Case 1: Postoperative care of the client following laparoscopy (33 marks)

Past and present medical/surgical history Jenna Campbell is a 28-year-old architect. She has suffered from chronic abdominal pain since she was thirteen years old, and dysmenorrhea since menstruation commenced at aged 15 years. Since the age of 20 years, menorrhagia has persisted, requiring two previous iron transfusions the last two years. Hemoglobin level two months ago was 106g/L, when Jenna was prescribed oral iron tablets. Last year she developed dyspareunia, and her GP referred her to University Hospital for further investigation as an out-patient, with a working diagnosis of endometriosis. Abdominal symptoms related to endometriosis were otherwise managed at home with analgesia. However, Jenna presented to University Hospital emergency department (ED) after 8/10 abdominal pain was not relieved by analgesia and vaginal bleeding. After assessment by the on-call physician, endometriosis was confirmed, and a laparoscopy was recommended with possible treatment provided during the procedure. She was subsequently admitted to your ward.

Medications- current and ongoing

It is now three days post Jenna’s laparoscopic procedure, where she was treated with the removal of endometriosis tissue and two ovarian cysts, through diathermy in the pelvic region. During theatre there was minimal blood loss. Jenna has remained in the ward due to abdominal pain, nausea, and haemoglobin monitoring. You are looking after Jenna post-operative day three at 14.00 and your assessment findings are:

CNS: Jenna appears to be in pain, her face shows grimacing, and she keeps trying to catch her breath as the waves of pain occur. On further assessment the type of pain has felt different today than previous days and occurring where her laparoscopic wound is located. It feels sharp, hot and is significantly worse on movement.

CVS: Manual BP 93/49 mmHg supine, 107 bpm sinus tachycardia. The doctor has prescribed a 1 litre bag of normal saline to run over 6 hours to improve blood pressure.

GIT: Jenna reports being thirsty but extremely nauseous, which has been continuing since the surgery but has worsened this morning. Her oral intake was 400 mls yesterday in total and her fluid balance so far since midnight is negative 250 mls.

Integumentary: Jenna’s Jackson Pratt drain was removed yesterday as there was no drainage. The dressings covering her five laparoscopic wounds are intact, however one 3cm x 3cm dressing is soaked, and another distal wound dressing has had slow persistent blood ooze since yesterday, needing two dressing changes overnight.

1. Outline a systematic assessment of the patient at the start of your shift, and provide a rationale for the observations undertaken, data collected, and assessment methods used. Identify any missing assessment information in the case study and outline how you intend to obtain this detail. (10 marks)
2. Using established clinical practice guidelines, design a comprehensive nursing care plan for the patient for the rest of your shift. Consider the following elements in your plan of care. (14 marks)
3. monitoring and surveillance (include physiological parameters)
4. safety and comfort
5. positioning and mobility
6. nutrition and hydration
7. communication and information needs
8. psychosocial supports
9. documentation of care

Case 2: Managing the diabetic patient (32 marks)

It has a small amount of purulent exudate on the Band-Aid. Kenny’s wife Ann explains he was gardening last week when he cut his foot on a spade. Kenny is non-compliant with his diabetic medications. His wife states he only takes them when he “feels like his sugar is up”. Kenny monitors his blood glucose levels via glucometer only a few times per week.

Signs and symptoms

1. Critically analyse the case study and identify the two priority nursing problems for the patient at the commencement of the shift and state these as nursing diagnoses. A twoor three-part NANDA statement is utilised as appropriate. (4 marks)

2. Analyse the case study and rationalise in no more than 150 words the pathophysiological basis for TWO signs/symptoms observed in the chosen case study (5 marks)

3. Explain with rationale, three nursing interventions associated with the safe administration of three of Kenny’s admission medications (9 marks)
4. Discuss how you would assess Kenny’s right foot wound and justify how would this inform your decision to identify one actual and two potential problems. Then, choose one problem (out of the three identified) to discuss one independent nursing intervention aimed at addressing that problem. (8 marks)
5. From the table above, what blood test result(s) would be the most significant to monitor, in relation to the insulin infusion and why? (2 mark)
6. You have just been notified by the doctor that the insulin infusion will be ceased and a Actrapid insulin sliding scale will be charted. When you inform Kenny, he becomes extremely agitated and refuses to have the insulin infusion removed. Explain how you would manage this situation and educate Kenny. (4 marks)

Case 3: Managing the client with chronic obstructive pulmonary disease (COPD) (23 marks)

Past and present medical/surgical history

Mrs Darebin, a 61-year-old woman has been brought in by ambulance to the emergency department (ED), with exacerbation of COPD. Six years ago, she was diagnosed with emphysema. For many years before this, Mrs Darebin was thought to have a mild bronchorestrictive disorder treated with inhalers, however over time this has become less effective to deal with her symptoms of shortness of breath. She was then screened for genetic causes of her respiratory condition and at age 38 years, blood tests illustrated alpha-1 antitrypsin (AAT) deficiency.

She has a history of rheumatoid arthritis, early-stage cirrhosis of the liver secondary to AAT, and gastroesophageal reflux. She was a social smoker and heavy drinker in her 20’s, but nonsmoker since. After her AAT diagnosis, she quit alcohol.

Medications- current and ongoing

Mrs Darebin lives alone and works in a café on a casual basis. Her husband tragically passed away two years ago from a work-place accident. She has two children that both live inter-state. Her exercise tolerance (no aids needed) has been decreasing over the last few months, normally 300m before moderate shortness of breath ensues. However, she is determined to continue with her exercise program. Over the last 10 days, she had complained of increasing fatigue, shortness of breath in the mornings, lack of appetite and oral intake and an intermittent cough. Exercise tolerance with moderate shortness of breath is approximately 80 meters.

She called the ambulance this morning after feeling faint, feeling palpitations and sudden wheezing unrelieved by her inhalers.

Denies nausea or abdominal pain, nil ascites on inspection. Liver palpation non tender. Denies dysuria, voided during the night, patient stated urine was a dark amber colour. Mrs Darebin’s chest Xray illustrates dynamic hyperinflation,flattened hemidiaphragm that is suggestive of emphysema, and bilateral lower lobe and left middle zone atelectasis.

1. Using the ABCDE approach, discuss the immediate nursing care priorities and the rationale in the management of this patient, for what you would implement in the first hour of care in the ED. (10 marks)
2. Discuss how you would assess Mrs Darebin’s respiratory status and justify how wouldthis inform your decision to identify two actual and one potential problem. Then,choose one problem (out of the three identified) to discuss one independent nursing intervention aimed at addressing that problem. (8 marks)
3. The plan is for Mrs Darebin to be admitted to the respiratory ward. Given the clinical assessment, data collection and nursing care priorities since arrival into emergency department, using the ISBAR framework, outline how you would handover Mrs Darebin to the ward nurses. (5 marks)