Assessment 1 Workbook: NSB334 Integrated Nursing Practice 4

This assignment is a workbook solution for the NSB334 Integrated Nursing Practice 4 course, focusing on a collaborative practice simulation centered around a patient named Mr. Dwight, who has a history of bowel cancer and is receiving palliative care. The workbook explores various aspects of Mr. Dwight's case, including his signs and symptoms prior to diagnosis, the anatomy and physiology of his hemicolectomy and colostomy, risk factors for bowel cancer, and his elevated blood glucose levels. It also delves into the use and importance of nasogastric tubes, routine checks, and social circumstances assessments in palliative care. Furthermore, the assignment analyzes assessment items in the emergency department, medication prescribed for pain management, and the prioritization of clinical assessment findings. The solution provides detailed answers to each question, incorporating relevant medical knowledge, nursing interventions, and critical thinking skills.

School of Nursing
ASSESSMENT COVER SHEET
Student Name: Student No.:
Unit Name: Integrated Nursing Practice 4
Unit Code: NSB334 Due Date:
Lecturer’s/Tutor’s Name:
Tutorial Day/Time:
Assessment No. 1 Assessment Title: Collaborative Practice Simulation
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Mr Dwight Simulation
Setting the scene
Refer to your simulation documents
Epidemiology / pathophysiology of disease processes
The National Health Priority Area of Cancer Control was established with the aim
of improving health outcomes in this area.
The most common diagnoses for cancer in men are prostate (1 in 5 males),
colorectal (1 in 11 males), melanoma of the skin (1 in 13 males) and lung (1 in 13
males). For women, the most common diagnoses are breast (1 in 8 females),
colorectal (1 in 16 females), melanoma of the skin (1 in 23 females) and lung (1 in
22 females).
Cancer screening programs have been large public health initiatives in this area
aimed at reducing illness and death resulting from cancer through an organised
approach to screening. It would be of benefit for you to research the three
cancer screening programs of BreastScreen Australia, National Cervical
Screening Program and the National Bowel Cancer Screening Program to
understand the importance of these programs and the benefits obtained.
The World Health Organisation defines palliative care as:
‘An approach that improves the quality of life of patients and their families facing
the problem associated with life-threatening illness, through the prevention and
relief of suffering by means of early identification and impeccable assessment
and treatment of pain and other problems, physical, psychosocial and spiritual.
Your own values and beliefs about death and dying may impact on your
interactions with a dying person, reflect on your own self-awareness as an
important strategy in palliative care nursing.
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Complete the following workbook questions from your simulation including the
clinical reasonining cycle:
Gain an initial impression of your patient
Question 1.
ReviewMr Dwight’s background and history. Mr Dwight has a history of bowel
cancer. What two (2) signs and symptoms might Mr Dwight have had prior to his
diagnosis? Why would these signs and symptoms have occurred?
Answer:
The two signs that might have occurred prior to the diagnosis of bowel cancer are
constipation and weight loss, accompanied with weakness and fatigue. Changes in the
bowel habit result in bowel obstruction, which contributes to constipation. This commonly
occurs due to physical blockage of the proximal colon, which in turn prevents passage of
solid, liquid or gases through the colon. Thus, formation of tumor in the far end of the colon
or in the rectum creates difficulties in the passage of the excretory wastes.This further leads
to bloating and abdominal cramps. Weight loss is another symptom that is associated with
fatigue caused by the cancer cells that use up the body’s energy. Energy is also consumed
by the immune cells that protects the physiological system by fighting against the disease.
Change in bowel habit also results in blockage of the colon that contributes to thie
unexplained weight loss and fatigue.
Question 2:
Mr Dwight has had a hemicolectomy with the formation of a colostomy. Discuss
the anatomy and physiology of this condition and the surgical procedure?
Answer:
Bowel or colorectal cancer represent a complex disorder caused due to certain genetic
alterations, which are associated with progression of the cancer from a pre-malignant lesion
to an invasive adenocarcinoma. An abnormal growth of cells is observed in the rectum or the
colon, that is a part of the large intestine. Colostomy refers to the surgical procedure of
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forming a stoma or an opening by drawing healthy end of the colon through the incision that
is made in the anterior wall of the abdomen. It is further sutured into place. This stoma in
combination with an ostomy pouching system helps in providing an alternative route for
passage of fecal matter outside the body. The process of right hemicolectomy involves an
removal of the right side of the colon, the cecum, hepatic flexure, and terminal ileum, along
with the lymph nodes and fat. through laparoscopy (Waters et al., 2012). The operation does
not encompass removal of the stoma. This helps in removal of malignant neoplasm from the
right colon. On the other hand, the procedure of ileostomy involves making a surgery in the
abdominal wall by bringing together the loop or ends of the small intestine on the surface of
the skin. It helps in collecting intestinal wastes in the artificial pouching system (Nagle et al.,
2012).
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Question 3:
What two risk factors can lead to bowel cancer?
Answer:
The 2 risk factors are:
 Sedentary lifestyle leading to excess deposition of body fat
 Significant family history of polyps or bowel cancer
Question 4:
MrDwights BGL on admission to the ED is 22 mmol. What level should a normal
BGL be? Explain MrDwights BGL reading and the interventions in place to
address his diabetes.
Answer:
Normal values of BGL ranges from 4-6.1 mmol/L during fasting. The mean normal BGL is
about 5.5 mmol/L. A BGL of 22mmol represents hyperglycemia, that suggests presence of
high blood sugar levels. The underlying factors that might have contributed to his condition
are related to increased consumption of carbohydrates, mental and emotional distress,
physical inactivity, obesity and infection. On arrival of the ambulance, Mr. Dwight reported
that he is diabetic. Thus, this increased BGL is due to the less insulin secretion in his body.
The primary intervention that should be implemented for lowering the blood glucose levels is
administration of insulin. The hormone is synthesized by the beta cells of the islets of
langerhans, located in the pancreas and effectively manages to convert blood glucose to
glycogen (Dall et al., 2014). There are 3 different types of insulin:
 Rapid acting
 Short acting
 Intermediate acting
Another intervention that can be applied is related to making dietary modifications. A holistic
nutritionist should be consulted for formulating a healthy-eating plan that has low calories
and fats and is rich in nutrients and fibers. This will also help in reducing the amount of blood
glucose.
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Review and recall knowledge on nasogastric tubes.
Question 5:
(a) Why does Mr Dwight have a nasogastric tube?
(b) What three routine checks need to occur of the nasogastric tube while situated in a
patient.
Answer:
a) A nasogastric intubation is followed in this case scenario for administering and
feeding oral agents and drugs to the patient. Mr. Dwight. He suffered from dysphagia
that resulted in difficulties in swallowing. The nasogastric tibue acts as a feeding tube
that makes it easier to consume the eatables as well as the medications. His inability
to eat due to continuous vomiting and lack of adequate food and liquid intake for the
past days made it necessary to administer him the nutrients and durgs using the
tube.
b) The 3 routine checks are as follows:
 The placement of the tube shall be verified by ausculaing air over stomach by
using a Toomey syringe (Irving et al., 2014).
 The pH content shall be checked by using a colour-coded pH paper to confirm
the presence of acidic contents in the tube.
 The length of the tube shall be marked from the nose to the tube’souter end.
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Question 6:
Why are these routine checks important?
Answer:
The routine checks are essential as they help the healthcare professionals identify presence
of any abnormalities in the insertion of the tube. Checking the pH testing of the tube helps to
verify its placement. Aspirates below 5.5 ensures that the tube has been inserted correctly.
Furthermore, the routine check also involves conduction of an x-ray that confirms the
placement prior to using the tube for feeding the patient. pH more than 6 indicates presence
of small bowel content or presence of some respiratory fluids.
Question 7:
Discuss the importance ofassessing Mr Dwights social circumstances in his
palliative care admission.
Answer:
Palliative care refers to the specialized medical care that is provided to older people
suffering from chronic illness. This kind of care focuses on providing relief from the stress
that these illnesses create on the person. There is a need to assess the social factors that
might have a role to play in delivering holistic care to the patient. This can be attributed to
the fact that research studies provide evidence for the presence of psychological distress
among one-third of palliative patients such ads, depression, anxiety and adjustment
disorder. The social circumstances act as major reflections of the psychological facet, which
refers to the physchological state of the concerned person. This helps in determining the
factors that might create a significant impact on the social life. Owing to the fact that
diagnosis of a chronic or terminal illness often leads to social withdrawal, due to immobility,
risk of infection, and recurrent hospitalizations, it is imperative to consider the circumstances
that might play a probable role in the patient’s behaviour.
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(a) Review current information
(b) Gather new information
(c) Recall knowledge (A&P, ethics, law, cultural safety)
Review current information: review and think about Mr
Dwight’s presentation, the observations that have been
carried out and what further assessment you would want
to carry out now?
Question 8:
Discuss in detail two (2) assessment items that should have occurred on Mr Dwight
in the Emergency Department.
Answer:
The 2 assessments that should have been carried out include the following:
 Triage for palliative care- This is the first stage fro determining the severity of the
symptoms presented by the patient. This determines the priority and the order of the
emergency transport and helps in sorting patients who require critical attention of the
healthcare professionals. Upon completion of this assessment, the nurses and the
physicians often label each patient and display their assessment findings, theteby
identifying the priority demands of the patient and delivering tailormade healthcare
services to meet their needs.
 Pain scale: This should also be used for all patients in combination with the complaint
that the patient presents. This helps in assigning patients with similar kind of health
complaints to a wide range of triage levels. Pain is a subjective sensation. This scale
is generally used to detect the alterations in the severity of the pain experienced by
the patients. Usually based on self-reports, the scale should have been used as an
assessment for formulating an appropriate treatment plan.
Question 9:
Discuss the medication prescribed for MrDwights pain in the palliative care unit.
Describe the mode of action of this medication and possible complications.
Discuss how this or is not the most appropriate medication for MrDwights case.
 Ms Contine- This is an opioid pain narcotic or extended release formulation of
morphine. This medication is prescribed for treating pain that ranges from moderate
to severe intensity. It contains morphine sulphate that is an opioid agonist, selective
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for the mu-receptors. It interacts with more than one classess of the receptors that
are located all over the body by binding and thereby activating the receptors in the
peri-ventricular and peri-aqueductal grey matter. These receptors are also located in
the spinal cord and the ventro-medial medulla that produces an analgesic effect and
relieves pain (Wang et al., 2012). The most common side effects of this drug include
the following:
a) Blurred vision
b) Absominal pain
c) Discomfort and pain in the chest
d) Reduced urination
e) Loss of consciousness
f) Weight gain
g) Hypertension
h) Extreme drowsiness
 However, these drugs should not be prescribed to patients suffering from breathing
difficulties or blockage in the intestine and the stomach. Mr. Dwight was suffering
from colorectal cancer. Thus, the medication should not have been administered.
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Interpret data – what does it all mean?
Question 10:
Effective and accurate clinical assessment skills are imperative for the nurse
working in emergency department. List two (2) highest priority clinical assessment
findings in Mr Dwight when he is admitted to the emergency department.
Answer:
 Respiratory rate- This assessment helps to detect the respiratory efficiency of the
geriatric patient. This refers to the number of breaths taken by a person per minute
and is usually measured at rest. Counting the number of breaths and the number of
times the chest rose helped in determining the presence of respiratory disorder. Mr.
Dwight’s RR was 24. This was beyond the range of the normal respiratory rate for an
adult (12-20), thereby indicating that he suffered from tachypnea.
 GCS- Determining the conscious state of the patient using the Glasgow Coma Scale
was another reliable assessment as it helped to predict the patient’s progression. It
helped to evaluate the impairment of consciousness in response to specific stimuli in
a patient. Mr.Dwight’s GCS score for motor, verbal and eye response showed higher
values, thereby indicating that he was conscious of his state and was not
unresponsive.
Question 11:
Effective and accurate clinical assessment skills are imperative for the nurse
working in palliative care. List two (2) highest priority clinical assessment findings
in Mr Dwight when he is admitted to the palliative care ward.
 Fall risk assessment- This is a critical priority that should be determined in case of
geriatric patients. Falls are considered as the major source of mortality and morbidity
among elederly patients. The increae of inpatient falls is influenced by cachexia (loss
of weight, fatigue, muscle atrophy and weakness), experienced by elderly patients.
Therefore, conducting an assessment of fall risk was of importance for preventing
any severe injuries or adverse events in the hospital setting. This risk assessment
would help in implementation of strategies that would improve the safety and quality
of care provided.
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 Cognition assessment- This helps in determining the presence of symptoms related
to delirium or confusional test among patients, which in turn causes a decline from
the baseline level of mental functioning. This is essential as it helps in identification of
disorganized behaviour, attention deficits, and fluctuating course. Therefore, it
facilitates accurate diagnosis of disorders that can impair thinking in the patient.
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Synthesise all information that has been collected and
processed.
Question 12:
Select three highest priority relevant nursing diagnoses for Mr Dwight in the
palliative care unit.
Answer:
 Diagnosis of the spread of metastasis by perfoming colonoscopy
 Diagnosis of impaired physical mobility with respect to loss of muscle tone and
strength
 Determination of the vital signs
What should happen to improve problems/issues and by when??
Question 13:
Discuss the three most important short-term goals for MrDwights management in
the Emergency Department.
Answer:
 Management of respiratory rate- The patient presented RR>26 that is higher than the
normal limits. This indicates that the patient should receive immediate medical
review. Thus, the goal is to increase airflow to the lungs by delivering supplementary
oxygen, using a cannula.
 Management of low heart rate- The patient presented a heart rate of 55 beats oer
minute that is associated with bradychardia or slow heart rate. Therefore, the short
term goal is to restore the heat rate by administration of medications such as,
epinephrine, atropine and dopamine.
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 Management of pain- The basic goal would be to reduce the perceived levels of pain
during the stay in the ED. This will help in reducing discomfort of the patient.
Administration of accurate analgesics such as acetaminophen will act on the central
and the peripheral nervous system and help in providing relief. Nonsteroidal anti-
inflammatory drugs can also be administered for reducing pain severity.
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Question 14:
Compare your answers in Q11 to what might be the three most important short-
term goals in the palliative care unit.
Answer:
 Reducing fall risks- Prevention of fall related fatal and non-fatal injuries will be one
major short term goal in the palliative ward. This can be brought about increasing the
lithting in the ward, removing all kinds of clutters from the passages, installing grab
bars in the showers, installation of bed rails and alarm bands that will give an alert
when the patient tries to get out of the bed.
 Improving cognition in the elderly- Cognitive impairment in older adults often occurs
due to side effects of medications, thereby causing delirium.The short term goal
would be to engage in an effective and meaningful conversation, asking for their
opinions, encouraging them to learn new hobbies, and solving puzzles. This would
create significant improvements in the cognitive skills of the person.
 Providing venous access- This would allow sampling of the blood, along with
administration of several medications and fluids. This would be achieved by insertion
of intravenous cannula.
What action/interventions will you do?
Question 15:
When caring for a person with a life-limiting illness, you also need to care for the
caregivers. Consider Mr Dwight and his social circumstances – list one strategy to
use to ensure that MrDwights family are considered in his care.
Answer:
It is essential to involve the family members while delivering patient centred care as the
family has an accurate perception of the health beliefs, demands and needs of the patient,
suffering from a chronic or terminal illness. Research evidences suggest that clinicians and
patients often have different views on the health goals (Barry & Edgman-Levitan, 2012).
Family members do not just act as passive observers, but adorn the role of important
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decision makers. Owing to his old age and reluctance to get admitted in the palliative care
unit of the hospital, it is of utmost necessity to involve his wife and three sons while deciding
for the therapeutic interventions that are intended to be implemented upon him. This will
create provisions for the family members to actively participate in monitoring the outcomes of
the proposed interventions and an effective conversation with the physicians will help them
to modify the action plan accordingly. Thus, it helps in managing chronic illness and avoids
complications and flare-up. They will be able to convince him to show compliance to the
treatment at the palliative care unit.
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Question 16:
Identify three (3) multi-disciplinary clinicians that you may refer Mr Dwight to?
Justify one in detail as to why it would be of beneficial to refer Mr Dwight to.
Answer:
Three multi-disciplinary clinicians who will be consulted for providing Mr. Dwight a holistic
healthcare service are a physiotherapist, a nutritionist and oncologist.
 Role of the physiotherapist- The physiotherapist will be a highly qualified primary
care practitioner eho will be able to manage the physical limitations in the patient. He
will be able to assess the effectiveness of particular modalities and interventions for
movement dysfunction, and musculoskeletal abnormlities that makes the patient
immobile. He will be able to use a wide range of treatment options that will help in
restoring function and movement, thereby relieving pain and preventing further
problems. The tailor made programs implemented by the physiotherapist will help in
strengthening his posture, muscle and improving the overall fitness.
Assess the effectiveness of actions
Question 17:
List two signs and symptoms that would indicate that MrDwights goals are being
achieved in the Emergency Department.
Answer:
 An increase in the heart rate that makes the levels reach the normal value between
70-80 beats per minute will indicate an improvement in the physiological conditions.
The common signs that will indicate this increase are elevated pulse rate. This will
help in assessing that arrhythmia has reversed and the condition is no longer life-
threatening. This can be achieved by adherence to proper mediction and dietary
changes.
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 A reduction in respiratory rate near 20-22 breaths per minute will also indicate that
the patient is not putting in much respiratory effort and the is a lowering of the
blockage in the airways. Thus, the breathing passages will get opened up, thereby
indicating an overall improvement in his condition. This can be brought about by
administration of intravenous fluids, gavage feedings and supplemental oxygen
through masks or cannulae.
Thus, an improvement in the above two physiological features will indicate that the goals
related to Mr. Dwight’s treatment are being achieved.
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What have you learned from this experience?
Question 18:
Why could the clinical use of blood and blood products be necessary for a patient
with cancer?
Answer:
Most cancers in the digestive system result in internal bleeding due to anemia (low amount
of RBCs). Furthermore, cancer cells that spread out in the bone marrow result in low blood
count. This thereby affects organs such as the spleen and the kidney. Drugs such as,
adriamycin and cytoxan also affect the bone marrow, leading to low blood count. Thereofre,
cancer patients may need blood or blood products.
Question 19:
If Mr Dwight were to commence on chemotherapy why would he have particular
safety risks?
Answer:
He would have particular safety risksdue to the following reasons-
 Chemotheraoy can create infection of the white blood cells.
 It can result in bleeding due to low platelet count
 It can also result in anemia from low hemoglobin
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Question 20:
What are the particular issues for patients undergoing chemotherapy that put them
at higher risk of Healthcare Associated Infections?
Answer:
Chemotherapy resuts in a drop in the count of white blood cells or neutropenia, which in turn
increases the risks of infection. These low levels of WBCs susally get recovered over time.
However, the issues associated with the higher risks of infection are as follows-
 A feeling of cold and shivers
 Running a high temperature around 37.5oC or 38oC, depending on the dose of
radiation that a patient is subjected to
 Headaches
 Lethargic feeling
 Muscle ache
 It suppresses the immune system depending on the patient’s age, the chemo drug
that is administered, the nutritional status of the person and the stage of cancer
(Nesher & Rolston, 2014).
 Old age beyong 65 years
 Unintentional weight loss
 Bed-bound or failure to take self care
 Associated complications of diabetes, high blood pressure, emphysema, bronchitis or
renal disorder
Thus, the aforementioned factors along with the strength of the chemotherapy increases
the risks of acquiring infection.
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Question 21:
Complete the nursing care plan below from the Palliative Care simulation. You will need to include all assessment data but then
choose the two highest priority nursing problems to address in planning, implementing and evaluating.
Answer:
Assessment (Subjective
and objective data)
Identification
(Patient Problem)
Planning (patient goals) Implementation
(Nursing/collaborative
interventions)
Evaluation
(Evaluation criteria)
Subjective- ‘My bowel
cancer will worsen if I
eat’ as verbalized by the
patient Mr. Dwight
Objective-
Request for medical
history, tendency to
show non-compliance to
treatment, vital signs
measured
Risk for lack of
knowledge on the
benefits of palliative
care services
After a close
assessment of the vital
signs, pain scores, and
state of consciousness
in the emergency
department, the patient
will be made to
verbalise the
understanding of his
colorectal cancer and
the treatment regimen.
Assisting the patient in
modifying his dietary
pattern
Providing help during
movement and carrying
out of daily activites
Reinforcing the
impprtance of showing
adherence to treatment
regimen
After 24 hours of
nursing ntervention, the
patient will be able to
understand the
importance of following
the interventions
implemented in the
palliatve care ward.
Subjective- ‘Why can I
not perform daily
activities all by myself?’
as verbalized by Mr.
Dwight
Objective-
Lack of knowledge on
the musculoskeletal
disorders
After a detailed analysis
of the limb strength and
the pain scale, the
patient will be made to
interact with a
physiotherapist to
understand the needs of
Consulting a
physiotherapist for
implementing effective
excersie strategies
Capability to perform
simple tasks such as
dressing, feeding and
walking short distances
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Measurement of the
pain score and the limb
strength
moderate exercises that
will increase muscle
strength
References
Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—the pinnacle of patient-centered care. New England Journal of
Medicine, 366(9), 780-781.
Dall, T. M., Yang, W., Halder, P., Pang, B., Massoudi, M., Wintfeld, N., ... & Hogan, P. F. (2014). The economic burden of elevated blood
glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes care, 37(12),
3172-3179.
Irving, S. Y., Lyman, B., Northington, L., Bartlett, J. A., Kemper, C., & NOVEL Project Work Group. (2014). Nasogastric tube placement and
verification in children: review of the current literature. Nutrition in Clinical Practice, 29(3), 267-276.
Nagle, D., Pare, T., Keenan, E., Marcet, K., Tizio, S., & Poylin, V. (2012). Ileostomy pathway virtually eliminates readmissions for dehydration in
new ostomates. Diseases of the Colon & Rectum, 55(12), 1266-1272.
Nesher, L., & Rolston, K. V. (2014). The current spectrum of infection in cancer patients with chemotherapy related
neutropenia. Infection, 42(1), 5-13.
Wang, X., Loram, L. C., Ramos, K., de Jesus, A. J., Thomas, J., Cheng, K., ... & Yin, H. (2012). Morphine activates neuroinflammation in a
manner parallel to endotoxin. Proceedings of the National Academy of Sciences, 109(16), 6325-6330.
Waters, J. A., Rapp, B. M., Guzman, M. J., Jester, A. L., Selzer, D. J., Robb, B. W., ... & George, V. V. (2012). Single-port laparoscopic right
hemicolectomy: the first 100 resections. Diseases of the colon & rectum, 55(2), 134-139.
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