NSB334 Integrated Nursing Practice 4: Simulation Workbook Report

This report provides answers to a collaborative practice simulation workbook related to NSB334 Integrated Nursing Practice 4. The simulation focuses on Mrs. Ruby Pascal, addressing various aspects of her care including type 2 diabetes, pulmonary embolism, and anxiety. The report covers the anatomy and physiology of type 2 diabetes, signs and symptoms, lifestyle factors, and risk factors for pulmonary embolism. It also discusses the NSQHS standard 8, risk factors for clinical deterioration, anticoagulants, communication techniques for person-centered care, interdisciplinary team members for discharge planning, clinical priorities, and short-term goals using the SMART framework, along with related interventions. The simulation emphasizes the importance of addressing psychological comfort and improving coping mechanisms for patients with anxiety.

School of Nursing
ASSESSMENT COVER SHEET
Student Name(s): Student No.(s):
Note: If this is a group assessment submission, please list the student name and
numbers of all group members in the above box.
Unit Name: Integrated Nursing Practice 4
Unit Code: NSB334 Due Date: Week 11, Friday 17th
May 2019 at 11:59pm
Lecturer’s/Tutor’s Name: Christina Parker/Karen Wynne
Tutorial Day/Time:
Assessment
No.
2 Assessment Title: Collaborative Practice Simulation
Workbook

Answer 1:
a. Anatomy and physiology of type 2 diabetes: Pancreas and hormones produced by
pancreas like insulin are the main anatomical structure involved in diabetes. The co-
morbidity of type 2 diabetes occurs because of pathophysiological alterations in these
structures and impaired production of insulin hormone (Eguchi & Nagai, 2017). In case
of type 2 diabetes, inadequate production of insulin hormone results in dysfunction of
the pancreatic beta cells and insulin resistance. Insulin resistance results in impaired
function of insulin thus leading to impaired glucose tolerance.. Relative deficiency in
insulin is a common physiological mechanism in patients with diabetes and this is
associated with insulin resistance too. Hence, diagnosis of diabetes is associated with
significant changes in the physiology of the endocrine pancreas and the alpha and beta
cells. The symptom of hyperglycemia is seen following combination of mechanisms like
resistance to insulin, inappropriate secretion of glucagon and inadequate insulin
secretion (Zaccardi et al., 2016).
b. Two sign and symptoms of the type 2 diabetes include frequent urination and fatigue
(Amiri, 2016). Frequent urination supports the diagnosis of diabetes mellitus because
urination is the first sign that denotes high blood sugar level is seen in the body of
patients with diabetes. This symptom emerges because of impaired insulin secretion
and insulin resistance. Impaired insulin secretion is the condition in which glucose
responsiveness decreases and insulin resistance is a condition in which insulin does
exert sufficient action according to blood concentration. As sugar builds up in the body
following pathophysiological changes in the pancreatic cell, the kidneys are forced to
work overtime to absorb the excess sugar. As kidneys fail to keep the load, excess

blood sugar is excreted into the urine along with other fluids. This form of changes gives
the perception to people to urinate frequently (Hadjadj et al., 2016). Hence, for this
reason, the symptom of frequent urination is linked to diagnosis of diabetes. For this
reason only, urine is a common test done in diabetic patient as it helps to detect excess
amount of glucose in the urine.
In addition, symptom of fatigue also supports diagnosis of diabetes because
increases urination leads to dehydration and decreases body’s ability to function
properly. As less number blood sugar is utilized for energy needs, it leads to symptom
of fatigue. Singh et al. (2016) gives the evidence that fatigue is a persistent symptom in
people with type 2 diabetes and it is linked to episodes of hyperglycemia in patient.
c. Two lifestyle factors that might have influenced development of type 2 diabetes
include sedentary lifestyle and smoking. This is said because low sedentary behaviour
is inversely associated with type 2 diabetes. Hamilton, Hamilton and Zderic (2014)
shows that increased sitting time is associated with greater risk of type 2 diabetes.
Smoking also influences diabetes because heavy smoking is associated with
higher risk of serious complications in diabetic patients such as heart disease and
kidney problem. Smoking increases inflammation and oxidative stress, thus leading to
direct damage of beta cell function and impairment of endothelial function (Chang,
2012).
Answer 2:
a. Four sign and symptoms of pulmonary embolism include cyanosis, leg pain or
swelling, excessive sweating and dizziness (Di Nisio, van Es & Büller, 2016).

b. Two risk factors of pulmonary embolism include obesity and cigarette smoking.
Being obese increased the risk of deterioration in patients experiencing
pulmonary embolism because obesity has impact on the respiratory system and
changes in respiratory mechanics due to obesity (Zammit et al., 2010).
In addition, cigarette smoking also deteriorate condition of patient. Several
studies have revealed about the association between cigarette smoking and
pulmonary embolism. Cigarette smoking is associated with increased risk for
VTE. Hence, reviewing of medical history of cigarette smoking in a patient can
explain the cause behind pulmonary embolism (Cheng et al., 2013).
Answer 3:
The standard 8 of the NSQHS focus on recognising and responding to acute
deteriorations. Two risk factors that increases Mrs. Pascal’s risk of clinical deterioration
includes chest pain and repeated admission to the hospital because of chest pain. This
clinical symptom might be a risk factor of future deterioration of symptoms as chest pain
might be an indicator of cardiovascular disease like myocardial infarction and angina.
Hence, delay in addressing chest pain symptom may deteriorate severity of pain and
even lead to death. Riley (2015) gives the evidence that acute onset of chest pain and
repeated hospitalization increases risk of heart failure and due to high risk of clinical
deterioration, the patient may require invasive cardiopulmonary support.
The second risk factor for acute deterioration in Mrs. Pascal includes history of
general anxiety disorder and worsening of anxiety. This may increase risk of acute
mental health deterioration as prolonged period of anxiety may predispose patient to
risk of depression. The patient may even engage in self-harm activities due to

deterioration of symptoms. Dewa et al. (2013) gives the evidence that sign and
symptoms of self-harm, anxiety and aggressions are factors relating to deterioration and
worsening of mental health symptoms should be taken with precaution as it will lead to
severe symptoms for patients such as psychosis, depression, mania and suicidal
thoughts or behaviour.
Answer 4:
a) Anticoagulants are the mainstay for the treatment and management of pressure
ulcers as use of anticoagulant is associated with decrease in recurrent
symptomatic venous thromboembolism. It helps to achieve faster pulmonary
reperfusion (Agnelli & Becattini, 2015).
b) Two contraindications of anticoagulants include severe active bleeding and
severe hypertension (Adderley, Ryan & Marshall, 2017).
c) Four nursing actions need to ensure safety while managing and administering
anticoagulants includes the following:
 Close monitoring of patient and conducting head to toe assessment of patient
to identify risk of bleeding and other side effects is important for the safety of
patient
 Patient education is also vital while administering anticoagulants to patient as
patients must be aware about risk of blood and the need to quickly inform
them when detecting such symptoms
 The six rights of medication administration should be followed to ensure that
right dose of anticoagulant is delivered through the right route.

 Nurse should take the approach to analyze interaction of anticoagulant with
other drugs and assess other medications used by patient as certain drugs
like nitroglycerine and protamine sulphate are antagonist to heparin. Any form
of drug incompatibilities should also be considered (Gee, 2018).
Answer 5:
1. Active communication with patient and expressing empathy are two
communication techniques integral for person centred care.
2. Active communication and engagement is vital for Mr. Pascal’s hospital
admission to build therapeutic relationship with patient and ensure that Pascal
has full trust on the medical team. Active engagement with patient may help to
identify the cause behind anxiety and any psychosocial issue that is leading to
increased risk of anxiety for Ms. Pascal. Research evidence shows that when
patient and staff engage in collaborative communication process, the quality of
shared decision making, self-reported health status, patient satisfaction level,
adherence to self-management behaviours and emotional health improves
(Schoenthaler et al., 2014). Active communication can help to achieve the same
outcome for Ms. Pascal too which would aid in her speedy recovery.
The communication skill of expressing empathy can help in exploring emotional
response of Ms. Pascal related to the care provided and understand who the patient is
psychologically prepare is manage her illness. Empathy can play an important role in
alleviating pain and suffering for the client. In case of Pascal, empathy can help in

satisfaction of the women with the care by increasing efficacy in communication
process, promoting therapeutic adherence and success of treatment. It also a patient
centered care approach that demonstrates respect to patient (Mudiyanse, 2016).
Answer 6:
Two more interdisciplinary team members who needs to be involved in discharge
planning for Ms Pascal includes the dietician and the clinical psychologist. The dietician
needs to be involved to ensure that Ms. Pascal take adequate food that maintains her
BMI and controls her weight. She has BMI of 35 which indicates she falls under the
obese category. As obesity can lead to additional health issues for Ms. Pascal, there is
a need to ensure that she takes important nutrients in adequate amount. Another
rationale for including dietician in discharge planning is that Ms. Pascal is suffering from
anxiety disorder and it is possible that she might leave the hospital in a poor nutritional
state. Hence, involvement of dietician will help to promote good nutrition and address
any nutritional deficiencies. Consulting dietician can help to improve body weight and
enhance recovery of patient by reducing admission rate (Laur et al., 2018).
The involvement of clinical psychologist is important in discharge planning as Ms.
Pascal had been admitted to the hospital for presentation of increasing anxiety twice
before also and the psychologist may help to plan appropriate strategy to treat her
anxiety. Psychologist can work to identify care needs for Ms. Pascal and inform the
family about coping style that Ms. Pascal needs to adapt to avoid recurrence of anxiety
symptoms. This will help patient to get adequate psychological support and overcome
the disease with hope and confidence (Yu & Yu, 2017). The psychologist can also help
to identify whether the patient is in need of any counselling session or not.

Answer 11:
As Ms. Pascal’s symptom had deteriorated because of increase in anxiety
symptoms , one clinical priority will be to increase psychological comfort for patient and
improve coping mechanism to help patient cope with anxiety attacks. Focusing on
promoting nurse-led self-management support is important to improve psychological
comfort for patient, encourage patient adapt positive coping skills and adhere to
medication regimen. Adequate support will encourage Ms. Pascal to verbalize her
needs and understand method to correctly take all the medications. Evidence has
revealed that nurse can play a major role in enhancing self-management skills of patient
with anxiety (Zimmermann et al. 2016). In case of Ms. Pascal, self-management support
may focus on enhancing self-care needs of the patient by engaging her in exercise
regimen, proper relaxation techniques and taking medications correctly.
Answer 12:
One short term goal that has been identified in relation to the clinical priority of
achieving psychological comfort for Ms. Pascal is to develop coping skills of patient to
appropriately response to anxiety attacks.
The short term goal as per the SMART framework are as follows:
 To develop coping skill of Ms. Pascal (specific)
 To assess development of coping skill by improvement in medication adherence,
following self-management advice and adapting relaxation techniques
(Measurable)
 To achieve the result by means of nurse-led psyschological support intervention
(Attainable)

 To achieve symptom control and prevent admissions to hospital for anxiety
attacks
 To achieve the desired result within 3 months
Answer 13:
To achieve the short term-goal, the following two intervention can help in promoting
health of Ms. Pascal:
1. Nurse led self-management support intervention can help to achieve the SMART
goals. A research investigating about nurse-led intervention to promote self-
management in patients with anxiety disorder has revealed that such intervention
increase self-efficacy of patients in managing their symptom (Zimmermann et al.,
2016). Another research justified that self-management support can help carers
to identify what strategies patients used for overcoming anxiety and give them
proper direction to cope with anxiety and control the symptoms (Shepardson,
Tapio & Funderburk, 2017).
2. The second intervention that is important for the recovery of Ms. Pascal includes
implementation of patient education using pamphlets. This can educate patient
about self-management technique and daily medications to be taken. It can also
include other elements like daily medication regimen, diabetes care, dietary plan
and type of physical activity to be done on a daily basis (Al Hayek et al., 2013).
Answer 14:
The outcome of the patient can be evaluated by two methods. The first method is
the assessment of anxiety symptom in patient by the use of tool like global assessment
of anxiety. The main advantage of using this tool is that it works to assess mood,

cognitions and behaviour of people thus giving the idea regarding reduction in severity
of symptoms for Ms. Pascal (Rose & Devine, 2014). Another method that can help to
evaluate the outcome of patient includes the use of questionnaire to understand the
experience of patient in relation to following nurse’s self-management related advice
and finding out barriers faced in implementing the advice. This may help to gain
subjective and objective data related to improvement in symptoms of Ms. Pascal. This
can help to identify how far the intervention was successful in achieving positive health
outcome for Ms. Pascal.

References:
Adderley, N., Ryan, R., & Marshall, T. (2017). The role of contraindications in
prescribing anticoagulants to patients with atrial fibrillation: a cross-sectional
analysis of primary care data in the UK. Br J Gen Pract, 67(662), e588-e597.
Agnelli, G., & Becattini, C. (2015). Anticoagulant treatment for acute pulmonary
embolism: a pathophysiology-based clinical approach. European Respiratory
Journal, 45(4), 1142-1149.
Al Hayek, A. A., Robert, A. A., Al Dawish, M. A., Zamzami, M. M., Sam, A. E., & Alzaid,
A. A. (2013). Impact of an education program on patient anxiety, depression,
glycemic control, and adherence to self-care and medication in Type 2
diabetes. Journal of family & community medicine, 20(2), 77-82.
Amiri, M. (2016). Diabetes mellitus type 2; an international challenge. Annals of
Research in Dialysis, 1(1).
Chang S. A. (2012). Smoking and type 2 diabetes mellitus. Diabetes & metabolism
journal, 36(6), 399-403.
Cheng, Y. J., Liu, Z. H., Yao, F. J., Zeng, W. T., Zheng, D. D., Dong, Y. G., and Wu, S.
H. 2013. Current and former smoking and risk for venous thromboembolism: a
systematic review and meta-analysis. PLoS medicine, 10(9), e1001515.
Dewa, L. H., Cecil, E., Eastwood, L., Darzi, A., & Aylin, P. (2018). Indicators of
deterioration in young adults with serious mental illness: a systematic review
protocol. Systematic reviews, 7(1), 123.
Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary
embolism. The Lancet, 388(10063), 3060-3073.

Eguchi, K. & Nagai, R., (2017). Islet inflammation in type 2 diabetes and
physiology. The Journal of clinical investigation, 127(1), pp.14-23.
Gee, E. (2018). Principles and nursing management of anticoagulation. Nursing
Standard (2014+), 32(23), 50.
Hadjadj, S., Cariou, B., Fumeron, F., Gand, E., Charpentier, G., Roussel, R., Kasmi,
A.A., Gautier, J.F., Mohammedi, K., Gourdy, P. and Saulnier, P.J., 2016. Death,
end-stage renal disease and renal function decline in patients with diabetic
nephropathy in French cohorts of type 1 and type 2 diabetes. Diabetologia, 59(1),
pp.208-216.
Hamilton, M. T., Hamilton, D. G., & Zderic, T. W. (2014). Sedentary behavior as a
mediator of type 2 diabetes. Medicine and sport science, 60, 11-26.
Laur, C., Curtis, L., Dubin, J., McNicholl, T., Valaitis, R., Douglas, P., Bell, J., Bernier, P.
& Keller, H., (2018). Nutrition Care after Discharge from Hospital: An Exploratory
Analysis from the More-2-Eat Study. In Healthcare (Vol. 6, No. 1, p. 9).
Multidisciplinary Digital Publishing Institute.
Mudiyanse, R. M. (2016). Empathy for patient centeredness and patient
empowerment. Journal of General Practice, 1-4.
Riley, J. (2015). The key roles for the nurse in acute heart failure management. Cardiac
failure review, 1(2), 123.
Rose, M., & Devine, J. (2014). Assessment of patient-reported symptoms of
anxiety. Dialogues in clinical neuroscience, 16(2), 197-211.
Schoenthaler, A., Kalet, A., Nicholson, J., & Lipkin, M. (2014). Does improving patient-
practitioner communication improve clinical outcomes in patients with

cardiovascular diseases? A systematic review of the evidence. Patient education
and counseling, 96(1), 3-12.
Shepardson, R.L., Tapio, J. & Funderburk, J.S., 2017. Self-management strategies for
stress and anxiety used by nontreatment seeking veteran primary care
patients. Military medicine, 182(7), pp.e1747-e1754.
Singh, R., Teel, C., Sabus, C., McGinnis, P., & Kluding, P. (2016). Fatigue in Type 2
Diabetes: Impact on Quality of Life and Predictors. PloS one, 11(11), e0165652.
doi:10.1371/journal.pone.0165652
Yu, J., & Yu, Y. (2017). Continuing Care Needs for Patients with Generalized Anxiety
after Hospital Discharge. Neuropsychiatry, 7(5), 494-500.
Zaccardi, F., Webb, D.R., Yates, T. and Davies, M.J., 2016. Pathophysiology of type 1
and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical
journal, 92(1084), pp.63-69.
Zammit, C., Liddicoat, H., Moonsie, I., & Makker, H. (2010). Obesity and respiratory
diseases. International journal of general medicine, 3, 335-43.
doi:10.2147/IJGM.S11926
Zimmermann, T., Puschmann, E., van den Bussche, H., Wiese, B., Ernst, A., Porzelt,
S., Daubmann, A. and Scherer, M., 2016. Collaborative nurse-led self-
management support for primary care patients with anxiety, depressive or
somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS
study). International journal of nursing studies, 63, pp.101-111.