Nursing 344

Week 1: Report Writing & GFHP

Report Writing

Pt records are sometimes called in evidence before a court of law in order to establish events that may have contributed to a pt’s death or injury. They may also be required as evidence for an inquiry or hearing by the NMB of NSW.

▪ Frequency of documentation relies on: - physical/ mental status of the pt. - the type of care provided (self care v. intensive care) - requirements of health care agency - any legal or other obligations that the health record must meet

▪ Content of documentation needs to be: - relevant - appropriate - accurate - requirements will vary according to pt acuity - content may be guided by framework (assessment, intervention, response)

▪ Documentation framework: - assessment: conclusions reached utilising subjective and objective data - intervention: reflects the action taken - response: reflects the pt’s response to the intervention

▪ Example of using framework to case: Mrs Pat Martin, a 28y/o lady has been admitted overnight via Casualty accompanied by husband. She is 16 wks pregnant and has been diagnosed with appendicitis by Dr Chan. At the moment she is only experiencing mild pain and has a low grade fever of 37.7. IMI Pethidine 50mgs was given at 2am, and may be repeated PRN. Shes been added to the theatre list at 9.30am. She remains NMB and has IV normal saline running over 10hrs. IV Keflin QID commenced, is next due 12md. Her husband remains at bedside. It is now 630am and Mrs Martin is resting, however she has not had much sleep overnight. Her 6am vital signs are: BP: 120/80 Respirations: 16, Ward urinalysis shows no abnormalities Temp: 37.7. Pulse: 80 (reg).

ASSESSMENT:
- Mrs Martin aged 28
- new admission via casualty overnight under Dr Chan
- accompanied by husband
- provisional diagnosis is appendicitis
- 16 wks preggas with low grade fever of 37.7
- obs at 600hrs: BP, R, Ward U/A NAD, T, P. (shown above in case)

INTERVENTION: She complained of mild pain at 200hrs, so you gave her;
- Pethidine 50mgs IMI with effect and may be repeated PRN
- Kept NBM
- Has IV norm saline which is patent and running over 10 hrs
- You gave her QID Keflin next due at 1200hrs.

RESPONSE:
- She slept intermittently through this shift
- She will go to theatre at 930am
- her husband remains with her

Gordon’s Funtional Health Patterns (GFHP) (Devised by Majory Gordon)

▪ A holistic approach to providing health care involving 11 components ▪ Nurse assesses clients by organising patterns of behaviour and physiological responses that pertain to a functional health category ▪ GFHP assist in the identification of a pateint’s: - strengths - dysfunction in health patterns (nursing diagnosis) - potential dysfunction patterns exist (risk factors) ▪ These 11 components include:

o Health perception/ health management pattern: - Client’s own perception of their health and how it is managed - Compliance with meds regimen, health promo and annual checks - Family history, risk factors, alcohol/ smoke intake, exercise, allergies etc o Nutritional metabolic pattern: - Pattern of food and fluid intake relative to metabolic need and pattern which indicate nutrient supply

|Functional Health Pattern |Description |Sample Questions |
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Nursing Process and Nursing Care Plan

▪ Continuous process involving 5 outcomes that needs to be established. It’s a problem solving approach to the identification & treatment of pt. problems. ▪ Provides organising framework for knowledge, judgement & actions that nurses bring to pt care. ▪ Using this, the nurse can focus on unique responses of pts to actual/ potential health problems ▪ 5 outcomes include:

1) Assessment: collecting subjective & objective data 2) Diagnosis: data analysis, problem identification, label 3) Planning: priorities, goals, interventions 4) Implementation: nurse initiated treatment, Dr initiated treatment etc 5) Evaluation: data, diagnosis, aetiologies, plans, interventions

Question: What is the difference between Nursing Diagnosis and Medical Diagnosis?

- Nursing: act of identifying & labelling human responses to actual/ potential health problems.

- Medical: determination of a cause of a pt’s illness/ suffering by combined physical exam, interview, lab test, review of medical records, knowledge of cause observed, signs & symptoms, & differential elimination of similar possible causes.

Week 2 Management of people with altered levels of consciousness & Stress and coping

Pt with a Stroke

▪ Stroke occurs when there is ischaemia (inadequate blood flow) to a part of a brain or haemorrhage into the brain ( death of brain cells. ▪ Functions of area of the brain affected include movement, sensation and emotion. Its severity is according to the location and extent of the brain involved. ▪ 53, 000 ppl affected each yr in Australia. Its also a leading serious, long- term disability ▪ FAST o Its an easy way to recognise and remember the signs of stroke This test involves asking: - Face: has their mouth drooped? - Arms: can they lift both? - Speech: Speech slurred? Do they understand you? - Time: Is critical. If you see any of these signs call 000 ▪ Who’s at risk?: o Ind. Australians 3.3 times > in males & 2.3 > in females o HTN sufferers o Heart disease: atrial fibrillation, MI, cardica valve abnormalities, cardiac congenital defects o DM o ^ alcohol consumption o hypercoagubility o hyperlipidaemia o obesity o Oral contraceptive use o Physical inactivity o Sickle cell disease

Inferior view of cerebral circulation:

Blood flow

▪ The brain requires a continuous supply of blood to provide the brain with oxygen and glucose ▪ Blood flow must be maintained at 750- 1000mls/ minute

Interrupted blood flow

▪ If interrupted (eg cardic arrest) ▪ Neurological metabolism is altered in 30 seconds ▪ Metabolism stops in 2 minutes. ▪ Cellular death occurs in 5 minutes.

Types of Stroke: 1. Ischaemic 2. Haemorrhagic

1. Ischaemic Thrombotic Ischaemic Attack: ▪ Temp. focal loss of neurological function caused by ischaemia in the vascular territories. Lasting between 15mins to 24hrs. ▪ Caused by micro emboli blocking blood flow ▪ TIA’s may resolve within 3hrs, they’re a warning sign of pregressive Cerebrovascular Disease Ischaemic Thrombotic Stroke: ▪ Thrombotic Stroke – Cerebral thrombosis is a narrowing of the artery by plaque. Plaques can cause a formation of a clot that blocks passage of blood through the artery. ▪ Signs – preceded by TIA ▪ Most patients with ischaemic stroke don’t have a decreased LOC in the First 24 hours. Ischaemic symptoms may progress in the next 72 hours. As infarction and cerebral oedema increases.

Ischaemic Symbolic Stroke: ▪ An embolus (blood clot or other debris) reaches an artery in the brain that’s too narrow, it lodges and blocks blood flow ▪ Sudden onset ▪ Severe neurological deficits

2. Haemorrhagic ▪ A burst blood vessel may allow blood to seep into brain tissues until clotting shuts off leak

Intracerebral Haemorrhage: ▪ Bleeding within brain caused by ruptured vessel ▪ Sudden onset within mins to hrs ▪ Often occurs during periods of activity ▪ Initial symptom: headache ▪ Neurological deficits, headache, nausea, vomiting, HTN

Subarachnoid Haemorrhage

▪ Intracranial bleeding into the cerebrospinal fluid: filled space btwn arachnoid and pia mater membranes on surface membrane of brain ▪ Commonly caused by cerebral aneurysm. ▪ Initial symptom – headache. ▪ Commonly caused by high activity and head trauma. ▪ Loss of consciousness. ▪ Nausea, vomiting, seizures and stiff neck.

Damage to left side of brain

▪ Right hemiplegia ▪ Impaired Speech and language ▪ Impaired right/left discrimination ▪ Slow performance, cautious ▪ Aware of deficits: depression, anxiety ▪ Impaired comprehension related to language, maths

Damage to right side of brain

▪ Left hemiplegia ▪ Left side neglect ▪ Spacial-perceptual deficits ▪ Denies and minimises problems ▪ Rapid performance ▪ Short attention span ▪ Impulsive ▪ Safety problems ▪ Impaired judgement ▪ Impaired time concepts

Stress & Coping

Physical and psychological response to an actual event/ stressful event that threatens, challenges/ exceeds person’s coping resources

It occurs when a class of events involving interaction between environmental stimuli and the adjustive capabilities or organism, trigger some kind of negative affect affect (fear, anxiety, frustration, depression etc)

▪ STRESSOR: Stimuli causing affect/ change o May be physiological, physical, social, environmental, spiritual, cultural o Internal: originate inside person (eg: fever, pregnancy, or emotion like guilt) o External: originate outside person (eg: marked change in environmental temp, peer pressure etc) o Eg of physical stressors: - burns, hypothermia, hypoxia, infectious diseases o Eg of emotional stressors: - Diagnosis of cancer, divorce, financial loss, grieving ▪ Stress has a latent impact on immune system as brain is connected to immune system by neuro anatomical and neuro endocrine pathways, thus person is more prone to sickness

CASE STUDY: MR WILLIAMS

▪ Identify short and long term health alterations that he will be experiencing. Present this in format of ‘Nursing Diagnosis’ ▪ For all, identify and discuss strategies (nursing and multi disciplinary interventions) to address these effects

Question:
Impaired physical mobility related to generalised weakness, muscle atrophy/ paralysed extremities manifested by decreased physical activity, limited range of motion, decreased muscle strength or control.

Intervention:
Outcome= improved balance performance, muscle movement, joint movement and ambulation
Interventions and rationales= ▪ Assess and doc. Range of motion, transfer abilities and positioning – determine extent of problem and plan appropriate interventions ▪ Maintain alignment with support pillows and foot board to prevent contractures ▪ Encourage pt to practice exercises independently to promote pt’s sense of control ▪ Refer to physio and continue plan as specified

Question:
Impaired swallowing related to weakness or paralysis of unaffected as manifested by drooling, difficulty in swallowing, choking.

Intervention: ▪ Swallow test to determine ability to swallow/ gag reflex ▪ Refer to speech patho and dietician ▪ Sit upright during and after meals ▪ Teach pt to have small bites ▪ Check oral cavity for food after eating ▪ Oral care ▪ Give thick fluids ▪ Suction/ self suction

Question:
Impaired verbal communication related to residual aphasia as manifested by refusal, inability to speak, word finding, use of inappropriate words, inability to follow verbal directions.

Intervention: ▪ Assess communication deficits and strengths ▪ Pen and paper ▪ Simple questions (open ended) ▪ Verbal prompts

Question:
Ineffective airway clearance related to inability to raise secretions as manifested by adventitious breath sound and ineffective cough.

Intervention: ▪ Refer pt to chest physio ▪ Breathing and coughing exercises ▪ Incentive spirometry to open and collapse alveoli and prevent atelectasis

Question:
Unilateral neglect related to visual field cut and sensory loss on one side of the body as manifested by consistent inattention to stimuli on affected side.

Intervention: ▪ Assess and document amount of visual field impairment ▪ Teach pt to turn head and scan environment ▪ Approach pt on unaffected side ▪ Provide visual stimulation ▪ Teach family and pt to stimulate affected side using touch, warm and cold stimuli ▪ Encourage pt to use cue cards and mirror

Week 3: Management of Crisis

DR ABCD: o Danger o Response o Airway o Breathing o Compression o Defibillator: shock produces simultaneous depolarisation of a mass of myocardial cells and may enable resumption or organised electrical activity - place on R parasternal area over 2nd intercostal space - midaxillary line over 6th intercostal space
Precordial thump: sharp blow delivered by rescuer’s fist to mid sternum of victim’s chest ▪ Cricoid pressure:

▪ Laryngoscope:

▪ Endotracheal tube:

▪ Non shockable rhythms: o Asystole o Pulseless electrical activity (PEA) o Electro Mechanical Dissociation (EMD) ▪ Shockable rhythms: o VF & VT ▪ Drugs given in situations of crisis: o Adrenaline o Amiodarone o Atropine

Week 5: Management of Renal Replacement Therapy and kidney transplantation

Acute Renal failure

▪ Rapid loss of renal function with progressive azotaemia (accumilation of nitrogenous waste products such as serum, urea, creatinine) ▪ Uraemia: renal function declines to point where symptoms develop in multiple body systems ▪ Usually develops over days/ hours with progressive elevations of serum urea and creatinine and potassium levels ▪ End stage renal failure: long term damage needing renal replacement therapy; 90 – 95% nephrons unfunctional ▪ Acute renal failure: sudden decline in renal function @least 50% decrease in GFR ▪ Acute on chronic renal failure: acute episode which may require treatment and then revert back to chronic, however may reach to end stage ▪ Pre renal ARF: o Decrease in vascular vol, C.O, systemic vascular resistance ▪ Intrinsic ARF: o Due to direct damage to functional tissue due to ischaemia ▪ Post renal ARF: o Obstructive causes ▪ ARF clinical course: o Initiating phase o Oliguric phase o Diuretic phase o Recovery phase

Chronic Renal failure

▪ Irreversible loss of renal function and affects nearly all organ systems ▪ Involves progressive irreversible destructions of nephrons in both kidneys ▪ Causes: o Glomerulonephritis o DM, HTN o Chronic reflux o Polycystic renal disease o Interstitial nephritis o Obstruction ▪ Diagnostic tests: o Renal ultrasound, bladder xray, renal biopsy ▪ Signs & symptoms: o Protein in urine o High creatinine, urea, K+ o Anaemia ▪ Management: o Determine and treat cause o Right salt and water balance o Control electrolyte imbalance o Early detection ▪ Dialysis: movement of fluid and molecules across semi permeable membrane from one compartment to another then to a dialysis solution. Used to correct fluid and electrolyte imbalances and remove wastes ▪ Renal replacement treatment: for severe kidney failure (stage 5 CKD)

Kidney transplant

▪ Choice for CRF pts ▪ Advantages: o Successful transplantation can improve quality of life o Extremely successful o Less expensive ▪ Disadvantages: o During procedure; bleeding, infection, damage to surrounding organs o Post transplantation pts are req. to take immunosuppressive meds and are monitored for signs of organ rejection

Haemodialysis: ▪ Pt’s blood pumped through a dialysis machine to remove excess waste products/ fluids ▪ Blood placed in contact with dialysate solution. Bloods then separated from dialysate by membrane (artificial kidney) that allows the substance to move from blood to dialysate ▪ Waste products (high concentration) diffuse into dialysate (lower concentration) ▪ Blood returned to the body and is replaced by fresh solution