You are working as an Enrolled Nurse in the Emergency Department (ED) when 82 year old Mr Barber (of Greek heritage - and Greek Orthodox religion) is brought in by ambulance at 8pm on the 6/3/2013. Handover from the paramedics is as follows:

• 6 hour history haematemasis and epigastric pain
• Vomited x 4 bright blood
• Mr Barber called the ambulance because he felt dizzy, sat down on the floor and was unable to get up
• Ambulance noted approx. 150ml haematemasis in a bucket on arrival

Past History:
• Diverticulitis
• Emphysema
• Ischaemic heart disease
• Osteoarthritis
• Morbid obesity: BMI 42

Social History;

• Mr Barber is the sole carer for his 80 year old wife who has dementia. Mrs Barber has been left in the care of a neighbour.

You note that Mr Barber's clothes are blood stained on arrival.He states that he is feeling nauseous.

Please answer each of the following questions:

1. The nurse completes an assessment of Mr Barber's condition on arrival. Explain the following in relation to the assessment process.

a) Discuss the type of infection control policy would be implemented for Mr Barber?

b) List the PPE precautions that the nurse would use during assessment.

c) Review the vital signs on the ADDS chart. Discuss how these parameters relate to evaluating the severity of blood loss? (50 words)

d) Review the medication chart and discuss the action of the drug prescribed for nausea.

2. The RN asks you to complete a 12-lead ECG on Mr Barber. Use the information in the case study to label the ECG below. (include patient identity information as well as symptoms)

3. Use the information in the presenting history and patient charts to write your initial nursing report in SBAR format for Mr Barber. This report will be written 20 minutes after arrival when you have completed your initial assessment.

MRN: 0598371
Family Name: Barber
Given Name: Frederick
Date of Birth: 2/3/1931 PROGRESS NOTES
Date/Time

4. Mr Barber is upset that his wife is unable to accompany him to the hospital because she isn't well. Give three questions you could use in your conversation with Mr Barber that would evaluate her safety to remain at home whilst he is in hospital. Ensure that your questions are phrased to take into consideration empathy, cultural or spiritual elements.

5. The neighbour looking after Mrs Barber telephones the Emergency Department and asks how Mr Barber is going. How would you respond to this telephone call as the nurse caring for Mr Barber?

The doctor orders a chest X-ray, Mr Barber is to be transferred to the radiology department at 20:40

6. Outline the preparation required to transfer Mr Barber to the radiology department for these tests. Include the following aspects in your answer:

a) What type of consent is required for this procedure?

b) Review the categories on the ADDS chart and identify the number and qualifications of staff members that should accompany him to radiology. Base this answer on your evaluation of his level of acuity and manual handling requirements. 

After returning from radiology, Mr Barber pushes the buzzer 20:55. When you respond, you note that he is vomiting blood.

7. Discuss the nursing interventions you would you initiate. Include the following in your answer:

a) Review the NSW rural emergency clinical guidelines for adults, non-traumatic shock guideline. List the assessments that you would complete in each of the DRABCD categories using the table below?

D
R
A
B
C
D

b) How do these assessments allow you to make a judgment on the severity of his blood loss?

Mr Barber is given analgesia and IV fluids. His pain settles and the bleeding ceases

Mr Barber tells you that he usually uses a purple Seretide inhaler for his emphysema. His GP changed his inhaler to a different type and he doesn't really understand how it works although it seems to help him. He is due for a dose and asks you to assist.

8. Discuss the information you would provide to Mr Barber. Include the following in your answer:

a) Explain to Mr Barber in simple terms how the actions of this drug relate to the pathophysiology of emphysema.

b) Review the type of inhaler prescribed on the medication chart provided and list the steps to correctly administer this medication.

While documenting his complex medical history, you find out that Mr Barber has osteoarthritis.
 
9. Please read Mr Barber's medication chart. Identify which of these medications would be used to treat the pain from his osteoarthritis.

10. What questions might you ask him to help determine the severity of his OA and how the symptoms impact on his activities of daily living?
 
11. You notice a bandage on Mr Barber's lower leg and he says that he cut his shin on a sharp piece of wood a few days ago. Summarize your duty of care in relation to this observation.

Mr Barber is observed in Emergency overnight. He has no further episodes of vomiting. The surgical registrar (Dr Owen) reviews his care at 8am. The plan involves:
o changing his osteoarthritis medication
o admission to surgical ward
o gastroscopy scheduled later in the day
Registered Nurse, Rosalyn Marshalnotes the following entry in Mr Barber's medical record.

MRN: 0598371
Family Name: Barber
Given Name: Frederick
Date of Birth: 2/3/1931
Date/Time
7/3/2013
08:00 S Nursing: Seen by Dr Owen at 08:00. Dr Owen noted that his vomiting has settled overnight. PROGRESS NOTES
B Mr Barber is anxious to go home as he is concerned about his wife.

A Vital signs within normal limits. Nil nausea or episodes of vomiting overnight

R For admission to surgical ward- Mr Barber informed by Dr Owen Naprosyn ceased, to continue taking paracetamol osteo for arthritic pain. Scheduled for gastroscopy this afternoon, informed consent completed by Dr Owen and consent form has been signed by Mr Barber......R Marshal, RN

When you go to see Mr Barber he states that he doesn't think he will stay for the gastroscopy because he has no one to care for his wife during the day. He doesn't think the procedure is necessary given that the vomiting has stopped and he feels better. This means that he is now refusing consent for the gastroscopy procedure.

12. What actions should you take now that Mr Barber has decided not to proceed with his gastroscopy?

13. What community assistance would be available for Mrs Barber whilst Mr Barber remains in hospital? Give an example of an allied health care worker who would make these arrangements prior to Mr Barbers discharge.