Download Agenes Smith

Pbl Group2 – Tu Meke
Agenes Smith
Action point:
Identify the factors that could be affecting wound healing for Mrs Smith. For
each factor identified, discuss the underlying patho-physiology.
Individuals such as Agnes Smith are predisposed to foot infections and diabetic foot
ulcers due to a compromised vascular supply which is secondary to diabetes
mellitus. Mrs. Smith’s wound will have a prolonged healing time and will be difficult to
treat due to impaired microvascular circulation. This is when the small branches of
the arteries throughout the body become damaged. This in turn limits the blood
supply to the superficial and deep structures of Mrs. Smith’s foot. Impaired
microvascular circulation hinders the white cell migration into the area of infection
and limits the ability of antibiotics to reach the site of infection in an effective dose.
Peripheral vascular disease is also prominent in individuals with diabetes. This is
when plaque builds up on the walls of the arteries causing them to become narrower
and harder and eventually lose the ability to allow adequate blood flow to the legs
and feet. This may mean that diabetic foot ulcers go un-noticed for days or weeks.
Therefore Agnes Smith will need to be educated on the importance of daily foot
examinations, and to report any changes to her doctor.
Action point:
Your student nurse asks you what the difference is between Type I and Type II
diabetes. Explain diabetes type I & type II to your student.
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Type 1 diabetes is a chronic (lifetime) disease that occurs when the pancreas does
not produce enough insulin to properly control blood sugar levels. Therefore type 1
diabetes can also be referred to as insulin dependant diabetes.
Insulin is a hormone produced by the beta-cells in the pancreas. It is vital to move
blood sugar (glucose) into cells, where it is stored and later used for energy. In type
1 diabetes the beta-cells produce little or no insulin, without enough insulin glucose
builds up in the bloodstream instead of moving into the cells.
Therefore people with type 1 diabetes must inject themselves with insulin everyday
to achieve the best blood glucose control.
Type 2 diabetes is a chronic (lifetime) disease marked by high levels of sugar
(glucose) in the blood. Type 2 diabetes is the most common form of diabetes.
When an individual has type 2 diabetes the body does not respond correctly to
insulin, therefore it can also be named insulin resistant diabetes. Fat, liver and
muscle cells do not respond normally to insulin therefore as a result glucose does
not get into the cells to be stored for energy.
When glucose can not enter the cells, abnormally high levels of sugar build up in the
blood, this is called hyperglycemia. High levels of blood glucose often trigger the
pancreas to produce more insulin, but it is not enough to keep up with the body’s
demand.
Family history and genetics play a large roll in type 2 diabetes as well as low activity
level, poor diet and excess body weight which can significantly increase the risk
getting diabetes.
Primary treatment is exercise and diet, but medication can be prescribed if needed.
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Action point:
Considering the underlying pathophysiology, discuss the reasons why
Agnes’s wound may not feel painful and has moderate-heavy amounts of
exudate.
One of the most common side effects of diabetes is neuropathy. It is likely that
Agnes is experiencing diabetic neuropathy. Diabetic neuropathy is a range of
disorders that can affect the sensory, motor and autonomic nerves. Damage to these
nerves interrupts the signals to and from the brain. It is likely that Agnes has
damaged sensory nerve fibres in her legs and feet, which has resulted in her wound
not feeling painful. People with sensory neuropathies have impaired pain sensation
and often are unaware of trauma to the feet, combined with poor circulation this can
lead to ulcers and infection.
The amount of exudate can be determined in part by the type of wound. Generally,
larger wounds produce more exudate than smaller wounds. Exudate is protein-rich
and cell-rich fluid that filters from the circulatory system into areas of the body that
are inflamed. Inflammation leads to an increase in blood vessel dilatation and
permeability with extracellular fluid formation, resulting in increased production of
exudate. Wounds in the inflammatory stage of healing produce more exudate than
those in later stages of healing. High levels of exudate may be a sign of wound
infection. Diabetes is known to impair the normal immune response rendering
individuals with diabetic foot ulceration susceptible to infection.
Action point:
Access the policy / guideline used by the staff in your clinical placement for
managing a patient who is experiencing hypoglycaemia. Fully discuss the key
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aspects of the policy / guideline within your team, and ensure you have the
knowledge necessary to respond safely and effectively in a similar situation.
Life threatening hypoglycemia: Ring emergency bell and do immediate capillary
blood glucose. Repeat test every 10 minutes until blood glucose is above 4mmol/L.
If patient is comatose or is having seizures, check airway is patent, place in recovery
position, ensure they are nil by mouth. (Do not attempt to feed the patient any
solids or liquids)
In a patient with an IV line give 50mL 50% glucose via IL line. Rapid IV push and
repeat of still unconscious and hypoglycemic.
In a patient without an IV line, reconstitute Glucagon 1mg from the resus trolley and
administer STAT IM and establish IV access. If no response after 15minutes
administer another 1mg of Glucagon IM STAT. Glucagon may take 15minutes to
have an effect and the action is short.
Then, commence IV 10% Glucose infusion 100mL/hour.
When patient is co-operative administer 3 Glucose tablets and follow
moderate/severe guidelines. Continue to do hourly capillary blood glucose tests until
next meal.
Moderate to severe hypoglycemia: Capillary blood glucose less than 4mmol/L patient
is conscious and able to swallow.
Administer one of the following: 3 x vita tablets
1 x tablespoon of jam, honey or sugar
½ glass of non-diabetic lemonade or coke
½ glass of ordinary fruit juice
Recheck blood glucose at 10 minutes
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Blood glucose above 4mmol/L = give longer acting carbohydrate e.g. crackers and
cheese, bread and marmite or 2 plain busicuits.
If glucose is below 4mmol/L = repeat administration of glucose tablets, jam/honey
lemonade or fruit juice.
Charles Smith
Action point:
Your student nurse asks….. “what about Mr Smith’s medications? He’s NBM
what do we do about his oral medications?” Review the policy/guidelines used
by the staff in your clinical placement relating to administration of medications
pre-operatively. Considering this, respond to your student nurse
Fasting before general anaesthesia aims to reduce the volume and acidity of
stomach contents during surgery, thus reducing the risk of regurgitation/aspiration.
Aspiration of gastric content may lead to serious morbidity and or mortality.
Aspiration is a consequence of a complex interplay of patient, anaesthetic and
surgical factors, such as anaesthetic technique and airway difficulties, in addition to
the actual gastric content. Reduction in volume and acidity of gastric content by an
appropriate duration of fasting is one mechanism to reduce the risk of aspiration. For
an AM or afternoon surgery no solid foods after 0200 hrs is advised and they may
drink clear fluids up to 2 hours before the time of surgery.
All routine medications with the exception of oral hypoglycaemics should be taken
while "nil by mouth". Water can be taken to assist swallowing however in the hour
before anaesthesia significant volumes of water should be avoided in order to
prevent post-operative problems related to water diuresis and a full bladder.
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A short time later the student nurse comes back to you to advise you that Charles is
demanding a drink as he is extremely thirsty and just can’t take it any longer.
Action point:
Your student nurse asks….”He’s so thirsty, couldn’t we just give him a glass
of water”
Respond to your student nurse, using appropriate medical terminology. Your
decision should be rationalized at a physiological level.
Well unfortunately we are unable to give him water to drink because, if you looked in
his notes you would have identified that he is NBM. Do you understand what NBM
is? It means you are unable to pass any fluids or solids through the mouth. Smoking
and chewing is not recommended either because this encourages gastric juice
content production. In Mr Smith’s case he is also requiring an operation which
means he will be under an anaesthetic. Patients requiring anaesthetic must be NBM
and have no content in the stomach because there is a risk of regurgitation and
aspiration of gastric contents which is a side effect of anaesthetic during the
induction and intubation stages. To ensure Mr. Smith is rehydrated it is very
important to act on this by administering him some fluids which will be NaCl via
intravenous infusion. Sodium Chloride will run through his body to rehydrate his
cells. It is important that the IV fluids are charted before administering the fluids.
Ensure to let the doctor know so he can chart it in Mr. Smiths medication chart. You
could give Charles a mouth wash using foam tip applicators to help his thirstiness.
Charles calls his bell complaining of pain. Following your clinical assessment you
determine Charles requires strong analgesia to help manage his pain. On Charles’s
medication chart you notice that he is prescribed Morphine as per the Opioid Policy.
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Action point:
Access the policy / guideline used by the staff in your clinical placement for
administration of opioids (not all areas will have one). Fully discuss the key
aspects of the policy / guideline within your team, and ensure you have the
knowledge necessary to respond safely and effectively in a similar situation.
Consider the patient's co-morbidities and general condition when prescribing opioids.
Patients with renal dysfunction should be prescribed Fentanyl and patient's with
significant lung disease (hypercapnia) are at risk of harm from respiratory
depression.
Assess the patient for pain. If the patient reports “moderate” or “severe” pain, check
if an analgesic has been prescribed as per “Adult IV protocol” in the patients drug
chart. If no IV analgesic is charted discuss with the medical team. Prepare a syringe
with the prescribed analgesic -the empty ampoule should be taped to the syringe.
Record drug used in the controlled drug register as per normal procedure. Two
nurses’ signatures are required, one must be on the IV register. Assess the patient Check for a respiratory rate greater than 10, a sedation score 2 or less, and blood
pressure and heart rate within the normal range as per the patients observation
chart. Any differences should be discussed with the patients’ medical team prior to
the administration of opioids. A patient under 65 years old with severe pain or visual
analogue scale greater than 7/10 should be administered 2.0mL intravenously. A
patient 65 years old with severe pain or visual analogue scale less than 7/10 should
be administered 1.0mL intravenously. A patient over 65 years old weighing less than
50kg should be administered 0.5mL intravenously. Record the administration on the
patients drug chart (2 nurses signatures required). Wait three minutes, stay and
observe the patient.
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If the patient is still in pain repeat the above steps until the patient is comfortable or
the steps have been repeated 5 times. Once the steps have been completed 5 times
and the patient is still in pain, request a medical team review of ongoing pain. The
pain team should also be notified and a PCA considered.
If the patient is not in pain 3 minutes after the last dose discard the remainder of the
drug into the sharps container. The amount wasted must be witnessed by a second
nurse, who will also sign the controlled drug register. Enter the amount wasted in the
controlled drug register as per normal procedure. If further doses are required at a
later time a new syringe is to be prepared
Just before Charles is transferred to OT, Lisa (his wife) telephones the ward. She
has only just got the message about Charles’s accident. She is frantic as she was
involved in a small drama involving their 8 year old child Francesca who had difficulty
breathing while running a cross-country course at school.
Charles is transferred to OT.
Francesca Smith
Action point:
Outline your immediate actions with rationale
Approach Francesca, introduce yourself and stop her from continuing with the race.
Stay with the child but at the same time, call for help and ask people to contact
Francesca's parents. If her mother is present ask whether her daughter has any
known allergies that might have triggered her daughter’s asthma attacks. Reason is
pollen and dust mite trigger asthma attacks. Check whether her daughter is on any
inhaler medications and if so administer the inhaler to help dilate the bronchioles for
oxygen to pass through.
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Monitor Francesca’s respirator rate and observe for change in colour, breathing
pattern and depth. Call for help if you notice Francesca’s condition getting worst.
Ensure the child is sitting in an upright position which maximize chest expansion.
Check airway, breathing, circulation and any disability and her level of
consciousness. Airway, check if there are any blockages/constrictions, excessive
secretions. Breathing
to check the respiratory rate and work of breathing (use of accessory muscle and
degree of fatigue)
any wheezing sound heard on chest auscultation that turn to silent. Circulation,
check the pulse rate and capillary refill time, look for signs of cyanosis , monitor O2
saturation (<90% needs oxygen administration)
Disability and level of consciousness, orientation to time, place and people is also an
indicator of level of severity. Patient’s responsiveness (check if patient speaks in
words instead of sentence).
If Francesca's breathing stabilises the nurse should provide rest and a quiet and
calm environment for the patient. Continuous monitoring patient’s pulse rate,
respiratory rate and O2 saturation. And check patient’s peak flow. If her condition
worsens contact an ambulance and administer O2 as per the school protocol until
they arrive.
Action point:
Detail the key aspects you would be looking for in the response from your
student nurse.
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
Asthma is a chronic condition; the pathophysiology of asthma is an
inflammation in the airways.

The stimuli activate the release of inflammatory mediators from mast cells,
macrophages, eosinophils and other cells in the airways.

The bronchi and bronchioles are tubes through in which air must pass to
reach the alveoli and it will be absorbed into the blood. The two main
branches of the bronchi split so that each reaches a lung.

The airway inflammation contains the cells such as mast cells, eosinophils,
epithelial cells, macrophages and activated T lymphocytes. The mucosa
which contains the inflammation and thickening of airway.

This can increase in the amount of mucus secretion and the contraction of the
airways in the body. The inflamed airways become small and blocked.

The epithelial layer of cells in asthmatic subjects is often inflamed and
damaged. The contraction of airway smooth muscle is regulated by Ca2+
dependent and Ca2+ independent mechanisms. The inflammatory mediators
released from inflammatory cells such as histamine and cysteinylleukotrienes.
The next time you check on Francesca, her mother Lisa tells you their GP gave
her a “spacer” to administer Francesca’s asthmatic inhalers. She asks you to
explain what it does and how she should use it
Action point:
Outline your response to Lisa (and ensure you include Francesca).
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
Spacers help increase the amount of medication that is deposited into the
airways.

A spacer helps delivery to medication and reduces throat irritation and fungal
growth in the upper airway.

Instructions to using a spacer:

Shake the inhaler 3 – 4 times well before used

Remove the cap from your inhaler, and spacer

Insert inhaler into spacer chamber

If it is the first time using the spacer prime it by pumping the medication in ten
times.

Wait for 1-2 minutes, this helps coat the medication into the spacer for better
use

Put in the inhaler into the spacer again

Bring the spacer to your mouth, creating a seal with the lips

Active the Puffer by pressing down to release the medication, a fine spray will
be shown inside the spacer.

Take 1 deep slow breathe, hold the medication in for about 5 to 10 seconds

Wait for 1 minute before repeating the step above

Continue this as per required every 4 hours

Only press one dose from the puffer into the spacer at a time.

Spacer cleaning: dismantle spacer after every use, wash all parts in soapy
water (detergent).

Do not rinse because detergent help reduce static charge.

Shake out excess water, do not rub

Allow to sit on bench and drip dry
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
Once dry replace the base together for next use.
TRACEY SMITH
Action point:
Identify your main concerns about Tracey’s health related to this information.
Outline how you will respond to Tracey and what education will you offer her.

Explain what Chlamydia is: how it is a bacterial sexually transmitted infection.

Tell her how Chlamydia is spread: vaginal, anal or oral sex without protection.

Give patient education: about condoms, how to use it, why it is important,
where she can get condoms: her doctor and nurses, family planning and
sexual health services.

Advise her to tell the partner if she has one that she has Chlamydia and get
him tested. All partners need to be treated even if they don’t have symptoms.
Information and booklets are available if the partner needs information.

Advise what will happen at the test: Men only need to do a urine test, where
as women need an internal check up. Other Sti’s will be checked up for too in
this process.

How can she protect herself from sti’s and Chlamydia in the future? Always
use condoms; there are female and male condoms available. It is a barrier to
prevent infection passing person to person.

Tell her want will happen if Chlamydia is not treated: Chlamydia can cause
pelvic inflammatory disease if it is not treated. This is when the women’s
reproductive organs become inflamed. It can cause ectopic pregnancy, it will
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be difficult to conceive when she wants to and she will have ongoing pain in
the pelvis.
Action point:
Identify presenting clinical signs for Chlamydia, gonorrhoea, and Human
Papilloma Virus (HPV). Identify modes of transmission. Outline best practice
management for each.
Chlamydia

An increase in vaginal discharge caused by an inflamed cervix;

The need to urinate more frequently, or pain whilst passing urine;

Pain during sexual intercourse or bleeding after sex

Lower abdominal pains;

Irregular menstrual bleeding.
Type of Infection: Bacterial; from the Chlamydia trachomatis strain which lives in
vaginal fluid and semen
Mode of Transmission: Mainly through vaginal and anal sex; although it is much
less common, it can also be passed on via oral sex and hand to eye contact. Mother
can pass it on to baby during birth.
Gonorrhoea

Pain or burning sensation when passing urine

Vaginal discharge that is yellow or bloody

Anal discharge
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
Bleeding between menstrual periods

Heavy bleeding with periods

Pain during sex.
Type of Infection: Bacterial; from the Neisseria gonorrheae bacteria
Mode of Transmission: Mainly through vaginal, anal and oral sex. Bacteria are
transmitted through vaginal and seminal fluids. Infection can show up in the
genital tract, mouth or rectum.
Human Papilloma Virus

Cervical Cancer
Modes of transmission: Sexual contact, Vertical transmission from an infected
mother to new born, horizontal transmission or sexual transmission, sexual abuse
and other pathways possibility of non sexual transmission example contact with
infected urogenital secretions from sharing towels or bathing together.
Action point
What is contact tracing? What are the legal aspects regulating this? What are
the ethical issues that may arise?
Contact tracing involves identifying and seeking people who have been in contact
with a person with a ‘notifiable’ condition, in order to prevent further spread and to
offer treatment and testing to people at risk. The present legislation has very few
provisions to support contact tracing and these tend to be limited to contacts that
have already been identified, rather than tracing further contacts.
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In most cases, contact tracing happens voluntarily. The legislation authorises contact
tracing by a medical practitioner where the person concerned does not voluntarily
inform others and any infringement on the person’s privacy is considered to be
justified on public health grounds.
For the purposes of identifying the individual’s contacts, the medical practitioner may
approach the employer of the individual, or any other institutions / businesses to
request names and addresses of contacts of the individual. When the medical
practitioner approaches contacts, as far as possible, the practitioner is required to
maintain the confidentiality of the individual who may have communicated the
condition to the contact or exposed them to the risk of contracting the condition.
Mele
Action point
Discuss how you would handle this situation and what your concerns are.
Include in this discussion the long term effects of dental caries with primary
dentition.
Upon arrival to Mele's house I will introduced myself to her and to her family
members. I will be telling her the reason of my visit which is the dressing of her skin
tear in her R) forearm. I will try to be engage to Mele and her family so I can build a
trusting nurse client relationship with her. I will also make assessments by asking
Mele questions that relates to her physical, social, emotional and spiritual well being.
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My concern is the overcrowding as there are eight people living in a three bedroom
house. Another concern is the financial difficulty as Mele relies only in her pension
while her daughter Siu is also relying in her Domestic Purpose Benefit. Another
concern is the untidy and smelly house which is not good for the health of Mele's six
grandchildren. And the most concerning of all is the grandchildren covered with
sores and have decayed teeth.
Dental caries (tooth decay) is a chronic, progressive lesion, and once cavitation has
occurred repair by a dental health professional is essential to prevent progress of the
condition. Good dental health is important for health, self-esteem and pain-free
living, and serious and persistent dental problems can disrupt work and social life.
Untreated caries can lead to hospitalization for acute medical complications.
Action point
Identify other agencies that need to be contacted and what your referral will
cover.
I will refer the family to Housing New Zealand/Work and Income so they can move to
a bigger and cleaner home to minimise overcrowding and reduce the likelihood of
the children developing skin infections. The children will also be referred to a skin
specialist to determine the sores that the children have and to treat them to prevent
the spread of infection to other family members.
I will also refer the children to dental services so that their teeth will be taken cared of
as soon as possible. I will talk to Siu that children's teeth should be checked as they
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have dental caries and I will tell her that the service is free to all children age 0-18
years old.
Another referral that I will make for the children especially those aged 3 – 5 is to refer
them to Plunket (Well Child) for general check of the children's health and wellbeing.
Children that are going to school will also be referred to the B4 school check
program to help them prepare to before school.
Action point
What is the treatment for impetigo and how do you minimize spread? Include
in the discussion how you differentiate between impetigo and scabies.
Impetigo is a skin infection caused by bacteria. Usually the cause is staphylococcal
(staph) but sometimes streptococcus (strep) can cause it, too. It is most common in
children between the ages of two and six. It usually starts when bacteria get into a
break in the skin, such as a cut, scratch or insect bite.
Symptoms start with red or pimple-like sores surrounded by red skin. These sores
can be anywhere, but usually they occur on your face, arms and legs. The sores fill
with pus, then break open after a few days and form a thick crust. They are often
itchy, but scratching them can spread the sores. Impetigo can spread by contact with
sores or nasal discharge from an infected person. You can treat impetigo with
antibiotics.
Prevent the spread of infection.

If you have impetigo, always use a clean washcloth and towel each time.
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
Do not share towels, clothing, razors, and other personal care products with
other family members.

Wash your hands thoroughly after touching the skin lesions.
Good general health and hygiene help to prevent infection. Thoroughly clean minor
cuts and scrapes with soap and clean water. You can also use a mild antibacterial
soap.
Impetigo is contagious, so avoid touching the draining (oozing) lesions.
Scabies
Unlike impetigo scabies is an easily spread skin disease caused by a very small
species of mite. Scabies is found worldwide among people of all groups and ages. It
is spread by direct contact with infected people, and less often by sharing clothing or
bedding. Sometimes whole families are affected.
Outbreaks of scabies are more common in nursing homes, nursing facilities, and
child care centers.
The mites that cause scabies burrow into the skin and deposit their eggs, forming a
burrow that looks like a pencil mark. Eggs mature in 21 days. The itchy rash is an
allergic response to the mite.
Scabies is spread by skin-to-skin contact with another person who has scabies.
Symptoms may include itching, especially at night, rashes, especially between the
fingers, sores (abrasions) on the skin from scratching and digging, thin, pencil-mark
lines on the skin
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Examination of the skin shows signs of scabies. Tests include an examination under
the microscope of skin scrapings taken from a burrow to look for the mites. A skin
biopsy can also be done.
Prescription medicated creams are commonly used to treat scabies infections. The
most commonly used cream is permethrin 5%. Other creams include benzyl
benzoate, sulfur in petrolatum, and crotamiton. Lindane is rarely used because of its
side effects.
MAX
Action point
Describe the prodromal phase and how this impacts on a client’s recovery
Prodromal phase – The prodromal phase in Schizophrenia is when the first
presentations of the disorder are present. These can include any of the following;
loss of interest in normal activities, withdrawal from family and friends, confusion,
loss of concentration, isolation, preoccupied with religion and philosophy. This can
have an impact on the client’s recovery, as depending on how long they have gone
through the prodromal phase they may have lost their support system.
Criteria for Mental Health Act – Client must be:
1. Must be mentally ill
2. Be a serious risk to self and others
3. Enshrine the ‘pares patriae’ (guardianship role) Motivation was not primarily
the protection of others, but of the person
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4. Law must ensure the protection of individual rights
Antipsychotic s – The most current types of Antipsychotics block two different
chemical receptors (both the dopamine, D2 receptor and a specific serotonin
receptor, 5HT2A). It is believed that by blocking both receptors it treats both the
positive () and negative symptoms (loss of emotional response, decrease in
speaking, difficulty sticking to tasks) of psychosis.
Positive symptoms - hearing things that aren’t there, seeing things that aren’t there,
feeling things that aren’t there.
Negative symptoms - loss of emotional response, decrease in speaking, difficulty
sticking to tasks.
Anxiolytic - are a class of medications used to help relieve anxiety, which a lot of
the time affects people who are experiencing psychosis. They work by blocking
GABA receptor sites, which tone down central nervous system activity.
Response to Max’s parents question about what is going on in the interview –
they are asking Max some questions privately because of confidentiality reasons I
can’t let you know what he is saying. Although when Max is finished you may ask
him yourself.
Action point
Describe what needs to be undertaken for a holistic assessment of Max in a
first assessment interview.
Holistic assessment – BATOMI assessment tool. HEADSS assessment; Home and
environment, Education and employment, Activities, Drugs, Sexuality and
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Suicide/depression. During the assessment it’s important to ensure that Max feels
safe and comfortable.
Action point
What information are you going to pass on to Agnes?
Schizophrenia short/long term –
Short term: in an inpatient setting they will assess the client, stabilise them, make
sure they have support/relapse systems in place and help them with the transition
back to life at home.
Long term: in an inpatient setting they will assess the client, stabilise them, make
sure they have support/relapse systems in place and help them with the transition
into community care. This will be over a long period of time to try and reduce the
chance of relapsing.
Alcohol and drug use – there are studies to suggest that some drug and alcohol
use may increase the chance of developing schizophrenia, although this has been
debated by other research. Although a person who has been diagnosed with a
mental illness is also more likely to develop drug and alcohol addictions.
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