Case Study: Nursing Care for a Patient with Complex Needs

This case study discusses the nursing care for a patient with complex needs who is undergoing surgery. It covers topics such as medication management, blood tests, preventing deep vein thrombosis, and using an incentive spirometer.

Assessment Task
- Written
Student Name Student Number
Unit Code/s &
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HLTENN005 Contribute to nursing care of a person with complex needs
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Assessment Name Case study Assessment Task No. AT1
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http://training.gov.au/Training/Details/HLTENN005
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Assessor
Assessors must hold current registration as a registered nurse with Nursing
and Midwifery Board of Australia”.
Note to Student An overview of all Assessment Tasks relevant to this unit is located in the
Unit Study Guide.
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Please answer all questions 1 – 32
Questions 1 – 16 relate to Ms Warral case study
Patient History
Name: Sue Warral
Age: 50
Ethnicity: Aboriginal Torres Strait Islander
Marital Status: Divorced from children’s father. Currently in a defacto relationship with James
Michaels (55)
Medical history: Chronic Asthma, hypertension, hypothryroidism, hiatus hernia, osteo arthritis
knee’s, smokes – 1 pack per week, alcohol - social
weight 95kg, height 160cm, BMI 37
Previous history of deep venous thrombosis
Occupation: Part-time reception duties at local primary school
Next of Kin: James Michaels Defacto husband
Dependents: 2 children (Rebecca 12yrs & Nathan 10yrs)
Family: Children visit their father every other weekend. Beryl’s mum and a sister live
nearby. The whole family gets together on a regular basis.
Interests: Socializing, gardening, reading
Ms. Sue Warral presents in your gynecological surgical unit for an abdominal hysterectomy tomorrow.
Ms. Warral has had three consecutive abnormal PAP smears in the past four months.
The patient states she has noticed an unusual vaginal discharge over the past six months. On further
investigation Sue was found to have stage II carcinoma of the cervix
She reveals to you she is anxious about the cancer and having young children to look after. She also
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confides that she is worried that her partner will still love her. Sue’s surgeon Dr Turner stated that they
would make a decision following the findings of the surgery regarding radiation therapy.
On admission to your ward, the day of surgery, you take Ms Warral vital signs;
BP 155/85, Pulse 88 bpm, temperature 36.6 ,respirations 18 , weight 95kgs
O2 sa 97%
Allergic to Penicillin
The patient gives you a list of her current medications.
Serevent – one puff twice daily
Salbutamol 1-2 puffs every 3 hours as needed
Metoprolol- 50mgs daily am
Thyroxine – 50mcgs daily am
Omeprazole 20mg daily am
Panadol osteo – two tablets TDS
You have been asked to prepare Ms Warral for theatre. Discuss the following procedures about the
patient’s history.
1. The patient has been fasting since 2400. Sue states she was not sure whether to take her morning
medications. State the reason why some of her prescriptions may be given, and some withheld on
the day of surgery. (50-100 words)
On the day of surgery, a patient is advised to alter some medication has it ensure she undergoes anesthesia
safely and it may delay the recovery after surgery. It is also necessary some medication taken to help
increase blood pressure which had been suppressed by anaesthesia and medicine for the patient. ...............
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2. Ms. Warral requires blood taken for a Urea & electrolytes (U & E) before surgery.
Discuss the rationale for this investigation & type of consent required. (50-100 words)
Urea and electrolytes show important information about the health of Ms. Warral such as the volume of
the blood and the PH level by regulating acid and base level in the blood.....................................................
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3. Discuss how you will perform a venepuncture on Ms. Warral using the vacutainer system, including
any infection control precautions you would take. Include rationale for actions. (procedure may be
written in list form. 100 – 150 words)
Before taking the venipuncture result, I have found out if she had ever had blood drawn before. If not, I
will explain to her the discomfort and prevent the anxiety of the patient (Loveitt). This procedure is
known as informed consent. In case she is concern about the test, I will have to explain to her that the
doctor has ordered further laboratory test to monitor the procedure. To prevent infection during this
procedure, a high level of hygiene should be kept. I will have to wear gloves, wash her hand with alcohol
to prevent disease, and after the test needles and tubes should be disposed of (Pang et al., 2018).................
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out if she had ever had blood drawn before if not I will explain to her the discomfort and prevent the
anxiety of the patient this procedure is known as informed consent if sh
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4. Discuss three (3) factors that make Ms. Warral at risk of perioperative deep vein thrombosis. (50-
100 words)
Age factor
Patient with older age are at risk of hypertension, postoperative dehydration and immobility are a risk
factor of DVT. Notably, this patient is usually associated with vascular sclerosis and higher blood
viscosity
Immobility
Due to her work has a receptionist in a local school lack of movement may lead her to a high risk of DVT.
Additionally, due to her surgery which is likely to prolong her bed rest, it may increase DVT.
Previous Risk Of The Same Illness
The previous occurrence of DVT from the health record of Ms. Warral it indicates she had been
diagnosed before with DVT which puts a high standard of getting the risk of DVT again.
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5. Mrs. Warral is to have anti-embolic stockings fitted to assist in the prevention of deep vein
thrombosis
Explain how to put anti-embolic stockings on a client (50-100 words)
Stocking prevents the patient from the risk of blood clotting. Before applying to stock, Ms warrant leg
should be measured using the fitting chart. One should insert the hand inside stocking as far as the heel. In
this light, on have to keep the hands inside the stocking and turn the stocking inside out. Finally, one
should pull the hose up and fit around the ankle and calf (Kato et al., 2016).................................................
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6. You complete the pre-operative ECG, as ordered.
 Looking at Lead 2 Please discuss PQRST and the method for calculating rate and determining
rhythm.
See :http://www.meddean.luc.edu/lumen/meded/medicine/skills/ekg/les1prnt.htm
 State the type of rhythm shown in the ECG below. The kind of rhythm is normal sinus rhythm
7. Ms. Warral is to use the incentive spirometer following surgery to prevent pulmonary
complications.
a. Discuss your explanation of how to use the incentive spirometer to your patient. (50-150 words)
Incentive spirometer helps patient lungs clear and helps the recovery process. Ms. Warral should sit on
the edge of bed help her hold incentive spirometer in an upright position. Place the mouth piece on her
mouth and make sure she seals her lips tightly around it (Higgins, Helm, Gould, & Kindel, 2018).
Additionally, make sure she breathes slowly, and as deeply as possible I would notice the yellow indicator
should reach the blue outlined area help her hold her breathe as possible and make sure she exhale slowly
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and allow the piston to fall to the bottom of the column. The process should be repeated after she can get
of bed safely and take frequent walk...............................................................................................................
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b. You are also asked to monitor Ms. Warral’s oxygen levels (Spo2) how would you do this
I would use pulse oximeter which contains a microprocessor and displays oxygen saturation will display
the monitor updates its calculation regularly to give oxygen saturation and pulse rate (Gautham,
Arulvelan, & Manikandan, 2016)....................................................................................................................
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Ms. Warral returns from theatre following abdominal hysterectomy & bilateral salpingo-oopherectomy.
She has insitu, a fentanyl PCA, oxygen 2l/min via nasal prongs, IV fluids, IDC – SD, bellovac drain &
vac dressing.
During the evening, you notice Ms Warrals’ bellovac drain has filled to 400ml. You observe her wound
& find a large collection of blood has formed under the vac dressing. In response to your questions she
has become increasingly drowsy & having trouble speaking.
8. Review the attached ADDS chart, make an assessment based on her vital signs & discuss the actions
you would initiate. Use the DRSABCD acronym as headings to explain your answer. (100 – 200
words
D
Checck if she has any danger
R
Ask her to breathe in deep
S
Call for help if needed
A
Check for any foreign object
B
Look if the wound has spread
C
Ask her if she is pain
D
Apply some nursing as soon as possible
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Ms. Warral stabilizes following the intervention of the Medical Emergency Team. Her surgeon orders
her 1gm cephalexin IV QID.
9. Review Ms. Warrals’ history & discuss your actions in response to this drug order. (50 – 100 words)
Because Ms. Warral has been smoking in the past which has to led her to the growth of asthma, she has to
avoid smoking (Gautham, Arulvelan, & Manikandan, 2016).
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10. The medical staff order the removal of the Bellovac drain & her IDC. What infection control
precautions are required for these procedures? (50 words)
First, you will have to perform hand hygiene by wearing gloves then you will have to confirm the medical
order correlate with the amount of drainage in the past 24 hours you will have to explain the procedure to
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Ms. Warral fails her Trial of Void a requires re-catheterization with an indwelling catheter.
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11. Discuss how you will perform a female urinary catheterization on Ms. Warral, including any
infection control precautions you would take. (procedure may be written in list form. 100 – 150
words)
First, you will have to perform hand hygiene if its possible she will have to wash her genitals with soap
and water after that I will have to explain to her the procedure and identify if she has any allergies, her
privacy should be highly considered (Epstein, 2016). Ms. Warran will remove her underpants and put her
legs in a recumbent position. She will then place the blue disposable sheet under patients buttocks
perform hand hygiene open catheter pack and separate trays by holding the nonsterile side of the plastic
sheet then you will have to open sterile gloves................................................................................................
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After 5 days in hospital Ms Warral is discharged home into community care with an indwelling urinary
catheter.
Access the document Working with People with Chronic & Complex Health Care Needs. (NSW gov)
http://www.adhc.nsw.gov.au/__data/assets/file/0003/301782/Working-with-people-with-chronic-and-
complex-health-care-needs-Practice-Package.pdf
12. Discuss two (2) resources that Ms. Warral may be able to access to assist in the supply of urinary
equipment. (50 – 100 words)
She can use catheters which is a hollow tube which drains directly from the bladder into a drainage bag
She will also have to apply pads which are available at most retails and pharmacies.....................................
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13. Explain the definition of a successful Trial of void according to the ACI TOV Clinical Guideline
(Community) accessed through Working with People with Chronic & Complex Health Care Needs.
(NSW gov) (50 – 100 words)
TOV is the ability to pass urine after three consecutive void with complete bladder emptying with no
or minimal post void residual then it will be considered successful................................................................
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14. Ms. Warral may require a bladder washout at some stage shortly if she is to go home with a urinary
catheter.
Under what conditions would a bladder washout be required
Bladder wash is necessary if Ms. Warral is found to have a lot of sediments in her urine, if she is not sure
her catheter is draining correctly . In case there has blocked and there is no replacement or if she has
been adviced to do bladder washout treatment................................................................................................
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Identify two nursing interventions you may do in regards to a bladder washout.
Assessed Ms. Warral if she has abdominal pain or spasms sensation of bladder fullness or catheter
bypassing.
Assessed her knowledge regarding the purpose of performing catheter irrigation..........................................
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15. Before Ms. Warrals discharge, you refer to her nursing history of osteoarthritis (OA) in her knee,
What questions might you ask her to help determine the severity of her OA and how may OA
impact her activities of daily living? (50-100 words)
I would ask her about her personal and family history then perform a full physical examination and
conduct diagnostic test I will also have to find out where she is experiencing pain and stiffness..................
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16. Ms Warral is concerned over her children and what is going to happen to them as they have had to
spend a lot of time at their father’s house, she is also feeling quite anxious about their care and has
stated that she is feeling entirely “down” following her surgery and isn’t sure how she will cope at
home once discharged. She has also stated that she been arguing on the phone with her ex-husband
in regards to her children’s care and she doesn’t know how to deal with this.
Outline 4 nursing interventions you can do to assist with the emotional, psychosocial wellbeing and
conflict resolution support of Ms. Warral, keeping in mind her cultural heritage
The need to make sense of the illness she will have to understand why she has been singled out and what
it means for her future and her family future (Bridges, Gibbs, & Hoehmann, 2017). they ill have to
understand and cope with the situation
Need for a spiritual belief to be acknowledged, respected and supported
A need to transcend the illness ad self
The need and purpose and meaning in the midst of illness.............................................................................
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Questions 17-28 are multiple choice questions with case studies
17. An 84-year-old male patient has been admitted to day surgery for removal of a 5cm carcinoma from
his back
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What is the most dangerous type of skin cancer, often characterized by black or dark brown patches
on the skin that may appear uneven in texture, jagged, or raised?
☐ Basal cell carcinoma
☒ Malignant melanoma
☐ Squamous cell melanoma
☐ Verruca cell
18. Nurse Mary is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention
should the nurse include in the plan of care?
☐ Turn and reposition the client at least once every 8 hours
☐ Slide the client, rather than lifting, when turning
☒ Provide a turning schedule of 2hrly to the nursing care plan
☐ Vigorously massage lotion into bony prominences
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19. Mr Jack has been admitted to your ward for eye surgery. You are completing the patient’s history as
part of the admission process and you see that Mr jack has clouding of the lens of his eyes, what
would this condition most likely be given that Mr Jack is 78 yrs old
☐ Strabismus
☐ Hyperopia
☐ Myopia
☒ Cataracts
20. Mr Stevenson arrives in the emergency room with a penetrating eye injury from wood chips while
cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is
the initial nursing action?
☐ Perform visual acuity tests
☒ Apply an eye patch
☐ Irrigate the eye with sterile saline
☐ Remove the piece of wood using a sterile eye clamp
21. Molly Jones is diagnosed with a disorder involving the inner ear. Which of the following is the most
common client complaint associated with a disorder in this part of the ear?
☒ Tinnitus
☐ Serous otitis media
☐ Burning of the ear
☐ Pruritus
22. Which instruction about insulin administration should the nurse give to a client?
☐ “Discard the intermediate-acting insulin if it appears cloudy.”
☒ “Always follow the same order when drawing the different insulins into the syringe.”
☐ “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
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☐ “Shake the vials before withdrawing the insulin.”
23. A male client is admitted to your ward with suspected pulmonary tuberculosis, he is placed in a
single isolation room. Choose the answer that best outlines the additional precautions required when
caring for this client.
☐ Gown and gloves plus a mask only if there is a risk of the patient coughing when you are
attending to his vital signs
☐ Standard PPE, mask and a shared room is fine as long as the patient doesn’t go near the other
patients
☐ Standard PPE, any sort of mask, normal room ventilation is fine as droplets can’t be spread
☒ Standard PPE plus a well-fitting mask specific for tuberculosis, dedicated patient equipment,
special room ventilation reequipments
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24. You are caring for Mr Smith a 56 yr old gentleman who was admitted to hospital with a blocked
suprapubic catheter and bladder infection requiring antibiotics. Which of the 4 answers below
outline nursing interventions that may apply to the care of a suprapubic Catheter?
☐ Checking for kinks or bends in the catheter tubing
☐ Ensure that the catheter bag is taped to Mr Smith’s Chest
☐ Hand washing
☐ Keeping the catheter bag below bladder level
☐ Documenting the color of the urine
☒ Remove the catheter if it becomes blocked again
25. Mr Corn is a 68-year-old male with a past medical history of cancerous polyps in the bladder. For
the past 5 years, he has undergone regular cystoscopy and bladder scrapings. He has now undergone
a surgical procedure (cystectomy) to form an urostomy / ileal conduit. Once Mr Corn has recovered
you are required to educate Mr Corn on how to empty his urostomy.
Which of the following educational points would you be able to inform Mr. Corn about when
emptying his urostomy bag (there is more than one point to choose)
☐ No need to wash hands as it is not a sterile procedure done by a nurse
☒ Empty the Urostomy bag every 2 – 4 hrs or when 1/3rd full
☐ Wait until the urostomy pouch is completely full before emptying
☒ Empty the urine from the urostomy bag into the toilet
☐ Remove the urostomy bag before emptying
☒ Wash hands with soap and water before and after emptying
26. Mrs Robertson has recently had bowel surgery to her large intestine for carcinoma of the bowel and
now has a colostomy. While Mrs Robertson is recovering, you are required to change the colostomy
bag on day five, what is an important factor to consider when placing a new colostomy flange over
the stoma
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☐ Measure the stoma diameter using a wooden ruler and cut out stoma hole in the colostomy bag
5mm larger than the stoma size.
☒ Measure the stoma diameter using a measuring guide and cut out stoma hole in the flange 2mm
larger than the stoma size.
☐ Measure the stoma diameter using a measuring guide and cut out stoma hole in the flange
10mm larger than the stoma size
☐ Take a guess at the stoma size and cut out stoma hole in the flange 5mm larger than the stoma
size to ensure that you cover the stoma and 5mm of surrounding skin
27. Choose 3 answers that best reflect nursing interventions for nasogastric tube feeding
☒ Enteral feeding tubes must be flushed prior to, and after medication administration (as per
facility policy)
☐ When preparing to administer feeds there is no need to confirm the position of the enteral tube
as it should be in the correct position
☒ When preparing to administer feeds nursing staff must confirm the position of the enteral tube.
☒ A enteral feeding pump must be used for bolus feeds only
☒ the head of the bed should be elevated 30-45 degrees during feeding (or upright if able) and for
at least 30 minutes after the feed to reduce the risk of aspiration
28. Choose 3 answers that best reflect nursing interventions for percutaneous tube feeding
☐ Due to the fact that the position of the tube has been confirmed by x-ray you only need to
confirm its position every 72hrs
☒ By providing education to the patient on their percutaneous feeding tube the risk of
complications is reduced
☒ Careful examination of the skin around the insertion site is required each shift (or as per facility
policy) to ensure that the area is free from infection and irritation
☐ If the percutaneous tube becomes blocked it should be removed immediately
☒ Always check tube placement before administering feedings and medications
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29. Match 2 conditions from the list below with the disorder
e.g. Osteoarthritis (condition) + Musculoskeletal (Disorder)
List of conditions: Diverticular disease, rheumatoid arthritis, Melanoma, Meniere's disease,
Pneumonia, Colorectal cancer, Bone fractures, Ovarian Cancer, Chronic Kidney, Disease asthma
Alzheimer's disease, Diabetes mellitus, Kidney Stones, Cellulitis, Glaucoma, Adrenal insufficiency,
Otitis, Multiple Sclerosis, Enlarged Prostate, Gland Macular Degeneration
Condition 1 Condition 2 Disorder
Bone fractures Rheumatoid arthritis musculoskeletal disorders
Melanoma Chronic kidney skin disorders
Asthma Alzheimer disease Pneumonia respiratory system disorders
Diverticular disease Colorectal cancer gastrointestinal disorders
Menieres disease Otitis ear disorders
Alzheimers disease Multiple sclerosis nervous system disorder
Diabetes mellitus Adrenal insufficiency endocrine disorders
Ovarian cancer Enlarge prostate reproductive system disorders
Kidney stones Enlarge prostate urinary system disorders
Gland macular degeneration Glaucoma eye disorders
30. Mr Jack Brown is a patient in your care and due to a small bowel obstruction, he is to have a
nasogastric tube inserted.
30a. Please outline the process of insertion
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First you will to explain to him the benefit and the risk to him and posile show the equipment to him
Make sure he in upright for optimal neck/stomach alignment
Examine nostril for obstruction so has to determine the best side
Measure tubling from nose to earlobe
Mark the measured length with marker
Make atlist 2-4inches of the tube is lubricated cause the procedure is usually discomfort to patient
Pass the tube via nare posteriorly
Instruct him to swallow and advance the tube as he swallow
If resistance is met try to rotate the tube gently
Advanced the tube until mark is reached
Attached syrige to free ends of the tubes
Secure the tube with tape
Document the reason for the tube insertation
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Six days later once Mr Jack Brown has recovered the Dr orders for the nasogastric tube to be removed.
30b. Outline how this procedure is done
Verify verbal/written order for removal from medial team you will have to discuss the procedure to him
Hand hygiene and prepare the equipment required
Make sure he is placed in upright in bed or chair
Aspirate the gastric content before removal
Remove securing adhesive strip or naso fix dressing
Instruct him to take deep breath and hold it will help in closing glottis and reduce potential risk of
aspiration whilst
When removing the tube pinch to prevent the content draining to the throat of him
Observe nasal mucosa for sign of trauma or ulceration and ensuring he is comfortable after removal
Document the procedure on fluid balance chart and in clinical record...........................................................
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31a. Outline 5 characteristics of critical thinking
Should have wide range of issue
Always remain updated on issues
Have self confidence
Ready to take oppturtinity on any resource available
Take opinions from others and always listening
Appreciate oppinions of the others..................................................................................................................
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31b. Outline the differences between critical thinking, creative thinking and problem-solving
Critical thinking is biased cause one os limited to specific ideas and strongly anlysing it unlike creative
thinkibg which one is rweady to welcome new ideas and thinking beyond problem solving is the idea of
coming with a solution to issue that has occurred by becoming creative and critical (Allman,Wilson, &
O'Donnell, 2016)) ...........................................................................................................................................
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32. The core standards that are available to support individuals, families and carers with disabilities
outline resources available.
Please use this weblink to access the core standards required
http://www.adhc.nsw.gov.au/sp/delivering_disability_services/core_standards
Outline 3 resources available to each of the following
People with disabilities
Disability include the government commitment to identifying and breaking down the bariers.
Disability complaints the guidelines ensure that the complaints are treated in fair and just manner.
Support people with disability by supporting the family and offering job opportunity.
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Older people
Create home for older people
Offer guidening and councelling
Provide wheelchair and equipment needed by older people............................................................................
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Carers
Offering job
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Giving non profit loan to the disable people to start business
Sponsor their education so that they can persue their career...........................................................................
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References
Allman, K., Wilson, I., & O'Donnell, A. (Eds.). (2016). Oxford handbook of anaesthesia. Oxford
university press.
Bridges, F., Gibbs, J., & Hoehmann, C. (2017). Laparoscopic sleeve gastrectomy complicated by
portomesenteric vein thrombosis: a case series. Obesity surgery, 27(4), 1112-1114.
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Copanitsanou, P. (2018). Mobility, Remobilisation, Exercise and Prevention of the Complications of
Stasis. In Fragility Fracture Nursing (pp. 67-83). Springer, Cham.
Epstein, N. E. (2016). 24–48 hour preoperative “surveillance” lower extremity venous Doppler's: Aren’t
they worthwhile prior to spine surgery?. Surgical neurology international, 7(Suppl 42), S1075.
Gautham, N. S., Arulvelan, A., & Manikandan, S. (2016). Anesthetic management of a patient with
polycythemia vera for neurosurgery. Journal of anesthesia, 30(5), 907-910.
Higgins, R. M., Helm, M., Gould, J. C., & Kindel, T. L. (2018). Preoperative immobility significantly
impacts the risk of postoperative complications in bariatric surgery patients. Surgery for Obesity
and Related Diseases.
Kato, F., Takeuchi, H., Matsuda, S., Kawakubo, H., Omori, T., & Kitagawa, Y. (2016). Incidence of and
risk factors for venous thromboembolism during surgical treatment for esophageal cancer: a
single-institution study. Surgery today, 46(4), 445-452.
Li, Q., Yu, Z., Chen, X., Wang, J., & Jiang, G. (2016). Risk factors for deep venous thrombosis of lower
limbs in postoperative neurosurgical patients. Pakistan journal of medical sciences, 32(5), 1107.
Loveitt, A. Additional Review Questions. Passing the Certified Bariatric Nurses Exam, 157.
Pang, H., Wang, L., Liu, J., Wang, S., Yang, Y., Yang, T., & Wang, C. (2018). The prevalence and risk
factors of venous thromboembolism in hospitalized patients with acute exacerbation of chronic
obstructive pulmonary disease. The clinical respiratory journal.
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