NSB334: Integrated Nursing Practice 4 Workbook - Mrs. Ruby Pascal

This workbook assignment for NSB334 Integrated Nursing Practice 4 focuses on the case of Mrs. Ruby Pascal, a patient with multiple comorbidities including obesity, type 2 diabetes, and anxiety. The assignment delves into the pathophysiology, signs, and symptoms of diabetes, as well as lifestyle factors influencing the condition. It also addresses a pulmonary embolism scenario, including signs, symptoms, risk factors, and the role of anticoagulation therapy. Furthermore, it explores nursing interventions based on the National Safety and Quality Health Service Standards, communication strategies for patient-centered care, and interdisciplinary team involvement in discharge planning. The assignment emphasizes clinical assessment skills, prioritizing patient care, and the importance of effective communication and teamwork in nursing practice.

NSB334 Integrated Nursing Practice 4
Mrs. Ruby Pascal Simulation
Setting the scene
Refer to your simulation documents
Epidemiology/pathophysiology of disease processes
The National Health Priority Areas of Obesity, Diabetes Mellitus and Mental Health was established with
the aim of improving health outcomes in all these areas.
Excess weight, especially obesity, is a major risk factor for cardiovascular disease, type 2 diabetes, some
musculoskeletal conditions, and some cancers. As the level of excess weight increases, so does the risk
of developing these conditions. In addition, being overweight can hamper the ability to control or manage
chronic conditions.
The main factors influencing overweight and obesity are poor diet and inadequate physical activity.
Increased energy intake from the diet without an increase in energy expenditure through physical activity
will result in energy storage as fat and weight gain.
Diabetes is a chronic condition marked by high levels of glucose in the blood. The main types of diabetes
are type 1 diabetes, type 2 diabetes, and gestational diabetes. The prevalence of diabetes has been
escalating over the last 3 decades, with rates tripling over this period—diabetes affected around 1.2
million people in 2014–15. Rates of diabetes are generally higher among males, the elderly, Indigenous
Australians and people living in remote and socioeconomically disadvantaged areas. Type 2 diabetes is
the most common form and is largely preventable by maintaining a healthy lifestyle.
Mental illness comprises a wide range of disorders and varies in its severity. The effect of mental illness
can be severe on the individuals and families concerned and its influence is far-reaching for society as a
whole. Around 7.3 million Australians aged 16–85 (45% of that age group) will experience a common
mental disorder such as depression, anxiety or a substance use disorder in their lifetime, according to the
2007 National Survey of Mental Health and Wellbeing. Estimates from the second National Survey of
Psychotic Illness conducted in March 2010 suggest that almost 64,000 people have a psychotic illness
and are in contact with public specialized mental health services each year.
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WORKBOOK QUESTIONS
1. Review patients background and history. Ms. Ruby Pascal has multiple comorbidities
including obesity, diabetes mellitus type 2 and general anxiety disorder. Choose
Diabetes mellitus type 2 comorbidity and complete the following questions.
a. Discuss the anatomy and physiology of the chosen comorbidity (Diabetes
mellitus type 2).
Diabetes mellitus type 2 is a metabolic disorder marked by high insulin
resistance whereby body tissues or cells do not respond accordingly to insulin
action. Insulin resistance occurs primarily in the liver to cause excessive
release of glucose into the bloodstream, in the adipocytes to cause excessive
lipid breakdown and in the muscles to cause impaired glucose transport,
phosphorylation, and oxidation as well as impaired glycogen storage resulting
in hyperglycemia. Current studies have proven that this resistance is highly
attributed to genetics and inactivity or lack of exercise(Pedersen & Febbraio,
2012). There is also decreased, but not lack of, production of insulin by the
pancreatic beta cells of Langerhans leading to impaired blood glucose control
and marked hyperglycemia. ( Weir & Bonner‐Weir, 2013).
(2 marks)
b. Identify two (2) signs and/or symptoms of the chosen comorbidity (Diabetes
mellitus type 2). Discuss how each sign and/or symptoms support the
diagnosis of the chosen comorbidity.
 Increased random blood glucose levels above 11 mmol/ L- Ms. Ruby
Pascal has a blood glucose level of 16 mmol/ L.
 Excessive weight gain characterized by a basal metabolic index of
more than 25- Ms. Ruby has a basal metabolic index of more than 35.
c. Identify two (2) lifestyle factors that may have impacted/influenced the chosen
comorbidity. Justify your answer.
 Lack of exercise, as stated in Ms. Ruby' s history. Exercise is efficient
when it comes to improving blood sugar control as well as decreasing
body fat content leading to better insulin sensitivity. However, lack of it
leads to high accumulation of fats resulting in obesity that contributes
to high insulin resistance hence diminished or impaired insulin action
and consequently the development of diabetes mellitus type 2.( Hardy,
Czech & Corvera, 2012).
 Unhealthy diet, as evident in Ms. Ruby' s history, also predisposes
one to develop type 2 diabetes mellitus. A diet containing high
amounts of fats and carbohydrates does no good to the levels of
glucose in the blood. as the high amount of fats encourage insulin
resistance hence impaired blood glucose level regulation. Pandey,
Chawla & Guchhait, 2015). (4 marks)
2. Ms. Pascal acutely deteriorated in the first simulation scenario due to a pulmonary
embolism. Please read the first simulation scenario.
a. List four (4) signs and/or symptoms of a pulmonary embolism.
 Severe chest pain which becomes worse when the patient breathes
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 Increased heart rate above the normal range of between 12 to 20
breaths per minute
 Productive cough sometimes containing bloody sputum
 Shortness of breath and rapid shallow breathing
(2 marks)
b. Identify and discuss two (2) risk factors of the primary diagnosis and how
they contributed to the acute deterioration.
 Prolonged immobilization as evidenced by her lack of exercise,
predisposed her to have a pulmonary embolus. Immobilization
increases the risk of alteration in blood flow by slowing down blood
circulation thereby increasing its chances of pooling and forming a clot
within the blood vessels causing a pulmonary embolism. ( Monreal, et
al 2015).
 Obesity with a basal metabolic index of more than 35 is a risk factor.
Some of the excess fats in the body end up deposited on the blood
vessel walls. At some point, a bit of it might slough off and get into the
bloodstream as a fat embolus. This leads to clogging of blood vessels,
especially arteries since they have narrower lumen than veins, and in
this case, pulmonary artery, thereby causing a pulmonary embolism.
(4 marks)
3. Review Standard 8 of the NSQHS. Identify and discuss two (2) risk factors that
increase Ms. Pascal's risk of deterioration. Justify each risk with evidence.
Prolonged hospital bed rest. The patient is in pain and needs medical attention and
close monitoring which restricts her from staying in bed with minimal movement if
any. This immobility slows down blood circulation thereby increasing the chances of
forming an embolus that clogs arteries leading to deterioration in her condition. (Yang,
et al 2015).
Anxiety, as mentioned in Ms Ruby’s history, after her husband was diagnosed with
cancer and has now worsened considering his admission to the hospital in addition to
their young family that she has the sole responsibility to provide for, is one of the risk
factors escalating formation of clots in the pulmonary artery and consequently
pulmonary embolism. ( Geiser et al, 2017)
(4 marks)
4. During the second scenario, Ms. Pascal requires anticoagulation therapy. In
relation to Ms. Pascal's clinical scenario.
a. Discuss the role anticoagulants in the treatment and management of
pulmonary embolism.
 The anticoagulants inhibit synthesis or formation of specific clotting
factors thereby preventing the formation of blood clots. Recent studies
have proven that low molecular weight heparin, (LMWH), to be more
effective in reducing bleeding as compared to unfractionated heparin,
(UFH). ( Saro & Palta 2014).
(1 mark)
b. Identify two (2) contraindications of anticoagulants. (1
mark)
 Severe active bleeding, for example, in platelet defect or
thrombocytopenia or a recent major surgery such as brain surgery or
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peptic ulcer disease or a history of intracranial hemorrhage is an
absolute contraindication.
 Low molecular weight anticoagulants should be avoided in patients
with renal failure or insufficiency as this will exercabate their condition
since their primary route of clearance is the kidney.
c. Review Standard 4 of the NSQHS. Using the standard and relevant literature,
list four (4) actions required of the registered nurse to ensure safety when
managing and administering anticoagulants.
 Safe documentation of patient information regarding medication
history, including allergies and adverse drug reactions and even the
medications they are currently using so as to ensure that the drugs
administered are safe and not harmful.
 A careful review of the patient's medication and information about their
needs and risks for clarification purposes and to avoid making
unnecessary medical mistakes in administering medications.
 Administration and close monitoring of the patient in the process in
order to observe any changes in the condition of the patient in
response to the medication being administered and act promptly and
accordingly.
 Safe disposal of instruments or medication containers after
administering medication so as to prevent spreading infections and
also to protect themselves and the patient from any physical harm as
a result of careless waste disposal. (2 marks)
d. Compare the difference between enoxaparin and warfarin. (2
marks)
Warfarin is a vitamin K anticoagulant administered orally and has a higher risk
of bleeding thus requires close monitoring in a hospital set up whereas
enoxaparin is low molecular weight heparin administered subcutaneously and
does not require monitoring, therefore, can be administered not just in the
hospital but even at home. (Bleker et al, 2016)
5. Communication is an integral part of nursing, with an emphasis on person-centered
care.
a. Identify two (2) communication strategies integral to person centred care.
 Active listening by maintaining an upright posture, keeping eye
contact, putting down necessary points and paraphrasing what the
other person says occasionally.
 Being open to patient feedback. Allow them to verbalize their concerns
freely without intimidating or judging them by creating a warm and
accommodative environment. Ensure they have understood the
relevant details pertaining to their health by asking them to paraphrase
the information given.
(1 mark)
b. Discuss and justify how each chosen communication strategy is important to
Ms. Pascal's hospital admission.
 Active listening, which involves paying maximum attention by
maintaining an upright posture and eye contact, understanding,
responding as well as recalling information, enables the nurse to
obtain a comprehensive history from the patient and put down all the
necessary details so as to administer relevant care and treatment
appropriately. (Bramhall, 2014).
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 Being open to patient feedback assures the nurse that the information
they have provided is well understood thus earning the client’s full
cooperation in the course of treatment thereby quickening the process
of recovery. (Riley, 2015) (2 marks)
6. Ms. Pascal has been referred to a general practitioner and diabetes educator for
discharge. Identify two (2) more interdisciplinary team members or teams who
potentially would be involved in discharge or discharge planning for Ms. Pascal.
Justify their involvement in Ms. Pascal’s care demonstrating an understanding of the
team’s involvement in discharge care.
 Nutritionist and dietitian: with the help of the patient, they draw up a
reasonable and affordable meal plan that will ensure low carbohydrate and fat
intake that will curb obesity thereby increasing the body’s insulin sensitivity
and in the long run managing diabetes mellitus type 2. (Sabour, 2015)
 Exercise therapist: together with the collaboration of the patient the exercise
therapist can promote physical fitness by incorporating repetitive physical
activities that ensure excess fat breakdown which increases the body’s
sensitivity to insulin thus managing diabetes mellitus type 2. (Kisner Colby &
Borstad, 2017) (4 marks)
Provide responses to either questions 7-10.
Questions directly related to Ms. Ruby Pascal Admission to the Ward Scenario:
7. Effective and accurate clinical assessment skills are imperative for the nurse working
with Ms. Pascal at all times. Identify and discuss (1) clinical priority for Ms. Pascal
who is rapidly deteriorating. Justify the priority with evidence.
Acute chest pain which gets worse on breathing related to pulmonary embolism
evidenced by patient guarding the area of pain and verbalizing pain of scale 5/10.
(Berliner et al, 2016)
(3 marks)
8. From the identified clinical priority in the ward, state one (1) short term goal for Ms.
Pascal’s management using the SMART framework.
The patient to be able to verbalize alleviated pain after thirty minutes following
administration of medication and breathe at a normal respiratory rate of more than 12
but less than 20 breaths per minute without feeling pain.
(2 marks)
9. Based on the short-term goal, state and describe (2) interventions (nursing,
collaborative or pharmacological) which would assist to achieve Ms. Pascal’s short-
term goal.
 Prescribe and administer IV morphine 4.6 mg, giving 1-2 mg as a slow bolus
every 5-7 minutes till the pain is relieved. (Pavlovic et al, 2014)
 Nurse the patient in Fowler’s position so as to relieve the chest pain as this is
the most comfortable position when having chest pain. (4 marks)
10. Provide and justify two (2) methods of how you would evaluate the outcomes.
 Physical examination of the patient to assess the level of pain evidenced by
non- verbal cues such as grimacing or guarding and their preferred sitting
position. Leaning forward with their hands on their knees could mean they are
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still in pain. They should be relaxed and comfortable sitting in Semi- Fowler’s
position.
 Direct communication with the patient asking them to describe any changes in
the way they feel provides feedback on the targeted symptoms which would
otherwise be difficult to evaluate physically. Let them describe their level of
pain compared to before administering medications and assess whether you
should continue, stop or change the regimen.
(4 marks)
References
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Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of
dyspnea. Deutsches Ärzteblatt International, 113(49), 834.
Bleker, S. M., Cohen, A. T., Büller, H. R., Agnelli, G., Gallus, A. S., Raskob, G. E., ... &
Middeldorp, S. (2016). Clinical presentation and course of bleeding events in patients
with venous thromboembolism, treated with apixaban or enoxaparin and warfarin.
Thrombosis and haemostasis, 116(12), 1159-1164.
Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard
29(14), 53.
Geiser, F., Urbach, A. S., Harbrecht, U., Conrad, R., Pötzsch, B., Amann, N., ... & Skowasch,
D. (2017). Anxiety and depression in patients three months after myocardial
infarction: association with markers of coagulation and the relevance of age. Journal
of psychosomatic research, 99, 162-168.
Hardy, O. T., Czech, M. P., & Corvera, S. (2012). What causes insulin resistance underlying
obesity?. Current opinion in endocrinology, diabetes, and obesity, 19(2), 81.
Kisner, C., Colby, L. A., & Borstad, J. (2017). Therapeutic exercise: Foundations and
techniques. Fa Davis.
Monreal, M., Mahe, I., Bura-Riviere, A., Prandoni, P., Verhamme, P., Brenner, B., ... &
Bertoletti, L. (2015). Pulmonary embolism: Epidemiology and registries. La Presse
Médicale, 44(12), e377-e383.
Palta, S., Saroa, R., & Palta, A. (2014). Overview of the coagulation system. Indian journal
of anaesthesia, 58(5), 515.
Pandey, A., Chawla, S., & Guchhait, P. (2015). Type‐2 diabetes: Current understanding and
future perspectives. IUBMB life, 67(7), 506-513.
Pavlovic, G., Banfi, C., Tassaux, D., Peter, R. E., Licker, M. J., Bendjelid, K., & Giraud, R.
(2014). Peri‐operative massive pulmonary embolism management: is veno‐arterial
ECMO a therapeutic option?. Acta Anaesthesiologica Scandinavica, 58(10), 1280-
1286.
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Pedersen, B. K., & Febbraio, M. A. (2012). Muscles, exercise, and obesity: skeletal muscle as
a secretory organ. Nature Reviews Endocrinology, 8(8), 457.
Riley, J. B. (2015). Communication in nursing. Elsevier Health Sciences.
Sabour, S. (2015). Validity and reliability of the new Canadian Nutrition Screening Tool in
the'real-world' hospital setting Methodological issues. European journal of clinical
nutrition, 69(7), 864.
Weir, G. C., & Bonner‐Weir, S. (2013). Islet β cell mass in diabetes and how it relates to
function, birth, and death. Annals of the New York Academy of Sciences, 1281(1),
92-105.
Yang, S., Yang, Y., Zhai, Z., Kuang, T., Gong, J., Zhang, S., ... & Wang, C. (2015).
Incidence and risk factors of chronic thromboembolic pulmonary hypertension in
patients after acute pulmonary embolism. Journal of thoracic disease, 7(11), 1927.
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