesthetic care unit (PACU). She has had laparoscopic gynaecological surgery and, so far, is recovering well. She has oxygen via a face mask and her respiration rate is 14 breaths/minute, oxygen saturations 99%. Her pulse is 76, blood pressure 110/60 and her temperature is 36.2°C. 30 minutes ago she was feeling rather sick so was given some more antiemetic and is now managing to take a few sips of water. She still has a bag of IV fluids that is running through a peripheral cannula, no drains or catheter in situ. Her stomach is feeling a little painful but she hasn't mentioned this to the nurse yet.
You have been asked by the ward to go and collect Jane from PACU. When you arrive you find she is awake and alert and the nurse hands over the information provided above. You ask Jane how she is feeling and she says she is ok but her stomach isn't feeling great.
- Using the criteria for discharging patients from PACU (see Box 13.13) and the information from handover, what else would you want to check before accepting Jane and returning her to the ward?
- You find that Jane has a pain score of 7/10; her wound dressings are all clean and intact. What would you do next?
Wound management
Case study: Pressure ulcer
Read the following case study:
Mr Toomey is an 83 year old gentleman who has had a previous above-knee amputation for peripheral vascular disease. He has very limited mobility and recently has become increasingly confused, in that he has been forgetting to eat and drink. He now spends the majority of his days sitting in his armchair and has had some episodes of urinary incontinence. He was seen at home by his GP who identified that he has a pressure sore on his right buttock and also diagnosed that he has a severe urinary tract infection. He has been admitted to the ward for intravenous antibiotics and also assessment of his pressure ulcer.
- What factors contributed to the pressure ulcer occurring? Were any of these avoidable?
You have been asked to assess his skin integrity including the pressure ulcer on his right buttock.
- What should you be observing for?
- What tool(s) would help you to carry out a comprehensive assessment?
- What measures should be put in place to manage the pressure ulcer and avoid any further skin deterioration?
His pressure ulcer has been assessed as grade 2.
