Assignment - Case Studies

Instructions

Please read the four scenarios and answer all the questions.

Answers are to be presented academically.

In text references are not required. However, students must cite the sources used after each answer (still using the Harvard in text format outlined in the SARG booklet). See the example below -

Question 1. What activities of daily living will Anastasia require with?

The patient will require assistance with many activities of daily living including

(Brown & Edwards 2011, p. 100; Koutoukidis, Stainton & Hughson 2013, p.38; Tollefson, Bishop, Jelly, Watson & Tambree 2012, pp.5-7) sources are cited together at the end of the answer instead of in text.

A detailed reference list will be required at the end of the paper.

Case Study 1

Scenario: A 78 year old Greek lady, Anastasia Kyrillos, has recently been transferred to the rehabilitation unit following a left sided Cerebro Vascular Accident (CVA). She has right sided hemiparesis, but has regained some function since the CVA occurred two weeks ago. She uses a wheelie walker (with a one person assist) to transfer from her bed to the chair and to walk short distances. Communication is difficult as Anastasia doesn't speak English and, secondary to the left sided brain injury, she has developed aphasia. Her family reports that she understands them very well but has difficulty expressing herself. Anastasia was living in a flat attached to her daughter's family home until the time of the CVA and hopes to return there following rehabilitation.

Medically, Anastasia had a history of poorly controlled hypertension which resulted in the haemorrhagic stroke. Currently her Blood Pressure (BP) is stable; she takes anti-hypertensive medication and requires regular checks of her BP. She has osteoporosis, which was diagnosed 10 years ago after she fell and fractured her right hip. She also has Diabetes Type 2 and takes oral hypoglycaemic medication. Anastasia has stress incontinence of urine and wears an incontinence pad during the day. Her bowel function is normal.

1. What activities of daily living will Anastasia require assistance with? Provide details of each.

2. What cross cultural communication strategies will nurses need to implement for Anastasia?

3. What are the actual and potential nursing care needs of Anastasia?

4. What are the potential health complications that might occur as a result of each of Anastasia's current medical conditions?

Case Study 2.

Scenario: A 22 year old male client, James Moorland, was involved in a motor bike accident 3 weeks ago and sustained a compound fracture to the right distal femur. He has been in the orthopaedic ward for 3 weeks and has undergone 2 operations on his leg; the first was to reduce the fracture using internal fixation (plate and screws) and to surgically scrub the compound wound, the second was a delayed primary closure of the wound.

It is one week since the delayed primary closure, and his bandages have been taken down. The wound is beginning to break down and there is a purulent, offensive smelling discharge present at the suture line. Swabs taken confirm the presence of methicillin-resistant staphylococcus aureus (MRSA). James has been placed in an isolation room and the hospital infection control team have been notified. Medically, James has no co morbidities; he has had no previous surgery. He is marginally underweight, with a Body Mass Index of 18. James has a history of poor nutrition, is a heavy smoker and regularly consumes alcohol. James is the third client in the ward to develop MRSA in their wound in the last month. The outbreak of infection is ward specific and no other surgical cases from other wards have cases of MRSA.

1. Discuss the means by which MRSA could be spread in a health care facility. Include in your answer the measures that should be taken to prevent this.

2. What risk factors may have contributed to James developing a nosocomial infection?

3. What strategies should be implemented to minimise infection risks to the remaining surgical clients on the ward?

4. Considering the workplace policies and procedures, what are the documentation and reporting requirements for nosocomial infections?

5. James is non-compliant with dietary supplements (i.e. vitamins and Sustagen drinks). What nursing care strategies should be implemented to improve James' nutritional status?

Case Study 3.

Scenario: A 53 year old client, Gordon Freemason, was attempting to clean his gutters at home and fell from a ladder. He sustained undisplaced fractures to his L4 and L5 vertebra, as well as, a depressed occipital fracture to his skull. Secondary to the skull fracture, he suffered an extra dural bleed. He went to surgery for an evacuation and drainage of the extra dural bleed, and his occipital fracture was surgically elevated. He was monitored for further intracranial bleeding for 12 hours post-operatively in the Intensive Care Unit (ICU) before being transferred to a ward.

He is on strict rest in bed and pressure area management involves regular log rolls. Gordon's Glasgow Coma Scale is 14/15, and he is alert and orientated. He has significant pain from his lumbar fractures and is receiving morphine via continuous infusion in the form of patient controlled analgesia (PCA). This is supplemented with regular 6 hourly paracetamol. He has intravenous fluids running. Gordon is an asthmatic and takes ongoing preventative inhalers. He had an upper respiratory infection prior to his fall and had been taking antibiotics for it. He is obese, with a body mass index (BMI) of 32. Gordon has a history of depression, which he manages with counselling; he is not currently medicated for his depression, but has been expressing negative thoughts and has spoken of committing suicide if he cannot regain his independence. He lives at home with his wife and their 3 teenage children. Gordon is under the care of the neurosurgical and orthopaedic teams.

1. How might Gordon's pre-existing medical conditions be affected by his fall and subsequent hospitalisation?

2. What are the actual and potential risk factors for Gordon following surgery?

3. Health care providers have a no lift policy in terms of workplace health and safety and manual handling. What methods could be used to lift Gordon off his bed in order to provide back care and change his bedding?

4. Healthcare providers are governed by legislation regarding medication administration. Hospital policy and procedures reflect that legislation. Gordon's morphine infusion is running out and a new bag of morphine and saline needs to be made up.

What schedule of drug is morphine and what are the seven rights of drug administration that need to be considered?

5. Considering that Gordon will be required to walk with a frame until his mobility and motor function return, what discharge planning needs will Gordon have if he is to return home?

Case Study 4.

Scenario: A 30 year old woman, Louise Young, has returned to the ward following laparoscopic surgery for a ruptured appendix. On return, her observations are temperature - 38.9°C, respirations - 28, pulse- 112 and BP - 140/75. She has four abdominal incision sites and each is covered with a transparent occlusive dressing. The wound sites are intact and each is oozing slightly.

Louise's abdomen is slightly distended and her estimation of her pain level is 8/10. Louise has an intravenous line in her left cubital fossa (inside elbow). She is receiving maintenance dextrose and saline fluids at 125mls/hour. She is to take nil by mouth, and has a nasogastric tube on free drainage. Louise has received intravenous fentanyl in recovery, and has an order for intravenous morphine on the ward.

Half an hour after her return to the ward, Louise's condition has deteriorated. Her observations are temperature - 40.1°C, respirations - 36, pulse- 160 and BP 100/55. Her abdomen is tight and distended. Her level of consciousness has deteriorated, she is only able to be roused if her shoulder is shaken and she is spoken at loudly.

1. When Louise initially returns to the ward, what are the priorities of care for her (keeping in mind observations, dressings, analgesia and any other care she may need on her return from theatre)?

2. What are the immediate actions that need to be taken upon finding Louise in this state of deterioration?

3. What might be happening to Louise?

4. What action should be taken if Louise's condition deteriorates further.