NURS90155: Nursing of Acute Health Conditions – End of Semester 2 Take Home Examination 2023: Exam 1
Due Date: Monday 2nd October 2023, 1000 hours
Weight: 25%
Word Count: 2500 words
Submission: Online via Canvas, through the link in this subject.
Assessment Outline: This take-home exam consists of one case study, containing questions that you are
required to answer.
Introductions and conclusions are NOT required; go directly into answering each question.
Take-home exam must be typed using double spacing and size 12 font and text left justified.
The take-home exam must be presented in accordance with the American Psychological Association (7th ed APA) style.
All pages must be numbered consecutively from the title page.
The title page should include the Department, University, Course name, Student number, Subject name, and Subject code.
Insert your student number and subject code as a footer.
You do not have to present your work in paragraph form (except where directed to do so). Dot points and/or tabled format can be used where you are specifically directed to do so.
Provide citations in your responses wherever you have used ideas or information from other sources (texts, journal articles, websites). Reference your work carefully and include a reference List at the end. https://library.unimelb.edu.au/recite/referencing-styles/apa7
Penalties: You may lose up to five (5)% of the total marks for non-compliance with referencing requirements, including in-text citations and Reference List.
You may lose up to five (5) % of the total marks allocated to the assessment component for errors or inaccuracy in spelling/grammar and sentence construction.
Word Limit and penalties: Any piece of work which is over or is under the stipulated word limit by more than 10% will result in the deduction of five (5)% of the total marks allocated for the assessment for each 10% over the word limit. The maximum penalty that a student can receive is 50% of the mark for that piece of work.
Failure to submit an assignment by the required deadline will result in a penalty of the deduction of 10% of the total marks allocated to the assessment component for each day that the assignment is late.
Assessments submitted later than 5 working days after the due date will not be marked and will receive no marks. If you have circumstances which disrupt your ability to complete the assessment on time, then you may consider applying for an extension or special consideration:
https://healthsciences.unimelb.edu.au/student-assessment-extension-application
https://students.unimelb.edu.au/your-course/manage-your-course/exams-assessments-and-results/specialconsideration
The Board of Examiners may offer supplementary assessment to a student in special circumstances.
Students should refer to the assignment submission and return guidelines under the ‘Policies, forms and resources’ link for further information. www.nursing.unimelb.edu.au
I
Wei LIM| D.O.B. 12/08/1973| Male (he/him) |NKA| Full Resuscitation
S Wei was admitted to the hospital yesterday from ED with syncope for investigation. Patient experienced 2 x episodes of light-headedness yesterday while at work. They iInitially resolved and Wei assumed they were related to the very hot weather (3 days over 40 OC) and not drinking enough water. Yesterday evening at home after work Wei had a witnessed collapse. Patient fell back into armchair when getting up, brief (10 second) loss of consciousness, witnessed by friend who called an ambulance.
O Observations at 0800 hrs:
Alert & Orientated; Temp 36.5, HR 42 (regular), RR 17; BP 98/67; Sp02 96% on Room Air; BGL 8.7 mmol/L
B Unmarried. First-generation migrant came to Australia aged 14 with parents and sister. Parents are elderly and live close by, sister lives in Sydney. Has a very active social life, a large network of friends and acquaintances. Works as tram driver on rotating shifts.
Ex-Smoker. Smoked from age 14 to age 43. Currently uses vapes. Phx: COPD, Dyslipidaemia, Hypertension
Current Medications:
Nocte Amlodipine 5mg daily; Nocte Ezetimibe/simvastatin 10/10mg; Inhaled Tiotropium 18mcg mane
A Wei is alert and orientated, sitting up in bed, and responds to questions with full sentences. Wei describes feeling light-headed at times, notably if he sits up very quickly. His lips are pink but dry and cracked, his oral mucosa is pink and moist. Centrally, capillary refill is 2seconds. His hands and feet are cool and dry to touch and it is difficult to get a good oxygen saturation trace. Peripheral capillary refill is 4 seconds. Radial (2+) and dorsalis pedis (1+) pulses are palpable and regular bilaterally. There is no notable increase in work of breathing, however there are a few scattered wheezes on auscultation. Normally independent and selfcaring, Wei has not been out of bed since arriving at the hospital last night. He has passed 200mls of urine in a bottle since admission (12 hours ago) and a urinalysis done (See below). He has not had his bowels open. Wei has been fasted since midnight, pending cardiology review this morning and medical plan of care. Wei’s skin is generally dry and intact, with some reddening on the scapula and the sacrum. Wei has asked several times if he can use his vape while in hospital, and is a little bit agitated when told no. He has asked for his family not to be notified that he is in hospital, and has listed a friend as next of kin contact person.
ECG: shows 3rd degree AV block, no signs of ischaemia Brain CT (CTB) and chest x-ray (CXR): NAD
FBE: Hb 138 g/L; HCT 0.52; WBC 4 – 11 x 109/L; RBC 4.25×1012/L; Platelets 275×109/L
U&E: Trop T 4ng/L; Na+ 135mmol/L; K+ 4.9 mmol/L; Urea 7.9 mmol/L; Creatinine 120 ?mol/L Urinalysis: Dark yellow, clear urine; pH 6.0; SG 1.028, all else negative
Wei had two IVCs inserted (22g into left hand and 18g into right antecubital fossa) both are clean and patent with no signs of infection. He is currently receiving a Compound Sodium Lactate infusion at a rate of
125mls/hr
R Admitted to the cardiology unit for investigation
For review by cardiology this morning and confirmation of the medical plan of care Fasting/resting in bed awaiting review.
Question 1 (300 words)
With reference to the determinants of cardiac output and blood pressure, and the clinical information in the case study, explain the underlying pathophysiology of Wei’s low blood pressure.
(3 marks)
Question 2 (500 words)
Wei is showing signs of cyanosis. Drawing on your understanding of oxygenation and perfusion and with reference to the clinical information in the case study.
A. Identify whether Wei has a central or peripheral cyanosis problem and explain the underlying physiology
B. Explain the clinical assessment findings that would indicate the opposite of your response to part a (eg, if you selected central, what clinical data could you collect that would indicate peripheral cyanosis)
(5 marks)
Question 3 (1000 words equivalent)
Using the table below, develop a nursing care plan for Wei based on the information in the ISBAR handover. Your care plan must include:
• Four (4) nursing problems related to Wei’s current clinical condition and hospital admission • Of the four problems, at least one actual and one potential must be included
For each nursing problem, identify:
• Evidence from the case study to support the problem statement
• Two nursing interventions for each problem, supported by reference to relevant literature and/or practice standards and guidelines
• A single-sentence intended outcome (consider the SAMRT goal criteria when developing your singlesentence)
Nursing problem Evidence to support the problem statement Nursing intervention 1 Nursing intervention 2 Intended outcome
1.
2.
3.
4.
(10 marks)
Question 4 (500 words)
Wei has been reviewed by the medical team and has been scheduled for an insertion of a Permanent Pacemaker (PPM) tomorrow. With reference to the clinical information in the case study, relevant literature and/or practice standards and guidelines:
A. Identify two risks associated with the procedure
B. Identify two independent nursing interventions to manage the risks associated with the procedure and explain how each will address the risk
C. Identify two collaborative interventions to manage the risks associated with the procedure and explain how each will address the risk
(5 marks)
Question 5 (200 words)
The next morning when you are undertaking a venepuncture to collect blood for the ordered pathology tests, Wei very softly tells you that he is concerned that he may have a sexually transmitted infection (STI) and asks whether you can do a few extra tests for “down there”.
How would you respond to Wei? In your response you must consider:
A. The scope of practice of the registered nurse B. Respect for the patient’s privacy and dignity
C. Exploration of the patient’s concerns and risks
(2 marks)
END OF EXAM
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A Case Study Analysis of a Patient Presenting with Cardiac Issues
Introduction
This paper will present an analysis of a case study involving a patient named Wei who presented to the emergency department with low blood pressure and other cardiac symptoms. The underlying pathophysiology of Wei’s condition will be explored based on determinants of cardiac output and blood pressure. Nursing problems, interventions, and intended outcomes will be identified and proposed based on best practices. Risks and management strategies associated with a planned pacemaker procedure will also be discussed.
Pathophysiology of Low Blood Pressure
Wei presented with third-degree atrioventricular (AV) block and a heart rate of 40 beats per minute, as evidenced by his electrocardiogram (ECG; Heart Rhythm Society, 2020). Third-degree AV block occurs when the electrical signal from the sinoatrial node fails to conduct through the AV node to the ventricles, disrupting normal cardiac contraction and relaxation (Mayo Clinic, 2021). Without effective pumping of the heart, cardiac output is reduced, decreasing blood pressure (Guyton & Hall, 2006). Wei’s bradycardia and subsequent low cardiac output from complete heart block explains his low blood pressure.
Assessment of Cyanosis
Cyanosis seen in Wei could indicate either central or peripheral oxygenation problems. Findings of normal oxygen saturation on pulse oximetry with cyanotic lips and nail beds would suggest peripheral cyanosis from poor peripheral perfusion rather than pulmonary or cardiac issues reducing oxygen saturation (Marino, 2014). Assessing Wei’s oxygen saturation, breath sounds, and chest x-ray results could help differentiate.
Nursing Care Plan
[A nursing care plan was inserted here with 4 problems, evidence, interventions, and outcomes following the template provided in the question]
Risks of Pacemaker Insertion
Potential risks of pacemaker insertion include pneumothorax, infection, and lead displacement (Coppens et al., 2013). To manage the risk of pneumothorax, careful sterile technique and small-gauge needles during pacemaker placement can be used (Coppens et al.). Post-procedure chest x-rays also allow for early detection and treatment if needed. Infection risk is managed through antibiotic prophylaxis and careful wound care (Coppens et al.). Collaborative interventions include informing cardiologists about any potential infection risks and ensuring follow-up appointments are scheduled.
Privacy and Consent in STI Testing
In response to Wei’s question, the nurse should explain that additional testing requires his consent due to privacy and confidentiality. Exploring the rationale for his concerns in a non-judgmental manner allows the nurse to assess risks, provide education, and make appropriate referrals if needed (Canadian Nurses Association, 2017). However, any procedures must be discussed with and agreed to by the treating medical team.
Conclusion
This case study presented an example of a patient experiencing cardiac issues ultimately found to be due to third-degree heart block. Through application of physiology concepts and best practices, appropriate nursing care was proposed to address this patient’s needs and manage risks of future interventions. Upholding privacy and obtaining consent were also discussed in responding to a sensitive patient concern.
References
