HLTENN004 Implement, Monitor And Evaluate Nursing Care Plans

Question:

Task instructions:

Part A

Medical diagnosis – using the information you have been provided with describe the presenting problem (description of the medical diagnosis which has resulted in them being admitted into hospital) for the individual in the case study. Then identify any past medical history for this individual. Include the impact this medical diagnosis and past medical history will have on the individual.

Age of individual – using the information you have been provided with explain how the individual’s age may/will impact their ability to meet their activities of daily living. You should consider their medical diagnosis in your answer.

Preparation for procedures – using the information you have been provided with describe how you would prepare this person for a procedure. You should consider their age and medical diagnosis in your answer.

Privacy and dignity – using the information you have been provided with explain how you will maintain this individual’s privacy and dignity while caring for them. You should consider their age, culture and gender in your answer.

Risk identification – using the information you have been provided with, discuss any risks that you have identified for this individual. The may include the following:

~ age (e.g. How does age increase their risk of potential issues/problems and what are those problems?)

~ anaesthesia and surgery

~ cognitive status

~ deep vein thrombosis, venous thromboembolism, pulmonary embolism

~ immobility

~ length of stay

~ mental health condition

~ non-compliance

~ nutritional status

~ pain

~ presence of morbidity

~ maintaining a safe environment, including risk prevention strategies.

Part B – Nursing care plan, based on the clinical reasoning cycle

Look, collect, process, decide, plan, act, evaluate and reflect.

Your nursing care plan must include:

Two (2) actual problems/issues including: how you will assist this person to meet their activities of daily living, and how you would manage pain and/or insomnia.
Two (2) potential problems/issues and their management including potential problems that may occur due to immobility for this person

Case Study: Natia Euta

Progress Notes:

20/09/2018	76-year-old female presented to emergency with R) sided headache, L) sided arm.—
2145	weakness and vertigo. CT Brain scan performed.-
	CT brain showedR) sided thrombolic CVA.Past Medical History (PMH) includes: Ht,
	Obesity,TIA (2014),Type 2 DM and OA. Plan – admit to ward. For speech
	pathologist, physio and dietician r/v. -Dr Chen
21/09/2018	Pt admitted to ward at 2350 on 20/09/2018 post R) CVA. L) sided arm weakness and
0630	vertigo.On arrival to the ward,pt complaining of R) sided headache, pain 6/10. –
	Analgesia as prescribed with nil relief, Dr Chen notified. Pt drowsy but rousable.GCS
	12.PEARL 2+. L) sided arm weakness, R) arm normal strength. Equallower limb
	strength. HR 72,Regular, BP 162/80, SaO2 97% on room air. Respiratory rate 14.Pt
	to remain NBM untilspeech path r/v. BNO (day 3). Incontinent of urine x2.Referrals
	made to speech path, physio and dietician — S Kerns RN
21/09/2018	R/V by speech pathologist. Pt to remain nil by mouth. Will require nasogastric feeding.
1000	Pt to be reviewed in 1/7.- B.Patal
21/09/2018	Pt has been r/v by speech. To have nasogastric tube inserted. Headache remains
1125	6/10. Awaiting physio and dieticianr/v. Will require admission to rehabilitation unit.
	Referral has been sent. Awaiting bed. –Dr Chen
21/09/2018	Nursing note am – Pt alert and orientated. Headache remains at 6/10, medications as
1500	charted. Vital signs as charted. Pt wash in bed. Skin dry and intact. Awaiting
	physio and dietician review. Nasogastric tube Inserted, awaiting X-ray confirmation
	of placement prior to use. Family in attendance.–M Dus EN
21/09/2018	X-ray confirms that the nasogastric is in correct position, okay for use. Please if
1800	commence nasogastric feeds at 20mls/hr, then increase to 40mls/hr in 6 hours,
	patient is tolerating feeds. –Dr Chen
21/09/2018	Nursing notes pm – Pt alert and orientated. Pain from headache remains at 6/10. Pt
2140	sitting up in bed. Vital and neuro obs as charted. Incontinent ofUrine. Skin excoriated.
	Family in attendance. Awaiting rehab bed. – H Dymond RN
22/09/2018	Pt has not slept overnight. Pt reports that this is due to pain and missing her husband
0615	and feeling very scared. Pressure area care has been attended to and patient has
	had a bed bath overnight in attempt to resettle her, with minimal effect. Excoriated
	skin in perineal area cleaned and a barrier cream applied. Pt’s lack of sleep is to be
	discussed with the Dr on the morning round. BGL pre-breakfast and was 6.2mmol/L.

Answer:

Part A:

Medical diagnosis:

The case study represents the care of a patient named Natia Euta, who had been a 76 year old Samoan lady who presented to the facility with the complaints of right sided headache, left-sided arm weakness and vertigo. The cerebral CT scan revealed the fact that Mrs Euta had suffered a right sided thrombolic Cerebral Vascular Accident (CVA). The presenting problems of the patient includes left-sided weakness and being nil by mouth. Cerebrovascular accident is the medical terminology for stroke, which is caused by the blood flow to the brain of the patient being blocked by a haemorrhage in the surrounding blood vessels. Considering the past medical history of the patient, she had hypertension, obesity, past episode of TIA, type two diabetes and osteoarthritis, and many of her part medical history correspond to being considering risk factors for the CVA she suffered. For instance, type two diabetes, high blood pressure and high blood cholesterol which is a common factor of obesity are iconic risk factors for CVA. Hence, the patient having these conditions and the lack of management of this co-occurring disorders had been the main contributor of the CVA she suffered. It has to be mentioned in this context that the importance of the also have been suffering from difficulty in sleeping, which indicates at the onset of post stroke insomnia or obstructive sleep apnea, which has been reported to be a common challenge experienced by stroke patients. As discussed by Aaronson et al. (2015), the issue of sleep deprivation is associated with stalled recovery and exacerbations in stroke patients, hence there is need for care interventions to address the issue faced by the patient. Another very important issue that the patient had been suffering from includes residual pain from the right sided headache which was the main reason for her to be admitted to the facility. Now it has to be mentioned that the patient has suffered a cerebrovascular accident and headaches after a stroke is a not uncommon, close to 15% of stroke survivors experience new persistent headaches. Elaborating further, the contributing pathophysiology behind the head ache is the internal bleeding after the CVA, although persistent headache after CVA event can be caused by effect of the drugs administered, especially dipyridamole and similar blood thinners, tension resulted headaches, and migraine headaches. Hence, this is also a very important sign and symptom which is associated with the CVA which needs to be addressed in this context as well. Lastly, the patient also had very high blood glucose levels which contributed to higher risk of several exacerbation events. Hence, it is also a very important concern that the patient had been facing, which needed immediate interventions.

Age of individual:

The patient is a 76 year old which is a very delicate condition which is associated with many co-morbid issues that the patient might suffer due to the CVA event. First and foremost, the age related health challenges might act as a considerable challenge for better life quality in the patient (Emberson et al., 2014). Elaborating further, considering her age, complex medical condition and disorders and the recent CVA that she had suffered, the risk of aphasia is extremely high. Aphasia is impairment of language which can affect the speech of the patient drastically. Aphasia is more or less a common outcome after a stroke event. As discussed by Ghotra et al. (2015), left or right sided cerebrovascular accident might easily lead to global aphasia. In this case, it has to be mentioned that in this case, the patient had already been facing speech issues for which speech pathology was requested for her, hence, considering her age this can be a grave issue which will affect her quality of life in the future. Along with that, the patient also had osteoarthritis which also is an age derived health adversity. As mentioned by Albieri, Olsen and Andersen (2016), the impact of a CVA also leads to mobility restrictions and limitation in the range of motion. Considering her age and osteoarthritis this will also be a considerable issue for her. Lastly, with increasing age, the healing ability of the body also diminishes, hence, healing the brain atrophy after the stroke will also be a challenging and time consuming factor.

Preparation for procedures:

A stroke patient has to be prepared for a varied range of different tests, assessments and invasive procedures and there are number of different activities for which the patient needs to be properly prepared for, such as ECG, EEG, inserting nasogastric tube, catheters and similar procedures. In this case, first and foremost, the vitals should be checked and in case there is any anomaly, it should be addressed before commencing with the procedure. The skin of the patient should be cleaned, dried and comfortable before commencement of any assessment like ECG and EEG. Informed consent should also be taken either from the patient or the family members in case the patient is not conscious or coherently alert before beginning the procedure as well (Weber et al., 2016).

Privacy and dignity:

Privacy and dignity are very important aspects in the care planning and implementation and it should be addressed at all circumstances. In this case, care should be taken that Mrs Yuta belongs to a culturally diverse background and her cultural identity and her best understanding of privacy and dignity should be explored and respected. Care should also be taken to inform her and take her consent in all of care activities should be taken and her rights autonomy and confidentiality should be respected. For a culturally diverse patient like her, care should also be taken to take her permission before entering her room, speaking her and touching her, any activity that might violate her sense of privacy.

Risk identification:

There are various risks and factors that has the potential issues that might complicate the recovery and quality of life as well. First and foremost, age and age related complexities will be a challenge for her, both physically and psychosocially. Along with that, the persistent pain that she had been suffering from would also be the reason of complex care needs for her, altering her response to the treatment and stalling her recovery (Jolkkonen & Kwakkel, 2016). The nutritional status will also affect her recovery, she already had affected appetite which might get aggravated due to the invasive and complex treatment that the patient will be going through. Due to her osteoarthritis, age and mobility restriction, maintaining a safe environment, including risk prevention strategies will be a very important concern. For instance she will have a considerable fall risk which will be difficult to manage for her. The affected cognitive status and risk of internal bleeding due to her age and the CVA will also be a notable challenge (Lip et al., 2015).

Part B:

Identify problem /issue

Establish Goal(with Time Frame)

Take Action

Evaluate Outcomes

Reflect on process

Pain from head ache in the right side which was scored as 6/10

The patient will be free from the pain that she is feeling and she will verbalizes being free from the pain within 24 hours

The patient should be assessed for pain assessment to derive the exact pain score at the moment.

The patient will be given the aid of analgesic drugs such as tricyclic antidepressant amitriptyline given at 75mg/day and anticonvulsants such as gabapentin.

Along with that, the patient will also be given the aid of non-pharmacological pain management techniques such as Transcutaneous electrical nerve stimulation, cognitive behavioural therapy (CBT), hypnosis, attention-diversion strategies, biofeedback or stress management and relaxation techniques (Oh & Seo, 2015).

The assessment will help in understanding the exact pain score right before administration of interventions which might help in better understanding of apt intervention.

The anti-depressants and anticonvulsants have been reported to help in post stroke thalamic pain drastically (Harrison & Field, 2016).

The aid of non-pharmacological pain management helped take the attention away from the pain and helped the patient relax.

The interventions helped reduce the pain from 6/10 to 3/10 within 24 hours and the patient relaxed visibly. It helped me understand the impact of these pain management techniques on such patients.

Insomnia and difficulty to sleep throughout the night

The patient will be able to retain normal sleep cycle and will be free from the obstructive sleep patterns within 24 hours.

The patient should be given the aid of psychotropic and sedative drugs to help her relax and sleep better (Sterr et al., 2018).

The aid of soothing non-pharmacological interventions such relaxation music, aromatherapy using lavender will be given to her.

The combination of psychotropic drugs and sedatives helped calm her anxiety regarding her husband and family and helped her fall asleep.

The soothing music and aromatherapy helped calm her nerves and helped her relax.

The patient showed better signs of sleeping without any major disturbances throughout the night in the next 24 hours

Risk of hyperglycaemic attack due to high blood glucose

The blood glucose level of the patient will be reduced to the normal range within 24-48 hours.

The patient will be given medication to lower her blood sugar such as intensive insulin therapy.

Drugs such as ulfonylurea agent glibenclamide will alos be given to minimize the risk of hyperglycaemia (Savopoulos et al., 2017).

The medication will help in lowering the blood glucose levels and evade the risk of exacerbation such as hyperglycaemic attack (Savopoulos et al., 2017).

The Glibenclamide helped in enhanced control over BGL and improved outcome after large artery stroke.

The blood glucose levels of the patent reduced drastically within 2

4-48 hours.

Risk of aphasia or speech difficulty.

The patient will evade the risk of complete speech impairment and the risk of aphasia will be managed within 48-72 hours.

The patient will be given speech therapy every 12 hours.

Drugs like memantine (Namenda) and piracetam will also be given to aid in speech retainment and evading risk of aphasia (Shrubsole et al., 2017).

The speech therapy helped in improving the speech of the patient (Shrubsole et al., 2017).

The drugs helped in evading the risk of aphasia significantly.

The patient benefitted greatly by the combination of pharmacological treatment and therapies.

References:

Aaronson, J. A., van Bennekom, C. A., Hofman, W. F., van Bezeij, T., van den Aardweg, J. G., Groet, E., … & Schmand, B. (2015). Obstructive sleep apnea is related to impaired cognitive and functional status after stroke. Sleep, 38(9), 1431-1437.

Albieri, V., Olsen, T. S., & Andersen, K. K. (2016). Risk of stroke in migraineurs using triptans. Associations with age, sex, stroke severity and subtype. EBioMedicine, 6, 199-205.

Emberson, J., Lees, K. R., Lyden, P., Blackwell, L., Albers, G., Bluhmki, E., … & Grotta, J. (2014). Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. The Lancet, 384(9958), 1929-1935.

Ghotra, S. K., Johnson, J. A., Qiu, W., Newton, A., Rasmussen, C., & Yager, J. Y. (2015). Age at stroke onset influences the clinical outcome and health?related quality of life in pediatric ischemic stroke survivors. Developmental Medicine & Child Neurology, 57(11), 1027-1034.

Harrison, R. A., & Field, T. S. (2015). Post stroke pain: identification, assessment, and therapy. Cerebrovascular diseases, 39(3-4), 190-201.

Jolkkonen, J., & Kwakkel, G. (2016). Translational hurdles in stroke recovery studies. Translational stroke research, 7(4), 331-342.

Lip, G. Y., Clementy, N., Pericart, L., Banerjee, A., & Fauchier, L. (2015). Stroke and major bleeding risk in elderly patients aged≥ 75 years with atrial fibrillation: the Loire Valley atrial fibrillation project. Stroke, 46(1), 143-150.

Oh, H., & Seo, W. (2015). A comprehensive review of central post-stroke pain. Pain Management Nursing, 16(5), 804-818.

Savopoulos, C., Kaiafa, G., Kanellos, I., Fountouki, A., Theofanidis, D., & Hatzitolios, A. I. (2017). Is management of hyperglycaemia in acute phase stroke still a dilemma?. Journal of endocrinological investigation, 40(5), 457-462.

Shrubsole, K., Worrall, L., Power, E., & O’Connor, D. A. (2017). Recommendations for post-stroke aphasia rehabilitation: an updated systematic review and evaluation of clinical practice guidelines. Aphasiology, 31(1), 1-24.

Sterr, A., Kuhn, M., Nissen, C., Ettine, D., Funk, S., Feige, B., … & Riemann, D. (2018). Post-stroke insomnia in community-dwelling patients with chronic motor stroke: Physiological evidence and implications for stroke care. Scientific reports, 8.

Weber, R., Reimann, G., Weimar, C., Winkler, A., Berger, K., Nordmeyer, H., … & Weber, W. (2016). Outcome and periprocedural time management in referred versus directly admitted stroke patients treated with thrombectomy. Therapeutic advances in neurological disorders, 9(2), 79-84.

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