Case study

Mrs Hiruni Jupangati

You are an Enrolled Nurse working in the small public hospital in Cattelanbaa, rural QLD. This is your first job since completing the Diploma of Nursing and you have been working here for the past month.

Mrs Hiruni Jupangati (born 20/05/1929) was admitted by her GP last night with exacerbation of asthma. She was born in Sri Lanka but migrated to Australia with her Australian Aboriginal husband whom she met during the 2nd World War. He worked as a stockman for a nearby cattle station until he retired to their small house in town 25 years ago. Their eldest son left home as a teenager and hasn't maintained contact with the family. Mrs Jupangati has 2 other children - a daughter who lives on a sheep station just out of town, and a son who is a remote Aboriginal health worker in the NT.

Mrs Jupangati has lived alone since her husband of 68 years died suddenly from a stroke 9 months ago. Although she is eligible for a place in a nursing home in Bigganbad,the regional centre 650km away, she is determined to see out her days at home. She receives support from the community nurse for wound care and her daughter who visits weekly to help with housework etc. She enjoys pottering in her vegetable and herb gardens, cooking Sri Lankan food, watching cricket and making robes for the Katina ceremony. Hiruni likes to spend time every day meditating, chanting from the Pali canon, and burning incense. The Buddhist monk visits once a month from Bigganbad and she attends the annual Poson and Katina festivals in Brisbane with her daughter.

Mrs Jupangati has some mild short term memory loss and her GP noted she seemed somewhat confused during his visit. While she is normally independent in performing her ADL's, Hiruni attends to them once or twice per week. She wears a light pad for some urge urine incontinence.After 45 years of smoking heavily she stopped 5 years ago. Mrs Jupangati had excision of cataracts and insertion of IOL 2 years ago and wears glasses for reading. She can mobilise short distances independently with a walking frame.

Mrs Jupangati has Osteoarthritis in her back, right hip and both knees. She had a left total hip replacement 6 months ago and is on the waiting list for the other joint replacements. She was diagnosed with Type 2 Diabetes Mellitus (DM) 5 years ago and has required insulin for the past 3 years. Her BGL's have been reasonably stable over that time.

Along with Asthma and Diabetes, Mrs Jupangati's medical history includes Rheumatic fever as a child, Ischaemic Heart Disease (she had CABG 25 years ago), Congestive Cardiac Failure (CCF), and Chronic Obstructive Pulmonary Disease (COPD). At age 67 Mrs Jupangati had a left mastectomy and axillary clearance for breast cancer. Treatment included radiation and chemotherapy. There has been no apparent reoccurrence although she has not complied with follow-up mammograms which can only be done in Bigganbad.

Mrs Jupangati has had four admissions to the local hospital in the past 6 months. One was for a fall and the other 3 for exacerbation of COPD and respiratory tract infections. She has a small skin tear on her right forearm, a diabetic ulcer on her left foot, and 2 small scratches from gardening on her right lower leg, all of which are being managed by the community nurse & GP. Mrs Jupangati has several missing and decayed teeth. She is complaining of painful areas on her coccyx and red right heel since watching the recent cricket test series on TV. She wears hearing aids though needs reminding to use them.

Patient observations on arrival to the hospital were as follows:

Height - 150cm
Weight - 87kg
BP 160/90
Pulse 108 irregular
Respirations 32
Temperature 37.8C
O2 saturations 84% room air
BSL 8.2mmol/l
Urinalysis - pH 6.0, SG 1010, Nitrates +, Leukocytes ++, Blood ++, urine cloudy and offensive

Current Medications:

Lantus
Actrapid
Seretide and Ventolin inhalers
Panadol Osteo
Voltaren Gel (her daughter gave this to her last week to help with arthritic pain)
Oxycodone PRN
Frusemide
Enalapril
Prednisolone
Atorvastatin
Coloxyl and Senna

Pending investigations:

Chest X-Ray
Blood tests
Spirometry
Mid-stream urine (MSU)

Other orders:

TED stockings
Bed rest with toilet privileges
Oxygen @ 2L/min via nasal prongs
Fluid balance & bowel charts

Q1: Using the attached Qld Health patient risk assessment form MR401, marked as Appendix "A", conduct a nursing history assessment on your new client. Use appropriate terminology and abbreviations where applicable during the completion of relevant health documentation.

Q2: Identify, list and briefly outline the use for the equipment required to obtain all of Hiruni Jupangati's observations and complete the assessment form.

Q3: List five (5) strategies you could implement to enable Hiruni to meet her emotional, psychosocial and spiritual needs. Identify 3 ways you would ensure both her privacy and confidentiality is maintained while she is an inpatient.

Q4: What communication techniques would you use when interviewing/assessing Hiruni and explain briefly how they would assist you.

Q5: Review Mrs Jupangati's vital signs and observations. Identify whether they are within the normal range. If they are not within normal range state what the normal range and variance is and what the variance may indicate. Discuss your relevant duty of care expectations as an EN.

Q6: Using the attached Nursing Care Plan, please complete the form addressing mobility, oral, hygiene & respiratory needs, wounds, nutrition, fluid balance & bowel function.

Q7: From the ANMC Competency Standards for Enrolled Nurses, discuss the role & responsibilities of the Enrolled nurse in developing and implementing Nursing Care Plans.

Q8: Describe how you would prepare Hiruni for collection of mid-stream urine (MSU) including gaining valid consent. Explain what constitutes a valid consent

Q9: Identify four (4) potential risks in collecting the MSU and discuss what you, as the EN, would do to minimise these risks. Briefly state what relevance an environmental policy/procedure would have to Mid-Stream Urine collection/testing.

Q10: Explain good documentation standards/principles you would use as an EN caring for Mrs Jupangati.

Q11: You enter Mrs Jupengati's room just before lunch and find her slumped on the floor in the toilet with a laceration to her head.

a) What is the EN's immediate response? Using the ANMC scope of practice framework, outline how you, as the EN, would apply the Australian Resuscitation Council's Basic Life Support guidelines in this situation.

b) Considering her age, cultural background and medical history, how could Mrs Jupangati's attitudes & values potentially influence the conduct of the resuscitation?

Q12: Identify three (3) potential risks to staff during the resuscitation and measures you could take to manage these risks.

Q13: Using your knowledge of anatomy and physiology identify and discuss three (3) possible causes of Mrs Jupangati's collapse.

Q14: In the context of Mrs Jupangati's medical history, discuss the possible implications of Rheumatic fever on her growth and development.

Q15: List Mrs Jupangati's analgesic medications. Outline the process you would use to assess the need to give the opioid. Is an [E]EN authorised to administer the opioid? If so, explain how legislative and regulatory standards support this practice and how the EN would ensure these requirements are met whilst performing this activity.

Q16: Review Mrs Jupangati's medical history & medications. Identify urgent patient education needs, describe how you would go about this and who you would involve.

Q17: Identify potential causes of Mrs Jupangati's poor oral condition and describe how you could assist her in maintaining proper oral health.

Q18: Discuss the potential cause of Mrs Jupangati's painful coccyx & reddened right heel and explain why this might have occurred. Outline how the EN will manage this concern effectively.

Q19: Access the Australian Diabetes Council's website, find the most appropriate education session you could recommend Hiruni attend after discharge, and briefly describe why you consider this to be the best suited to her needs.

Q20: Summarise the discharge planning requirements for Mrs Jupangati, including the community services required, and prioritise those requirements that would need to be in place prior to her going home. Discuss what strategies you would use if one or more of these services were not available in Cattelanbaa.

Q21: Complete the attached Qld Health Patient Discharge Checklist form MR420, marked as Appendix "D", for Mrs Jupangati.

Q22: A student nurse, who is doing her final placement at Cattelanbaa hospital, asks you what her responsibilities will be, as a qualified Enrolled Nurse, in relation to mandatory reporting in a residential aged care facility. How would you respond and what sources of information could you refer her to?
Discuss that require situations that fall under mandatory reporting requirements

Q23: Identify (one of each) ways you could employ waste minimisation, environmental responsibility and sustainable practice strategies in your everyday work as an EN at Cattelanbaa hospital.