A young patient with a history of substance abuse who is pregnant
Choose ONE patient journey, whereby you explore TWO therapeutic interventions which can be employed to manage the patient’s problems in the acute or recovery (rehabilitation or end of life) phases. You should choose ONE pharmacological (oral or subcutaneous injection/s) AND ONE non-pharmacological intervention. Critically evaluate the evidence surrounding the interventions and the application to your chosen patient journey. Determine what the nurses’ role is in applying the interventions you have chosen and how you might encourage the patient to adhere to the proposed plan. Apply evidence to evaluate the role of the nurse.
Guidance for Coursework
The guidance offered below is to assist you in offering some structure to your assignment with suggestions of approximate word counts for each section. These are only a guide and are not absolutely rigid, but the emphasis in marking the work will be based upon the development of critical thought. This will be discussed further within the lectures.
Brief introduction to the essay, noting confidentiality
150 – 175 words This should be a holistic introduction, adding why the two interventions were chosen and any clinical pathways that have been used.
The assignment should be written in the ‘third person’.
Body of the essay – to include TWO interventions within the care of one of the patients used from the ‘Patient Journeys’ in Module 5012AD
2200 words • Focus on therapeutic approaches such as rehabilitation, acute treatment, palliative care phases and/or a particular medication. When analysing medication link to NICE guidance, the benefits and limitations of the drug; all within the treatment of the patient.
• Explore the evidence base behind the interventions.
• You need to analyse the nurses’ role and responsibilities in the application of these approaches to the patient journey of your choice. It is important that you include evidence from literature to support your thinking, along with any gaps you might think need exploring, where the literature is lacking. You may choose to break the body of the essay into 3 parts- intervention 1, intervention 2 and the nurses’ role
Conclusion
150-175 words No new information here, other than a summary of your thoughts about future assessment and care-delivery
References and general comments
Use APA system – see the website.
Use current evidence from nursing journals as well as texts.
Logical structure which acknowledges the person in the case study
Write in the third person.
Instructions for submission
An electronic copy of your coursework should be submitted through Turnitin. This will be on the official AULA Page which you will be automatically enrolled. Please follow the instructions on the AULA page when the time comes.
• There will be a draft submission area for you to check your essay for plagiarism.
• Please ensure that you keep an electronic copy of your coursework in case of query.
• Submission date for this coursework can be found on Aula
• Front Sheet: only put your student identification number (S.I.D) and the essay title on your front sheet to allow for anonymous marking.
• Format: Third person
• Font: Ariel, Times or Calibri 11 or 12
• Line Spacing 2.0
• Ensure spacing between paragraphs
PLEASE NOTE:
We take in confidence issues that you may raise or write about in assessed work but if you divulge issues that, in our opinion are concerned with professional malpractice or contravene the Code of Professional Conduct, we do reserve the right to investigate these and may need to divulge them to third parties
Submission date
The Coursework should be submitted online, via Turnitin, by Friday 24th March 2023, 18:00h. Consider uploading the work to Turnitin during the day and DO NOT leave it until the last minute. If you go past the 18:00 h deadline, your work will not be considered as a submission.
(It is essential that you keep a copy of your completed assignment for yourself, preferably a paper copy).
Word Count
Penalties may be applied for exceeding or failing to reach any word limit set. The limit for this work is 2,500 words. Pieces of work that exceed or are below 10% of the 2,500 word requirement will receive a 10% reduction of the total mark.
Please note, the word count is calculated from all words included from the beginning of the text (does not include the front sheet) to the start of the reference list.
Unratified results
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Ratification of results/Exam Board
To be notified via SOLAR.
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PLAGIAIRISM AND CHEATING
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Patient Journeys – an introduction
As explained in the module guides, these modules are designed to build on year 1 study. Though the supporting presentations provide support for your achievement of the module learning outcomes, success will require focused self-directed study as there is a great breadth of content which is considered by this module as a foundation for the 2nd year.
In summary, this guided study extends your knowledge of anatomy & physiology to consider common adult health problems pathology, this covers both acute conditions from which patients may fully recover (for example, respiratory infections). It also introduces pathology for long term /chronic conditions which require regular planned management and care to support clients such as coronary heart disease, diabetes mellitus, chronic obstructive pulmonary disease and cancer care.
This guided study has been developed by the module team to facilitate your assessment skills as applied to pathophysiology for clients with common conditions. The patient journeys presented cover an important common pathology and encourage you to develop your understanding of the nurse’s role in managing care. Each patient journey considers care within an inpatient setting and then follows the individual to explore care provision in the community. Health promotion is an important role for the nurse and each journey shows how health education and screening must be incorporated into care.
The guided study should assist with your achievement of learning outcomes. There will be one focused patient journey added each week, giving six in total.
Patient Journey Name Clinical Presentation
Patient Journey 1 Mrs Fryth COPD
Patient Journey 2 Mr Joshi Cardiac (ACS)
Patient Journey 3 Mr Dawson Colorectal Cancer
Patient Journey 4 Mr Helman Stroke (CVA)
Patient Journey 5 Mrs Terry Dementia
Patient Journey 6 Mr Croft Diabetes Mellitus
Patient Journey 1:- Mrs Fryth (COPD)
History
Susan Fryth is 58 year old female; she is divorced with 2 grown up children and grandchildren who live locally. She was diagnosed with COPD 8 years ago, initially she thought her recurrent cough was a smoker’s cough; she suffers from recurrent acute chest infections in the winter months. She had been a heavy smoker (30 a day since the age of 16 until diagnosis) however has subsequently quit on several occasions, at present she has quit for a year. She lives alone and until last year worked in a local café but her health has now forced her to stop working due to frequent periods of recurrent chest infections and breathlessness. She has been getting increasingly breathless and her GP has evaluated her due to her failing respiratory function (respiratory rate of 28 and oxygen saturation of only 93% on air) and has now decided that she requires emergency hospital admission for further assessment (arterial blood gases, chest x-ray, ECG) and medical management (oxygen, bronchodilators, oral corticosteroids ) and physiotherapy to improve respiratory function.
A – E assessment
Airway Airway clear
Breathing Respiratory Rate 28 bpm. Oxygen sats 88% on 28% oxygen via venturi mask
Circulation Pulse 96 weak and regular. BP 160/98 mmHg. Capillary Refill – perfusion test normal
Disability AVPU – Alert. Blood Glucose 6.8mmol/L
Exposure Temperature 38 degrees Celsius.
Other hx Emergency admission via ED following GP visit.
Lives alone, unemployed due to her health issues.
See patient details for risk factors.
On steroid medication for exacerbation of COPD
Some points to consider
• COPD may be mild moderate or severe, how can you differentiate between these?
• What factors influence whether a person with COPD should be treated in hospital or at home?
• Whilst in hospital, Mrs Fryth is prescribed bronchodilator therapy and commenced on oral corticosteroids. Explore the action and side effects of these commonly used drugs.
• Advancing disease may require patients to be managed with LTOT (Long Term Oxygen therapy) for at least 15 hours a day. What home assessment would be required in order for this to be commenced.?
• What priorities and lifestyle advice are identified in relation to priorities for implementation of care?
• Due to Mrs Fryth frequent infections and breathlessness she is finding it increasingly difficult to shop and cook adequate meals, as she lives alone, she finds it easier just to snack. A nutritional assessment tool shows she is at risk of malnutrition and she explains she feels she has lost weight recently as her clothes are feeling loose.
• Her BMI is 19. Malnutrition is a common concern with COPD; whilst in hospital what should the nurse do, to maintain nutrition?
• Smoking cessation is identified as a key area for management of COPD, what resources are available in the community to support this aspect of care?
• Home assessment, in preparation for discharge identifies several problems in relation to Activities of Daily Living, she has no toilet on the ground floor so is reluctant to drink adequate fluids, and how may this impact on her COPD?
• What support and self-help measures are recommended by the British Lung Foundation?
• What other members of the Multidisciplinary team may be involved in the care of Mrs Fryth?
• What preventative immunisation should be offered to this vulnerable individual to reduce the risks caused by seasonal community infections?
Patient Journey 2:- Mr Joshi (Cardiac)
History
Mr Pritam Joshi is a 47 year old man, he is married with 3 children (aged 11, 14 and 16) who are all at secondary school. He works as a self-employed electrician and has a small business locally. He brings in the main income for the family; his wife has a part time job in the local supermarket. This morning, as he was working, he developed a severe crushing chest pain (assessed as a 3 by the 0-3 pain scale, so severe pain in intensity) which spread down his arm, he also felt breathless and became pale and clammy. His apprentice who was working with him called 999 and he was brought into the Emergency Department (ED) as a suspected Acute Coronary Syndrome (ACS). The paramedics have inserted an intravenous cannula before arrival in ED and have confirmed that the 12-lead-electrocardiogram (ECG) shows changes consistent with ACS. He arrives in the ED 50 minutes after his presentation of symptoms and he has had analgesia. His care follows the NICE (2020) ACS care pathway approach.
Following a PCI, Mr Joshi was transferred to the Coronary Care Unit which is usual for the first 48 hours as staff ratio and experience allows close observation for complications. His wife has now been able to visit and though clearly upset, is aware that he is receiving the most appropriate treatment. His further medical history reveals several risk factors which are relevant for his confirmed diagnosis of myocardial infarction and CHD.
Mr Joshi is overweight with a BMI of 32 and his waist girth is over 35 inches, this shows excess central obesity. He was diagnosed with Type 2 Diabetes 8 years earlier and smokes about 20 a day.
Mr Joshi is discharged home after 5 days, it appears that he has now developed hypertension which will be monitored and treated in the community by the GP service. Within his surgery, the practice nurses are trained to follow up and evaluate hypertension and he has an appointment to see them for review in 2 weeks. The practice nurse often has a key role in the evaluation of prescribed medication. Knowledge of side effects is important as these may impact on concordance with prescribed treatment. Acceptance of this diagnosis as a chronic disorder, possibly life-long is also an important role for the nurse .
Mr Joshi was commenced on an ACE inhibitor, 20mgs O.D. Atorvastatin, statins, Clopidogrel and low dose Aspirin.
Some points to consider
• How would you describe the pathology of coronary heart disease which has caused this acute admission to hospital?
• He has severe acute pain due to his cardiac ischaemia, which is treated with intravenous opioid.
• Why is it an important priority to manage this severe pain effectively? Provide two examples of opioids used for cardiac pain, giving the normal doses & potential side effects.
• Thrombolysis is advocated as a treatment option for those centres which do not offer a PCI service for MI. What is Thrombolysis and what complications are recognised as a result of Thrombolysis?
• What drugs are used in thrombolysis? How are they administered? What are the key points?
• Explain why diabetes leads to macrovascular degeneration which has possibly contributed to the development of coronary heart disease for this man?
• He has several non-modifiable risk factors which increase his predisposition to CHD, these are male gender and middle age. Explain why these factors increase the risk of cardiac disease?
• Explain the modifiable factors you can identify which may be suitable targets for health promotion as he recovers from this episode.
• Explore the role of the nurse in the support and rehabilitation of this man and his family and his subsequent preparation for discharge in 5-7 days
• What complications are associated with poorly controlled hypertension? Though antihypertensive medications are frequently required to manage hypertension, the lifestyle aspects are also an important target for health promotion.
• What would the nurse need to focus on to motivate and support him in behavioral changes to reduce his hypertension?
Patient Journey 3:- Mr Dawson
History
Mr Dawson is a 65 year old married man who has recently retired from his job as a teacher. He has recently received a postal screening kit for Colorectal Cancer which tests for faecal occult blood (FOB). Mr Dawson has taken samples as requested and was notified that the result was positive which means he requires further investigation.
Following the positive result, he is booked to undergo a colonoscopy as an outpatient at the local hospital, his wife accompanies him for support. This investigation will allow biopsy and will help to identify the appropriate management.
Following the colonoscopy and biopsies, Mr Dawson is found to have familial polyposis syndrome which is an inherited genetic disorder. Brooker & Nicol (2003) identify that the risk of people with polyposis developing colorectal cancer at around 70%. Following the histology results and investigations (chest X-Ray and computed tomography, CT ) to evaluate possible spread so that the extent of cancer could be estimated (Staging); he is believed to have bowel cancer, possibly Stage 2 also known as Dukes Stage B. (CANCER RESEARCH UK stages of colorectal cancer January 2010 (http://www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/statistics-and-outlook-for-bowel-cancer#outlook)
One week following radiotherapy he has an elective rectal excision; due to the position of the tumour close to the rectum it is thought that Mr Dawson may require formation of a permanent colostomy. The final decision will be made during surgery so consent involves explanation of the rationale for this option.
• How does the stoma nurse support him in preparation for and support following this major impact on body image? (Brooker, Nicol 2011) (Patient information for stoma September 2009, http://www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/surgery/if-you-need-a-colostomy-for-bowel-cancer (Colostomy association uk information for pts 2011, http://www.colostomyassociation.org.uk/index.php?p=3&pp=0&page=Information)
Surgery was planned and undertaken. Abdominoperineal resection was performed and a permanent colostomy created. An A-E approach to consider his post- operative assessment needs in the first 24 hours following surgery in order to plan appropriate care was undertaken.
Histology report from the resected tumor identified that there was not a clear resection margin, therefore this increases the risk of local recurrence. He was therefore followed up by the regional oncologist. Chemotherapy was recommended as adjuvant therapy with 5-FU delivered as a bolus 4 weekly for 6 months. This required Mr Dowson to attend the regional cancer unit.
A – E assessment
Airway Airway clear
Breathing Respiratory Rate 16 bpm. Oxygen sats 99% on 28% oxygen via venturi mask.
PCA at 24% risk of sedation and respiratory depression with IV opiods.
Circulation Pulse 90 weak and regular. BP 140/90 mmHg. Wound drain inspected. Wound dressing checked for haemorrhage. Stoma checked for vascular health. Fluid balance checked.
Disability AVPU – Alert (but drowsy when first returned from theatre). Sedation score 0 – 3 categorical scale to detect respiratory depression.
Exposure Temperature 36.5 degrees Celsius.
Other hx Pain 0-3 unidimensional intensity scale at rest and on movement.
PONV (post-operative nausea and vomiting check 0-3 scale known risk of surgery and opiod therapy)
Multiple Invasive procedures risk of HAI (hospital acquired infections)
DVT high risk prophylaxis and monitor (calf pain recognition of significance).
Some points to consider
• Consider if the NEWS assessment would show any parameters causing concern from the observations recorded above on return to the ward.
• If the sedation score rose to “difficulty rousing” and his respirations fell to 10 what may the implications be and what actions should be taken.
• Using Roper Logan & Tierney (1980) activities of daily living model of Nursing identify his main problems and plan his care for the first 24 hours following this major bowel surgery.
• As this is major abdominal surgery, Mr Dawson will have the risk of severe acute pain, examine how the acute pain should be managed in the first 5 days following surgery by examining the analgesics and routes of analgesia available to manage this pain successfully? Epidural PCA , IV. Look at your information from 4012NHS to help here.
• Following his discharge, days after surgery, what follow up care in community is available to enable him and his family to cope with the impact of this surgery? In particular the surgery may lead to impotence due to damage to the nerves, what advice is available?
Colostomy association support available: http://ww.colostomyassociation.org.uk
Bowel cancer support available: http://www.bowelcanceruk.org.uk/home/about-us/information
Patient 4: Mr Helman (Stroke)
History
Mr Nigel Helman is a 49 year old man, he is married with 3 children (aged 9, 11 and 19). He works for a company as a long-haul lorry driver. Nigel smokes 10-15 roll-ups a day and drinks socially at the weekends; however this can be up to 18-24 units. Mr Helman has not visited the GP in the last several years. His wife Ellen is a full-time Practice Nurse in a local GP practice. Nigel woke this morning at 07:30 hours and went downstairs to make a cup of tea. Whilst sitting in the arm chair watching the morning breakfast show Nigel found he was unable to lift the cup from the coffee table. He attempted to call his wife but his speech was slurred. Nigel tried to get out of the chair and fell, due to a left-sided weakness. Ellen entered the room and found Nigel slumped on the floor. Ellen noticed Nigel also had a left-sided facial droop. Ellen recognised the symptoms of stroke and called ‘999’. On arrival the Paramedics conducted the FAST assessment and Nigel tested positive. The crew alerted the emergency department and Nigel arrived at a local hospital that provides hyper-acute stroke care within fifteen minutes of onset of symptoms.
A-E assessment
Airway Airway clear
Breathing Respiratory rate = 24 breathes per min. Oxygen sats 95% on room air.
Circulation Pulse 84 and regular. BP 152/88mmHg. Capillary refill is normal.
Disability AVPU – Alert. GCS 16. NIH Scale 11. Blood Glucose 6.1mmol/L.
Exposure Temperature 36.8.
Other hx Consider psych-social assessment (fear, anxiety, families needs)
Stroke Patient Journey continued….
The Stroke Nurse and Registrar meet Mr Helman on arrival in the emergency department. The team receive a handover from the Paramedics and commence the assessment and investigations. History taking reveals that Mr Helman had similar symptoms a week earlier, however these resolved after a couple of minutes. Mr Helman had not informed his wife as he had not wanted to worry her. The team inform Mr Helman that the history he has provided leads them to suspect he had a Transient Ischaemic Attack the week prior. Mr Helman has a 12 lead ECG and is placed on continuous cardiac monitoring. Blood samples are taken and sent for routine tests and clotting and coagulation screening. A full set of clinical observations are undertaken including blood glucose monitoring. The results include BP 152/88mmHg; HR 84 bpm; RR 24/min; Blood Glucose 6.1 mmols/l and O2 sats 95% on air. Blood results are all within normal parameters. Neurological assessment reveals Mr Helman has a Glasgow Coma scale of 15, pupils are equal and reacting to light and whilst Mr Helman has full strength in his right arm and leg, there is a severe weakness in the left limbs. Mr Helman is then assessed using The NIH Stroke Scale, which reveals a score of 11 indicating a moderate Stroke. http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
An urgent CT scan is performed and there is no evidence of a haemorrhage. The Consultant attends and discusses the option of thrombolysis as a treatment for Mr Helman. Mr Helman provides informed consent, a bolus is given and the infusion is commenced. Mr Helman is transferred to the acute stroke ward and receives close supervision and further assessments.
Care within the first 72 hours post-stroke is referred to as the hyper-acute phase. Within the phase of the patient’s care a range of assessments by various members of the multi-professional team are undertaken. The Royal College of Physicians (2012) https://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf guidelines detail these responsibilities. The Nursing guidelines can be found on page 155.
On arrival to the stroke unit Mr Helman receives a swallow screen assessment. The assessment is used to identify anyone with dysphagia. Dysphagia is defined as ‘eating and drinking disorders which may occur in the oral, pharyngeal and oesophageal stages of deglutition’ (Royal College of Speech and Language Therapy 2006). Screening for dysphagia is imperative as it can cause aspiration pneumonia amongst other serious complications. It is suggested that within the first 24 hours post-stroke between 30-40% of conscious and assessable individuals have dysphagia (Perry and Boaden 2010). The risk of aspiration pneumonia is high within this patient population. Further information can be found on the BMJ best practice website http://bestpractice.bmj.com/best-practice/monograph/226.html In response to the emerging evidence regarding the high risk of dysphagia swallow screening and assessment has therefore been included in the Stroke guidelines.
Mr Helman did not demonstrate evidence of dysphagia and commenced diet and fluids as per local Trust guidelines. Dysphagia is not a static condition and individuals can deteriorate or improve, therefore regular screening and assessments should be undertaken if there is any evidence of change in the individuals condition.
Mr Helman progressively improves over the forthcoming days, regaining some power to both his arm and leg. Mr Helman’s mood appears more positive and he has asked about lifestyle changes that would reduce his risk of further strokes. You sit with Mr Helman to discuss his previous lifestyle choices and information needs.
Blood pressure monitoring during Mr Helman’s admission reveals that Mr Helman has Stage 2 hypertension (http://www.nice.org.uk/guidance/CG127/chapter/1-Guidance and https://www.nice.org.uk/guidance/cg127 for definition). The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure a 10% increased risk of mortality from stroke (NICE 2011) and is therefore the most important Stroke risk factor (Stroke Association 2014). http://www.nice.org.uk/guidance/CG127/chapter/introduction.
• Mr Helman is initially commenced on an ACE inhibitor. After a few days, Mr Helman refuses the medication due to the side-effects. Why is an irritating cough a common side-effect of ACE inhibitors?
• What alternative antihypertensive medication is recommended by NICE?
Hypertension appears to be the cause of Mr Helman’s stroke, however further investigations, inclusing a carotid doppler, are undertaken to rule out other causes. A carotid doppler (ultrasound) is a painless test that uses high-frequency sound waves to create pictures of the insides of the carotid arteries.
• What is the purpose of carotid dopplers in stroke care management?
• What treatment options are available to those with abnormal findings?
There are no abnormalities identified on Mr Helman’s carotid doppler examination and discharge planning commences. Whilst planning Mr Helman’s discharge from hospital it becomes clear that Mr Helman was not aware that he would be taking secondary prevention medication long-term. Mr Helman is being referred to the community nursing team and medication evaluation has been included in the referral. Community nurses have a key role in the evaluation of prescribed medication. Awareness of side-effects is important as these may impact on concordance with pharmacological treatment.
• Mr Helman is prescribed 75mg clopidogrel daily http://cks.nice.org.uk/antiplatelet-treatment#!scenario:1 and simvastin 40mg nocte http://cks.nice.org.uk/lipid-modification-cvd-prevention#!scenario:1. What is the rationale for these drugs?
Scheduled follow-up is required for all stroke survivors. This is identified as 6 weeks, 6 months and then on an annual basis. Audit of follow-up has been undertaken in the acute hospital settings for several years and this will soon be extended to post-acute stroke services https://www.rcplondon.ac.uk/projects/sentinel-stroke-national-audit-programme
Patient 5: Mrs Terry (Dementia)
Older adult scenario
Mrs Dawn Terry is a 72 year old lady who is retired, widowed and lives alone. She has two married sons, Jon and Mathew who live nearby. Mrs Terry has always been a healthy lady with no significant health problems. She lives independently getting her shopping locally, travelling by bus or sometimes her son takes her in his car to the supermarket. She has always paid her own bills and rent. Mrs Terry has a large garden and has always grown her own vegetables and fruits and enjoys tending to her shrubs and flowers. She also enjoys baking for her family.
Mrs Terry has recently had some moments of forgetfulness and confusion which is worrying her family. For example, her family find lots of milk stored in her fridge and her freezer; she has occasionally forgotten to put sugar in her cakes and forgotten her son’s birthday. She is a very self-sufficient and independent lady and says her family fusses too much. One day her daughter-in-law visits and finds the gas hob is on but it is unlit. This causes her great concern for Mrs Terry’s safety. It is agreed in the family that the gas needs to be disconnected immediately and for a GP appointment to be made. Mrs Terry agrees to this finally admitting she has been a bit more forgetful recently. The family arrange a rota to go round to check on Mrs Terry more often.
Mrs Terry is accompanied to the GP appointment by her eldest son Jon. The GP assesses Mrs Terry and listens to her and Jon’s concerns. After listening to the history of the problem, conducting a physical examination, urinalysis and taking blood tests to rule out other conditions, he suspects the early signs of dementia and refers her to the memory clinic for assessment. He explains that she will be under the care of the old age psychiatrist attached to the memory clinic whilst assessments are conducted.
Six weeks later Mrs Terry is then assessed by specialists at the memory clinic. The specialist takes an oral history of the development of memory problems from Mrs Terry and Jon. The physical assessment results have not detected any problems.
Following on from the oral history Mrs Terry undergoes a more detailed assessment of her memory and thinking processes. She is asked questions and given some paper exercises such as copying shapes which test memory, orientation, language and visual-spatial skills. This assessment can also be used as a baseline to measure any changes (Alzheimer’s society 2015).
Mrs Terry was subsequently diagnosed with Alzheimer’s Disease (AD). A Community Psychiatric Nurse (CPN) was allocated to assess Mrs Terry in her home. The nurse advised that the gas hob remained disconnected and that meals needed to be provided or Mrs Terry needed assistance with them. A support assistant would visit daily to see that Mrs Terry was well, would offer food and drink and would spend time chatting to her. This would ensure well-being and another person to check on her. Jon assured the CPN that the family would continue with their rota of scheduled visits. The CPN advised that should personal care be needed at a later date then Mrs Terry would be re-assessed for further input for home care services. Jon broke down in tears and said that his family were very upset at this diagnosis even though they had known it was coming. He expressed the family’s anxieties of their mother/grandmother not remembering who they are. They were however pleased that their mother did not seem anxious/distressed for the most part. The CPN listened carefully and suggested other forms of support.
One evening Jon receives a phone call from Mrs Terry’s neighbour, Mrs Green, to say that they have found his mother wandering round outside after dark. As well as being aware that this was very unusual for Mrs Terry, Mrs Green was concerned as she did not have her coat on despite the autumn temperatures and rain. Mrs Green took her home and made her a cup of tea and said she would wait with her until Jon arrived. She did not think Mrs Terry needed a doctor but didn’t want to leave her alone at the moment as she still seemed disorientated talking about being “worried about getting home to mother”. Jon went to stay with his mother that night.
The next day Jon arranged a family meeting as his concerns were growing. He also contacted the CPN. As a result the CPN organised another assessment and home care services were commenced to assist Mrs Terry to get dressed and have breakfast and then again to help her undress for bed in the evening.
One night, a few weeks after this commenced, Jon received a call from the Police stating that his mother had fallen and had been taken to the emergency department. Jon and his wife rushed to the emergency department. Mrs Terry was in pain, bruised and confused.
It was suspected on examination that Mrs Terry had a right fractured neck of femur. She was given IV paracetemol for pain relief. This diagnosis was confirmed by x-ray. Mrs Terry underwent a right-sided hemi-arthroplasty.
She was prescribed:- a). Oxygen 2 litres via nasal spec. b). IV normal saline. c). IV paracetamol. d). PRN oramorph e). prophylactic antibiotics – cephalexin IV x 3 f). PRN lactulose g). clexane.
As Mrs Terry begins to recover from surgery and her confusion returns to pre-surgery levels. Her observations are within normal limits. She has input from the Physiotherapist and Occupational Therapist. Mobilisation begins and progresses well. Plans for discharging Mrs Terry home begin.
Points to consider
• Consider: What are the many possible causes of confusion/forgetfulness?
• Review the Mini Mental State Examination (search “MMSE”).
• What scans might Mrs Terry be considered for? Would they prove useful in diagnosis and why/why not?
• Why might a scan showing no unexpected changes not rule out conditions such as Alzheimer’s disease.
• Read Around: What non-statutory (non NHS) support is available?
• How is Mrs Terry likely to deteriorate in her functional abilities?
• What might the impact of dementia have on Mrs Terry’s lifestyle?
• What is Mrs Terry’s perception of reality at this time?
• What is considered to be the best person-centred response to someone when they perceive a parent is still alive (you know they are not)? Choose one of options a). you remind Mrs Terry her mother is dead. b). You ask her questions about her mother (e.g.) was your mother strict then? Did you have to be home by a certain time? c). you go along with her perception and say you will take her to her mother.
Person-centred dementia care
• What post operative assessments and observations should take place? Consider: Pain analgesia.
• How is pain best assessed according to NICE (2011) CG124 Hip Fracture: the management of hip fracture in adults? Online available: http://www.nice.org.uk/guidance/cg124/chapter/1-recommendations#analgesia [accessed 10/9/15]
• What are the difficulties in assessing pain in those people with cognitive impairment like Mrs Terry? Why is it that people with cognitive impairment receive less analgesia? • NEWS, • nutrition and hydration, • medications, • precautions in relation to new hip, • skin/wound care, • possible potential problems related to reduced mobility and orthopaedic surgical procedures. • peripheral neurovascular assessment (5 P’s) Dykes PC (1993) Minding the five P’s of neurovascular assessment American Journal of Nursing 93 (6) 38-39
• Mrs Terry’s confusion worsens after surgery – why might this be?
• Mrs Terry needs to be assessed more extensively once it is established that her life is not be in imminent danger.
• In relation to history, observation, palpation and Range of Movement (ROM) what would a nurse be looking for?
• What complications could develop following a #NOF.
Patient 6: Mr Croft (Diabetes)
Mr Croft lives alone, he was divorced over 15 years ago and has no children, his next of kin is identified as his brother who lives locally and whom he sees most weeks. He has a friendly neighbour whom he has known for over 10 years and a small group of friends locally. Mr Croft has a supportive employer and he works from home as well as travelling around the country as a company representative for a roofing company. He values his job and recognises he needs to be fit enough to visit sites and climb ladders to view the proposed jobs. He explains that he had access to an excellent practice nurse who has just retired and he feels he has not got to know the new nurse yet.
He has put on about a stone in weight since he stopped smoking 2 years ago and he has a target to lose about 2 stone in order to be fitter, the calf pain was preventing him from walking as far as he wanted and he is hopeful that after the operation his circulation will improve. He hopes the improved circulation will assist him to exercise and enable him to lose weight.
He is aware that the work related travelling tends to have a negative impact on his diet but he is motivated to improve. He is aware that he must be careful about his feet, he gets them checked annually at the surgery, he remains scared that eventually if he does not improve his diabetes control (latest glycosylated Haemoglobin 64mmol/mol 8%) he may risk an amputation which is why is finally stopped smoking 2 years ago after he was warned of the risks by his practice nurse.
A – E assessment
Airway Airway clear
Breathing Respiratory rate = 17 breathes per min. Oxygen sats 98% on 24% oxygen with IV OCA. Risk of sedation and respiratory depression with IV opiods.
Circulation Pulse 94bpm and regular. BP 150/98mmHg. Wound dressing checked for haemorrhage. Check limbs for vascular sufficiency, limb temperature and pedal pulses. Fluid balance assessment IVI and renal output hourly checks may be monitored.
Disability AVPU – Alert but drowsy when first returned from theatre. Sedation score 0 – 3 categorical scale to detect respiratory depression (IV opiod risk.
Exposure Temperature 36.7.
Other hx Pain 0 – 3 unidimensional intensity scale at rest and on movement. PONV (post-operative nausea and vomiting check – 3 scale caused by opioid therapy). Multiple invasive procedures risk of HAI (hospital acquired infections). DVT high risk prophylaxis and monitor (calf pain recognition of significance).
Additional information
Mr Croft is 54 years old, he has had type 2 DM for the last 10 years; he was a long term smoker ( 40 a day) and over the last 3 years had suffered from Intermittent Claudication (pain in his calves when walking). Recently the pain is now restricting his mobility and he has to stop after 50 yards. He has a diagnosis of peripheral vascular disease and has quit smoking 2 year ago. http://www.nhs.uk/conditions/peripheralarterialdisease/Pages/Introduction.aspx) NHS advice treatment for peripheral arterial disease . http://www.nhs.uk/Conditions/peripheralarterialdisease/Pages/Treatment.aspx
Following a recent angiogram it is now planned that he should have surgical angioplasty to improve the arterial blood flow and reduce his risks of limb ischemia and amputation. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_072779.pdf)
• Define intermittent claudication and investigate arteriosclerosis that causes this condition, identify the possible deterioration that can lead to rest pain and tissue necrosis possibly requiring amputation.
• What characteristic observations of the leg can be identified which indicate peripheral ischemia?
• Explain the recommended non-surgical interventions which are initially recommended for an individual with this condition in order to prevent further deterioration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000990.pub2/pdf/abstract)
• The Vascular Nurse Specialist Role, NHS North Bristol Trust, http://www.nbt.nhs.uk/sites/default/files/filedepot/incoming/Vascular%20specialist%20nurse.pdf
• What is the purpose of the angiogram? And what is the rationale for percutaneous transluminal angioplasty or bypass surgery (arterial graft) as an intervention? (NHS Choices what is an angiogram, http://www.nhs.uk/conditions/Angiography/Pages/Introduction.aspx)
• What particular preparation and support is required for a Diabetic patient who requires planned surgery of this sort?
Following arterial graft surgery (revascularisation) Mr Croft returns to the ward; Using Roper Logan & Tierney activities of daily living model of nursing identify his main problems and plan his care for the first 24 hours following this surgery.
Use an A-E approach to consider his post- operative assessment needs in the first 24 hours following surgery in order to plan appropriate care.
Consider if the NEWS assessment would show any parameters causing concern from the observations recorded above on return to the ward. https://www.rcplondon.ac.uk/sites/default/files/documents/news-observation-chart-with-explanatory-text.pdf
Pain assessment and effective use of analgesia to manage Mr Croft’s surgery is essential. As he has suffered from pain pre-operatively due to the ischemia he may require more analgesia and an individualised approach to his pain management as compared to the usual post-operative patient. This may require referral to the acute pain team for advice to ensure he is not provided with too low a dose of opioid as he is not opioid naïve.
Following discharge, Mr Croft will receive continuing care from his GP services and practice nurse who specialises in DM support. With particular reference to his ongoing risk of limb ischemia and gangrene as a complication of DM, what assessment support and advice should be offered by the nurse to minimise these risks? (NICE Type 2 diabetes foot care guide 2015) http://guidance.nice.org.uk/CG10/QuickRefGuide/pdf/English)
• What other complications are recognised as common risks in DM, and what does the primary care team do to screen for and manage these problems? http://www.diabetes.org.uk/Documents/Professionals/primary_recs.pdf)
• What support is available from the Diabetes UK charity and the NHS in relation to support and management of his ongoing Diabetes? http://www.diabetes.org.uk, http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Living-with.aspx
