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?
1. The assistance for Anastasia includes a nursing aide, who can help her to transfer from her bed to the chair and to walk short distances. This is because Anastasia uses a wheelie walker after her CVA. Anastasia does not speak English so she should be assisted with an interpreter which can help her as well as her health care professionals to ease the process of communication. Anastasia is also suffering with an acquired language disorder because of CVA (Code, 2012). Therefore, a multi-disciplinary team should work together to improve her condition. The team includes physician, physiotherapist, speech-language pathologist, social worker and a clinical neuropsychologist.
2. The cross cultural communication strategies that nurses need to implement for Anastasia are: slow and clear communication, clarification, frequently verify for understanding, avoid typical idioms while communicating, avoid jargons, focus on specific meaning of communication, efficiently select the communication medium, give proper instruction and maintaining patience (Jirwe, Gerrish and Emami, 2010).
3. The actual and potential nursing care needs of Anastasia includes thorough monitoring of her blood glucose level as she is a patient of type II diabetes. Anastasia also had a history of poorly controlled hypertension that resulted in the CVA (Lammert, 2008). Therefore, her blood pressure needs to be monitored regularly. She is also under the administration of antihypertensive drugs. Monitoring helps the nurse to manage her BP. Proper monitoring also helps in reduction of the risk associated with further CVA. Anastasia has osteoporosis and also had a fall and fracture. So, the nurses should always take care about her support while allowing her to move from one place to another. This will reduce the chance of further fall. Anastasia wears incontinence pad, so a nurse aide is necessary who can take care of her hygienic factors.
4. Various potential health complications might occur as a result of each of Anastasia’s current medical conditions. Anastasia is hypertensive and diabetic. Both these reasons are harmful enough to make her condition worse. Higher blood pressure might lead her to another chance of CVA (LeMone and Burke, 2008). If osteoporosis is left untreated it increased the risk of falls and fractures, vertebrae fracture can cause her to compress, and curving of spine can takes place and result in a stooping posture, termed as kyphosis and ultimately loss of mobility because of osteoporosis. If stress incontinence of urine is left untreated it can affect the kidney, bladder and the urinary tract in terms of forming infection. If aphasia is left untreated, Anastasia might develop a serious speech complication.
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?
1. MRSA can be spread in a health care facility by various means. In hospitals MRSA can be spread from one patient to another by the hands of health care staffs. The gloves they wear may become contaminated with MRSA when they touch a patient’s wounds during dressings or devices like intravenous tubing. Patients who are suffering from severe weakness in immune system because of any medical condition or treatment are the most probable to get affected with MRSA, frequently and rapidly (Nimmo and Coombs, 2008). The other chances are close proximity to already affected health care staff or patients. Prolonged stay in hospital is one of the causes of spreading of MRSA infection. The infection can also spread if contaminated waste materials are not disposed in an appropriate disposal box. If one touches these contaminated products like fluid waste, used needles, there is a chance that the person can spread MRSA to other individuals. To prevent spread of infection, health care professionals should maintain proper hand hygiene while working within the health care set up. They should also use ‘use and throw’ gloves between patients.
2. James has undergone 2operations; the first was internal fixation and the other one delayed primary closure of the wound. James might have developed a nosocomial infection because he might have got affected with the ward specific infection (Bennett et al., 2005). The surgical instruments used in James surgery, might not have been sterilized properly.
3. Strategies need to be implemented to diminish the MRSA infection risks to the remaining surgical clients on the ward. This can be achieved by implementing inspection and screening of patients, staffs, patient isolation and grouping, obliteration of MRSA carriage. The health care personnel have the responsibility to implement guidelines rests with the higher management of the institution. As it is proved that MRSA is mainly transferred from hand, therefore, guidelines associated with hand hygiene should strictly be followed by the health care personnel. For instance, maintaining hand hygiene before entering and after leaving critical care wards, open rooms and isolation rooms used for grouping MRSA cases.
4. Documentation and reporting requirements can be considered as one of the important aspect under the infection control policy. Documentation is essential for all reprocessing of re-usable equipments and instruments and for the sterilizers in accordance with the guidelines. Not only the instruments but any kind of nosocomial infection outbreak needs to be reported and documented for future evaluation, if necessary and also to maintain a record (Gosbell et al., 2006). MRSA infection needs to be reported too Infection Control and the record can only be maintained accurately through documentation, including communication with other health care staffs and families. If patients need immunization, then vaccine should be arranged by ward medical staff on medication chart.
5. James is slightly underweight with poor nutrition. He is a heavy smoker and regular drinker. In this situation nurses should take care of his nutritional status. James is unwilling to receive dietary supplements. Therefore, James needs to be referred to a dietician who can structure a protein rich diet for James. It is the nurse’s responsibility to make James understand that drinking and smoking have killing effects on the system and he should not entertain these habits in order to maintain a good health and wellbeing. James had undergone a severe fracture that might affect his bone, so his diet should include calcium rich foods.
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?
1. The pre-existing medical condition of Gordon includes his asthmatic condition. Prior his fall he had an upper respiratory infection too and was under antibiotic administration. Gordon takes preventive inhalers. His fall might affect his asthmatic condition. The increase pain because of the fracture in his lumber region can augment the suffering of perspiration. Another issue could be his obesity. Because of the fall he is strictly in bed rest and requires pressure area management. Obesity can affect the application of log roll to turn Gordon while maintaining spine alignment. Gordon has a history of depression, which has been managed by counseling but because of his severe fall he cannot attain the regular counseling and that might augments his negative thoughts like committing suicide.
2. The actual and potential risk factors after surgery may include the possibility of brain herniation. Intracranial hemorrhage increases the intracranial pressure and can damage delicate tissues of the brain or can limit the supply of blood to the brain. Severe increase can cause brain herniation. Being obese there is a chance that Gordon might develop a pressure ulcer if his pressure area is not under proper management. His occipital fracture was surgically elevated so a chance of infection in surgical site can be considered as a potential risk factor. Additionally background infusion can diminish inherent PCA safety (Lintzeris, 2006). Respiratory depression can takes place if background infusion is applied.
3. Methods to lift Gordon off his bed could include application of log roll to move him maintaining his spine alignment; bed-stick which could be attached to the side of the bed and allows him to sit up; overhead bar that helps Gordon to lift and reposition himself.
4. Morphine comes under schedule II drugs. The seven rights of drug administration includes right patient, right medication, right dose, right route, right time, right documentation and right reason. Right patient includes check patient name and the order, right medication includes proper check for medication label and order, right dose confirms dosage appropriateness using existing drug reference, right route confirms if the patient receive medication y ordered route, right time includes confirmation when last dosage was administered, check correct time and frequency of ordered medication (Dubut de Laforest and Farrère, 2010).
5. Gordon’s discharge planning requires employment of a nurse aide at Gordon’s residence. This is because if Gordon is walking with the help of a frame there is a possibility that Gordon can lose his balance so a nurse assistant should be always there by his side during his movement unless his motor function returns. Gordon should be referred to a physiotherapist to resume his physical activity. The physiotherapist can train him with light aerobic exercises, which can also help to control his obesity. His discharge plan should also include continuation of his depression counseling.
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 – 38.9â°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 – 40.1â°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?
1. After returning to the ward Louise’s priorities of care includes thorough observation, dressings and analgesia. Half an hour after returning to the ward her temperature and respiration rate increased. Her pulse rate increased and blood pressure dropped. She has four abdominal incision sites which were oozing slightly, so care is utmost important in this case to avoid surgical site infection. She was in tremendous pain, so the health care professionals should monitor and control her intravenous analgesic dose along with saline. During the operation her BP was excessively high but after transferring her to the ward her BP reduces, so the responsible nurses should properly monitor her blood pressure level.
2. The immediate actions for Louise may include additional support of oxygen mask to support her breathing. Her tachycardia condition is thought to be because of her medical illness, this should be managed with proper medications. The distended and tight abdomen might be because of necrotising fasciitis or gas collection within the abdominal muscles.
3. Louise might be suffering from Necrotising Fasciitis. Necrotising Fasciitis after laparoscopic appendectomy can takes place in certain cases (Raghavendra, Mills and Carr, 2010). This condition includes abdominal pain along with tightness feeling and swelling of abdominal wall. It is also considered as unusual complications. Necrotising Fasciitis is considered as a disease condition of quickly spreading infection, generally located within the fascial panes of connective tissues.
4. If Louise’s condition deteriorates further the responsible care providers should communicate her health condition to the doctor in order to understand if Louise needs any change in medicinal administration. Louise received IV fentanyl and has ordered for IV morphine. In this case the nurse should communicate with the doctor whether to follow the same or needs any alteration. Louise’s level of consciousness has deteriorated so the nurses should be able to record timely observation and if any abnormality is identified.
References
Bennett, N., Boardman, C., Bull, A., Richards, M. and Russo, P. (2005). A statewide smaller hospital nosocomial infection surveillance program: The first report, Victoria, Australia. American Journal of Infection Control, 33(5), pp.e176-e177.
Code, C. (2012). Apportioning time for aphasia rehabilitation. Aphasiology, 26(5), pp.729-735.
Dubut de Laforest, J. and Farrère, C. (2010). Morphine. New York: Harper Perennial.
Gosbell, I., Barbagiannakos, T., Neville, S., Mercer, J., Vickery, A., OʼBrien, F., Coombs, G., Malkowski, M. and Pearson, J. (2006). Non-multiresistant methicillin-resistant Staphylococcus aureus bacteraemia in Sydney, Australia: emergence of EMRSA-15, Oceania, Queensland and Western Australian MRSA strains. Pathology, 38(3), pp.239-244.
Jirwe, M., Gerrish, K. and Emami, A. (2010). Student nurses’ experiences of communication in cross-cultural care encounters. Scandinavian Journal of Caring Sciences, 24(3), pp.436-444.
Lammert, E. (2008). The Vascular Trigger of Type II Diabetes Mellitus. Exp Clin Endocrinol Diabetes, 116(S 01), pp.S21-S25.
LeMone, P. and Burke, K. (2008). Medical-surgical nursing. Upper Saddle River, N.J.: Pearson/Prentice Hall.
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