Assessment and Discharge

Case Study : Developing an individualized care plan

Example care plans

Anxiety related to being unable to care for her mother

For Anna to feel reassured that her mother is being looked after:

Allow time for Anna to discuss her home situation.
Support Anna to be able to speak with her mother over the phone.
Be flexible with visiting times to allow her mother to visit out of hours if required.

Acute pain related to unknown cause

For Anna to state she is comfortable with pain score less than 3 (pain scale 0 - 10):

Assess pain hourly using a pain assessment chart.
Administer prescribed analgesia and monitor effect.
Provide Anna with information and support for any investigations she may have.

Risk for fluid deficit: nil by mouth

For Anna to state she does not feel dehydrated and to be in a slight positive fluid balance:

Administer prescribed IV fluids.
Maintain an accurate fluid balance chart.
Encourage Anna to rinse her mouth regularly.

Infection Prevention and Control

Case Study : Source isolation

1. What precautions should be taken for this patient? For how long?
   
   Universal precautions (standard practice) and handwashing with soap and water.
   Source isolation (due to the risk of Clostridium difficile having been on antibiotics).
   Follow source isolation guidance for attending to the patient.
   Advise that young children do not visit in order to minimize the risk of infecting them.
   Remain isolated for 48 hours after the last episode of diarrhoea.
2. What information would you give to Mr Peters and why?
   
   What the suspected infectious agent is (C. difficile) and its modes of transmission.
   Why isolation is required and for how long.
   Precautions he should be taking, i.e. standard precautions.
   Precautions the nursing staff will be taking and advising his visitors to take.
   Advise that small children are potentially at increased risk of infection due to underdeveloped immunity so it is better for grandchildren not to visit at the present time.
3. Would the precautions you take be any different if you were visiting Mr Peters in his own home? If so, how?
   
   The same infection control procedures should be followed.
   Infectious waste bags should be provided if not within his home already.
   Advise to wash linen on a hot wash.
   Minimize visitors and advise them of procedures for effective hand hygiene.

Communication

Case Study : Consent

What steps do you need to take in order to gain consent for Rose to have her operation?

Elimination

Case Study :Diarrhoea

1. What precautions should be taken?
   Universal precautions.
   Nurse in a side room (ideally).
   Discuss with infection control team.
   Patient education.
2. What information would you want to include in your assessment of her diarrhoea?
   History of onset, frequency, medical history.
   Colour, consistency, form of stool.
   Stool cultures, blood tests.
   Any associated symptoms. For example, pain, vomiting, fatigue.
   Fluid and food intake.
   Current management strategies (pharmacological, non-pharmacological).
   Coping strategies.
3. What nursing interventions is she likely to require?
   Infection prevention and control.
   Fluid management.
   Dietary management.
   Anti-motility medication once infective causes have been excluded.
   Additional medication to control the inflammation caused by the Crohn's disease.
   Pain management.
   Support and information.

Case Study :Constipation

What advice would you give to Mr Jones?

Moving and Positioning

Case Study :What are the risk factors for developing pressure sores?

1. What are his main risk factors for developing a pressure sore at this time?
   His age, fractured hip and resulting lack of mobility.
2. What tool could you use to assess this risk?
   Norton or Waterlow.
3. What manual handling aids might you require to assist this patient with repositioning?
   Sliding sheets, hoist, additional pillows (depending on desired position) (See Procedure guideline 6.1) (See Procedure guideline 6.2)

Case Study :Moving the unconscious patient

1. What are the main considerations prior to repositioning Ms Jones?
   
   Maintaining her airway.
   Ensuring she is repositioned at least 2 hourly.
2. How many staff are required to move Ms Jones?
   At least four members of staff (one to be in charge of airway).
3. What equipment is required to assist in moving her safely?
   
   Manual handling equipment.
   Pillows and towels to ensure a comfortable position.
4. What should the team be considering during the procedure?
   
   Communicating with Ms Jones, explaining the procedure.
   Checking and maintaining skin integrity.
5. What should be done after Ms Jones is repositioned?
   
   Monitor colour, temperature and pulses of the limbs.
   Document that the procedure has been carried out, within the patient's records.

For the full procedure, refer to Procedure guideline 6.8: Positioning the unconscious patient or patient with an airway in supine

Nutrition, fluid balance and blood transfusion

Case study: Assessing nutritional status

1. Using the formula provided within this section, calculate John's current body mass index (BMI).
   
   68 / (1.88)² = 19.2
2. Now calculate his percentage weight loss.
   79.4 - 68 / 79.4 = 14.4%
3. Based on your calculations, is John malnourished?
   Yes.
4. What other signs/symptoms of malnourishment does John have?
   Loose fitting clothes, jewellery, wasted appearance, lethargy.

Patient comfort and end-of-life care

Case study: Pain

1. What tool would you use to do this?
   For example: numerical rating scale 0-10.
2. What else would you want to find out about his pain?
   Location, duration, type (e.g. stabbing, dull ache), precipitating/alleviating factors.
3. What pharmacological interventions may be appropriate?
   Review his oral and patient-controlled analgesia. Is the PCA working effectively? Has he had all of his oral analgesia as prescribed?
4. What non-pharmacological interventions may be appropriate?
   For example: information and reassurance, comfort measures (positioning, pillow), relaxation, music, distraction, TV.

Respiratory Care

Case study: Respiratory assessment and smoking cessation

1. You need to assess her respiratory status; what else should you be observing for?
   
   Ease and comfort of breathing, rate, pattern, her position, rate and ease of breathing when speaking or moving, her colour and appearance, any audible breath sounds.

2. What would be your first step in encouraging her to stop smoking?
   

   Assess her desire to stop smoking.
   Have a discussion about the benefits of stopping smoking.
3. What other forms of support may she benefit from?
   
   In consultation with other members of the nursing and multidisciplinary team, suggest pharmacotherapy and behavioural support.
   Provide any available self-help material and potentially refer her to more intensive support such as the NHS Stop Smoking services http://www.nhs.uk/smokefree.

Case study: Cardiac arrest

1. What should you do next?
   Shout for help.
   Check the surrounding area to make sure it is safe, no slip/trip hazards, no wires/electric cables in the way.
   Check level of consciousness by gently shaking shoulders saying, Are you alright?
   Use ABC to check airway – breathing – circulation.
2. One of the healthcare assistants comes to help you. What should you ask him to do?
   Call the cardiac arrest team, get another nurse to come and help and bring the cardiac arrest trolley.
3. 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?
   Along with the other nurse you commence 30 chest compressions followed by two rescue breaths using the Ambu-bag.
4. What should you be prepared to do once the cardiac arrest team arrive?
   Continue to help as directed by the team and your nursing colleagues. This may include reassuring other patients in the immediate ward area.
5. What may be the possible causes for her cardiac arrest?
   The most likely causes may include hypovolaemia, thrombosis, metabolic causes.

Interpreting diagnostic tests

Case study: Swab sampling

1. Before carrying out the MRSA screen, what should you do to prepare Mr Wills?
   Provide information about the procedure and why it is required.
   Gain verbal consent prior to commencing the procedure.
   As he has been in hospital recently, check his recent records for previous MRSA screening results.
2. Which is the most important area of the body to take a swab sample from when screening for MRSA?
   The nose.
3. What other areas of Mr Wills’ body would you need to take swab samples from?
   Axilla.
   Groin.
   Abdominal wound.
   Check whether he has any other broken areas of skin that should also be swabbed.
4. Once you have taken the swabs, what should you do with them in order to ensure they are ready for collection?
   Ensure there is a completed laboratory form.
   Ensure that each specimen swab is correctly labelled with the patient's full details.
   Ensure that specimens are placed in a plastic bag along with the laboratory form.
   Ensure that the specimen bag is placed in the designated collection box.

Observations

Case study: Breathing assessment

1. You wish to assess Mr Lyle's breathing, how might you prepare him?
   Provide information to Mr Lyle and obtain verbal consent for the assessment.
   With permission, remove his shirt as this will help you to observe his chest movements more accurately.
   Encourage an upright position. Leaning slightly forwards, using a pillow to rest his arms on, may assist further in achieving a comfortable position and maximize chest expansion.
2. In carrying out an assessment of his breathing, what observations should you be making?
   The colour of his skin and mucous membranes.
   The degree to which he is using his accessory muscles, whether he has nasal flaring on inspiration or pursed lips on expiration.
   The rate, rhythm and depth of his respirations, with the rate being counted for a full minute.
   Shape and expansion of his chest, noting any asymmetry.
3. What additional parameters will help you to determine his respiratory status?
   Pulse oximetry, peak expiratory flow reading.
   Medical and smoking history; co-morbidities.
   Refer to Procedure guidelines 11.4: Respiratory assessment and pulse oximetry. and 11.5: Peak flow reading using an manual peak flow meter.

Medicines management

Case study: Complications of IV infusions

1. What may be causing this discomfort?
   Phlebitis, infiltration
2. In consultation with your supervising nurse, what actions would you suggest taking?
   Ensure the fluid is being administered at the correct rate.
   Ongoing assessment of the site: document any swelling, pain, erythema, warmth around the site or up the length of the vein.
   Use of a scale, e.g. VIP.
   Ensure all fluid being administered is accurately documented on the fluid prescription and balance chart.

Perioperative care

Case study: Safe discharge from the post-anaesthetic care unit

1. 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?
   Explore her abdominal pain, using a pain score. She may require further analgesia prior to discharge from PACU.
   Check her abdominal wound dressings for any signs of oozing from the laparoscopy sites.
   Review her vital signs with the nurse in PACU to ensure they are within normal limits.
   Check that her documentation is completed.
2. You find that Jane has a pain score of 7/10; her wound dressings are all clean and intact. What would you do next?
   Ask the nurse if she can give Jane some analgesia prior to transferring her back to the ward. You should wait to ensure this has had sufficient effect prior to transfer.
   Reassess Jane to ensure that she still meets the minimum discharge criteria outlined in Box 13.13 prior to signing that you agree to return her to the ward.

Wound management

Case study: Pressure ulcer

1. What factors contributed to the pressure ulcer occurring? Were any of these avoidable?

   Contributory factors include: immobility, impaired nutrition, peripheral vascular disease, incontinence, confusion and infection. The impaired nutritional intake and the limited mobility could have been reduced with appropriate care. The incontinence could have been assessed earlier and steps taken to manage it appropriately and to treat the urinary tract infection.

You have been asked to assess his skin integrity including the pressure ulcer on his right buttock.

2. What should you be observing for?
   Assess all his pressure areas for erythema.
   Any broken areas of skin.
3. What tool(s) would help you to carry out a comprehensive assessment?
   Use of the Waterlow pressure ulcer risk assessment would assess his overall risk of developing further pressure ulcers.
   Use of a pressure ulcer classification system would identify the stage of his pressure sore.
   A wound assessment chart would accurately document his existing pressure ulcer and intended management.

His pressure ulcer has been assessed as grade 2.

4. What measures should be put in place to manage the pressure ulcer and avoid any further skin deterioration?
   Repositioning equipment
   Correct use of manual handling devices
   Patient information and orientation aids/prompts to boost, and then maintain, his nutritional status and hydration
   Transparent film dressing (retains moisture, prevents friction)