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John Grant Case Study

Q. 1 How might John’s care be enhanced by being cared for in a primary nursing environment? Are there any disadvantages to this model of nursing?

Ans:-John’s care can be enhanced by being cared for in a primary nursing environment because after moving from ICU to HDU, the patient requires a higher quality care which can only be possible through primary nursing. Primary nursing is a method of nursing practice in which continuity of care will be provided to patients within a nursing unit or hospital which means that one nurse would take care of all the needs of a small group of patients in a specific area. It may enhance care of a patient as he is being kept under continuous supervision of the same nurses. All his problems are being taken care of properly. It is done through various nursing activities like applying ice cold pack to the injuries on head, chest and abdomen which help to reduce inflammation, checking for signs of infection at chest tube insertion site. Neurovascular observation like pulse, nerve function etc also monitor by nurse to take care of uncertain problems.
Disadvantage of this nursing system are like unexpected discontinuation, due to absence of a nurse, in close relationship may hurt patient’s feeling. More over this practice is very expensive since the patient-to-nurse ratio is higher. If nurse is not knowledgeable enough then it may affect patient’s care (Kozier, et al. 2004).

nursing environment

Q. 2 Discuss the importance of performing and documenting a thorough nursing assessment at the commencement of your care of John?

Ans:-One of the basic objectives of nursing is to monitor patients’ progress and to interpret observations including blood pressure, pulse, temperature, respiratory rate and consciousness level, thus ensuring the prompt detection of adverse events or delays in recovery. As far as nursing assessment is concern, the purpose is to gather all the data and information required to identify patient problems and symptoms that are sensitive to nursing care. Also, to provide an evidence base from which other referrals and judgments are made. All patient assessment data provide foundation of care planning and patient’s status evaluation. It’s also useful for problem identification, effective communication, planning of future treatment and evaluation of patient progress (Bradshaw, 2010). Acute admissions and emergency admission pressure are recognized as a major problem for nursing care because nurses are under greater pressure to make clinical judgments and priorities care for different patients. Prioritization and correct judgment can only be possible when some data or previous assignment reports help are present as a supporting document.

Q. 3. John has an arterial line insitu. Discuss the reasons for insertion, nursing management of the device and potential problems a client may experience?.

Ans:-Arterial lines are inserted in critically ill patients to facilitate comprehensive and continuous assessment, to closely monitor the patient in case of hemodynamic instability and to deliver fluid and drug.
A cannula is a sterile tube that is inserted directly into an artery which is connected to fluid filled transducer kit. Nursing management should ensure that safety checks for arterial line are completed regularly during the shift and documented each shift. An aseptic technique is used for changing arterial cannula site dressing and during blood sampling. Personal Protective Equipment (PPE) is worn and disposed of correctly after procedure; sharps are cleaned away as per Standard Infection Control Precautions. Arterial lines are clearly and appropriately labelled, check that arterial line flush solution (0.9% Sodium Chloride) is put up as prescribed, the pressure on the pressure bag is maintained at 300 mm Hg (Funnell, et al. 2009).
Problems:
Potential Problems may be: thrombosis evidenced by loss or weaker pulse below cannula site, sensation and mobility to extremity beyond cannula; arterial bleeding can be very rapid and pose the risk of major haemorrhage due to the cannula becoming dislodged and site is bleeding; air embolism evidenced by over dampened arterial waveform, tachycardia, cyanosis, loss of consciousness, infection evidenced by redness, pain, inflammation, swelling or pus at arterial line insertion site, raised temperature, raised heart rate (George, 2000).

Q. 4. At night, John becomes tired. He is treated with CPAP while he sleeps. Discuss this mode of ventilation. In your answer, you must include the reasons for use on a fatigued patient, how it works at cellular level, and the nursing management of a patient on CPAP ventilation.

Ans:-A CPAP machine increases air pressure in patient’s throat so that patient’s airway does not collapse when they breathe in.CPAP works by assisting the alveoli to stay open and stop collapsing, therefore allowing greater gas exchange. CPAP delivers a constant positive pressure to the airways of a spontaneously breathing patient during inspiration and expiration through a noninvasive mask.
John has multiple chest injuries and poor lung function.  He has a chest tube probably because he has rib fractures and perhaps a haemothorax. He cannot breathe sufficiently to meet his oxygen demands. When he is lying down, this is more difficult.
Nursing management: The nurse should check the CPAP circuit for proper functioning i.e. absence of circuit leaks and adequate inspiratory air flow. Patient should be directly supervised by nurse at all the time.
Cellular Mechanism: CPAP raises inspiratory pressure above atmospheric pressures and then applies posititive end expiratory pressure (PEEP) to exhalation. Intrinsic PEEP (auto-PEEP) is usually about 5 cm water. It must be overcome before negative pressure can be generated to inhale more air. If one exhale against resistance, smaller, dependent airways are “splinted” open at the end of expiration, and small bronchi and alveoli don’t collapse. When alveoli stay open, repiratory effort doesn’t have to be expended to re inflate them. This reduces respiratory work, relieves respiratory muscle fatigue and decreases work of breathing. Increased pressure in the airways also allows for better distribution of gases, which leads to an increase in alveolar pressure and re-expansion of collapsed alveoli. As alveoli stay open, gas-exchange time can double. This increases oxygen levels in the blood and decreases CO2 levels—as long as respiratory diffusion and pulmonary perfusion dynamics work properly. This reduces hypoxia and reverses hypercarbic ventilator failure (Mattera, 2010).

Q. 5 John has an intercostal catheter in situ. What is the purpose of an inter-costal catheter and why is it on underwater seal drainage? Discuss the nursing assessment and management of this device during client treatment.

Ans:-  Intercostal catheter is also known as chest drain. This devise is primarily used to drain pleural effusion fluid from chest cavity. It can also be used to drain pus. The free end of this device is connected with an underwater seal unit which is kept below the chest level. This underwater seal is maintained to ensure that air or fluid escapes from the pleural space of chest cavity in one direction and doesn’t return back with changing posture of patient. Nurses are also required to ensure that this drain is properly sterilized and insertion space is free from any form of infection. Haemorrhage is another prominent complication which is seen in intercostal catheter, a nurse has to ensure that it is firmly placed, secure with stitches and patient is properly immobilized when catheter is inserted (Noppen, 2002).

Q. 6 When administering S/C heparin, some nurses swab the area with an alcohol swab before injecting and some nurses do not. What Evidence of Best Practice (EBP) can you find that supports or does not support swabbing skin with alcohol preparation before a subcutaneous injection. In your answer, you must include journal references

Ans:- It is argued conventionally that some people are allergic to ethyl alcohol and its interaction with heparin can produce extreme results. However over the period of time it is observed and informed in many medical journals and books that alcohol swabbing is done to sterile the region where subcutaneous injection is to be given and it is very important to ensure that place is free and secure from potential infection causing bacteria (Coombe, et al. 2005).

Q. 7 John has been prescribed six medications. Discuss the reasons he may have been prescribed these medications based on his presenting complaint. Should John be prescribed sedation for his restless behaviour? Why/why not?

Ans:- John has been prescribed metaclopromide which is a anti emetic, ceftriaxone which is a third generation cephalosporin antibiotic for infection control, paracetamol as a anti pyretic, phenytoin which is for correction of epilepsy and as ananti depressant, irbesartan which is angiotensin receptor antagonist used for  management of hypertension in patient and Clexane which is a low molecular weight heparin used for prevention of clot formation inside the patient (Nagle, 2005). All drugs are based on presenting complaints of the patient. (Rang, 2007).

Q. 8 John’s path to recovery will be a process of physical and emotional challenges. Discuss the physical and emotional needs that John may need when being discharged from hospital.

Ans:- John is an older patient who is suffering from both physical as well as psychological complications. In such situation patient needs a complete support from his family after being discharged from the hospital. John is going to face a very severe shock when he realizes the loss of his wife and faces his guilt. This is a tough phase because broken ankle and other injuries will make him more dependent on other people and her companion of life is gone. This means a toll on both physical as well as emotional needs of body. Patient is clearly indictaing that he is at a high risk of getting into clinical depression. He would require a psychological evaluation to understand the severity and probability of his slipping into clinical depression.
His nursing intervention plan would be very extensive in nature. Initially his nursing intervention would focus on his physical needs because patient’s mobility and limb movements are restricted making him dependent on nursing care for daily needs. Slowly when patient is able to recover from physical injuries then his nursing plan would incorporate psychiatric component to a higher level. Entire plan would be developed and supervised by a psychiatrist while its execution and incorporation in patient’s daily life would be done by a experienced psychiatric nurse.

Q. 9 Healthcare facilities define their mission statement/values/philosophy. This statement underpins their code of practice. Select a statement/mission/philosophy of one Australian hospital and discuss how their code of practice may be reflective of John and his family’s personal and social belief system.

Ans:- hospital which is selected for this question is Royal Perth hospital in Perth. Vision of this hospital is “Royal Perth hospital, committed to excellence in health care”. Values of the hospital are as follows
Service:-   Serving the healthcare needs of the people of Western Australia in a caring manner
Excellence:–  Consistently performing at the highest standard
Respect:-   Demonstrating respect for our patients, their families and carers, as well as each other in all aspects of our work
Organisational Learning:-Promoting a culture of continual learning in all aspects of our work
Integrity:-  Behaving ethically and honestly at all times
If we take their values as their code of practice then in this case John and his family’s personal belief system is highly aligned with the values of hospital because they are looking for a holistic care and aim to receive excellence in the entire care plan which is the very commitment of this hospital.

Reference

  • Noppen, M. 2002. “Manual Aspiration versus Chest Tube Drainage in First Episodes of Primary Spontaneous Pneumothorax: A Multicenter, Prospective, Randomized Pilot Study”. American Journal of Respiratory and Critical Care Medicine 165 (9):
  • Rang, H. 2007 Pharmacology. China: Elsevier.
  • Nagle, H. 2005 Pharmacology: An Introduction. Boston: McGraw Hill.
  • Coombe, D.R. and Kett, W.C. 2005. “Heparin sulfate-protein interactions: therapeutic potential through structure-function insights”. Cell. Mol. Life Sci. 62 (4):
  • Bradshaw, J. 2010 Innovative Teaching Strategies in Nursing and Related Health Profession, 5th edition, Jones & Bartlett Learning.
  • Kozier, B. et al. 2004 Assessing, Fundamentals of Nursing: concepts, process and practice, Canadian Edition. Prentice Hall Health: Toronto.
  • George, J.B. 2000 ; Nursing Theories: The Base for Professional Nursing Practice; Upper Saddle River, New Jersey: Prentice Hall.
  • Funnell, R.,Koutoukidis, G.& Lawrence, K. 2009Tabbner’s Nursing Care (5th Edition), Elsevier Pub, Australia.