Nursing Case Studies: Quality Measures, Discharge Planning, and Ethics

This assignment presents a series of nursing case studies addressing critical aspects of healthcare delivery. The first case study focuses on quality performance tools for a COPD patient, emphasizing cost-efficiency, high-quality care, and patient satisfaction. The ASPIRE tool and patient satisfaction surveys are highlighted. The second case study details discharge planning for a knee replacement patient, including education, medication management, and community resource referrals like medical equipment, grocery delivery, and physiotherapy. The third case study explores ethical dilemmas in end-of-life care, particularly concerning patient autonomy and treatment decisions, with strategies for resolving conflicts involving stakeholders like the patient, power of attorney, and healthcare professionals. The final case involves patient assessment.

Running head: NURSING ASSIGNMENT
Case Studies
Name of the Student
Name of the University
Author Note

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Case study, Chapter 1
a)
Quality measures refer to that facilitate the measurement or quantification of major
healthcare processes, patient perceptions, outcomes, and organizational structure or systems,
associated with the capability of providing high-quality health care services. These major goals
include safe, effective, patient-centred, equitable, efficient, and timely care. Some of the tools
that can be used to determine the quality of the care services being delivered include the Hospital
Inpatient Quality Reporting (IQR) Program. The IQR involves collection of quality data from the
hospital with the aim of driving quality improvement by transparency and measurement of the
data that were publicly displayed, for helping the patient and her family to make informed
decisions about healthcare. This in turn would also encourage the hospital to improve the cost of
inpatient care that was provided to Suzanne Jones. The cost effectiveness of the care delivered to
the patient could be evaluated by performing a Cost-Effectiveness Analysis (CEA) that would
estimate the health gains and costs of the intervention being implemented in the scenario. This
would create provisions for quantification of the net cost associated with the interventions and
would also help in conducting an assessment of the costs per disability-adjusted life year of the
patient. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program can
also be put to use for quality measurement of the delivered healthcare services. This would
promote the use of surveys, encompassing the experience of the consumer or service user. It
would address a range of healthcare services and utilise comparative information, thereby
assisting the healthcare professionals to evaluate and improve their performance. The Six
Sigma/Toyota Production System will also help in decreasing the defects and operating costs of
the healthcare service, while improving the patient outcomes. Furthermore, the Lean Production

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System would also play an integral role in identifying the needs of the patient and would work
towards improving the healthcare delivery by removing steps that non-value added and incurred
high costs.
b)
The ASPIRE tool is most essential in determining evidence based implementation of high
quality healthcare services to the patient, which in turn would improve the patient outcome and
satisfaction. The importance of this quality performance measurement tool lies in the fact that it
has been developed with the aim of assisting allied healthcare professionals for evaluating their
clinical performance, in terms of bringing about improvements in the quality of the healthcare
service, administered upon the patient. The importance of the tool can be attributed to the fact
that it manages to capture the integral elements of healthcare performance measurement that
includes upfront goal articulation, performance measure identification, clinical area
prioritisation, and mapping measures to major information sources. The fact that the care
delivered shows adherence to evidence based practice can be established by analysing the
performance data and reporting the patient results. Thus, the tool ASPIRE will make use of a
collaborative approach between the healthcare professionals and skilled researchers, which in
turn will facilitate the process of conducting an appropriate performance evaluation. Satisfaction
of the patient Suzanne Jones can be determined with the use of a patient satisfaction survey tool
that will bring about quality improvement. The PSQ-18 tool can be used for this purpose. It
generally encompasses survey questions on general satisfaction of the patients, technical quality
of care, interpersonal manner, communication, time spent with doctors, convenience and
accessibility, and financial aspects of the care. Computing the scores of the responses provided
by the patient Suzanne will help in providing an accurate overview of the satisfaction levels.

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Thus, there is a need to focus on achieving excellent or high rating of patient satisfaction, which
in turn would provide assistance to the concerned healthcare professionals to improve the quality
of healthcare service delivery (Thayaparan & Mahdi, 2013).
Case Study, Chapter 2
a)
Discharge is usually coordinated and planned with the patient, family members and
associated healthcare agencies. However, several steps must be ensured by a nursing
professional, prior to discharge of the patient Mr. Jones after his right knee replacement. The
following preparations should be taken in advance by the nurse:
 Educating the patient about his diagnosis and the reason why he was admitted to
the healthcare centre in the first place. Understanding the condition would help in
a better transition from the healthcare setting to home.
 Thorough discussions must be conducted with the concerned surgeons and
physicians
 The patient must be adequately informed about the prescribed medications, its
benefits, potential adverse effects, dosage and mode of administration.
 Owing to the fact that Mr. Jones will be injected Lovenox subcutaneously daily,
proper instructions should be given to his daughter for the injection
administration.
 He should also be educated on the usage of medical equipment, such as, walking
crutches or wheelchair
 Adequate information must be provided on lifestyle changes, if required

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 His daughter must be educated on procedures of cleaning or dressing the scars or
wounds
 The nurse should also make use of a discharge checklist, which will facilitate a
seamless and smooth transition from the hospital to home.
b)
There are a range of community resources that would facilitate the seamless transfer of
the patient Mr. Jones to his home or community. Some of the major referral and resources that
are crucial in this context are as follows:
 Medical equipment- These will help in an easier recovery and increase
independence of the patient, following the surgery.
 Grocery delivery- Presence of such community resource would help in shopping
and delivering groceries to the home of Mr. Jones
 Signing up for ready-to-eat meal services will greatly assist the patient
 Healthcare facility websites will provide adequate information on orthopaedic
surgeons and allied health facilities.
 Physiotherapists will help in restoring mobility and muscle strength of the patient
 Frequent follow-up visits with the surgeon will help in reclaiming an active
lifestyle
 Other referrals would include organisations that would install toilet safety frames,
grab bars, tub chairs, hand held shower head and tub transfer benches, which in
turn would assist the patient to seamlessly conduct the daily activities.
 Elderly social clubs would also play an integral role in helping Mr. Jones to meet
up with friends, acquaintances and socialise with them. These will provide a range

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of activities that will eliminate isolation and improve the overall patient health
(Moffet et al., 2015).
Case Study, Chapter 3
a)
Ethical dilemma faced by nursing professionals are generally vast in their scope, while
caring for end-of-life patients. Oncology and hospice nurses can navigate several ethical
dilemmas by delivering best possible care services, while allowing the concerned patient,
caregivers, and family members adequate opportunities for experiencing end of life with dignity.
One major ethical dilemma that arose in this context can be attributed to the failure in deciding
about the treatment plan for the patient Mrs. Elle. Decision making is a complex process of
perceptions and thoughts and sets up a range of challenges for the concerned patient and families
to decide for end of life. Healthcare professionals have the general duty of displaying respect
towards the rights of the patient for making decisions about the course of medical care, without
creating an influence on the decision of the patient. However, in this context, owing to the old
age of the patient, the healthcare professionals could not convince the person with the durable
power of attorney for taking the necessary healthcare decision. Although Mrs.Elle had stated her
wish of not undergoing any kind of amputation, the hospice nurse suggested for blood
transfusion, which might increase her life expectancy and develop the need for right foot
amputation, in spite of low chances of surviving the surgery. This resulted in an ethical concern
over conducting blood transfusion based on the laboratory reports or preventing all labs, while
respecting the patient’s wishes of dying peacefully. Owing to the fact that the hospice nurse is
called on for acting as a mediator through difficult situation, compromising with the patient
autonomy, while trying to advocate for the patient, presents several ethical challenges.

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b)
The key stakeholders in this scenario are the patient Mrs. Elle, the power of attorney, the
hospice nurse, and the physician. The major gain that the patient has is associated with the fact
that in spite of being incapable of exerting end-of-life decisions, her previous statements
regarding a peaceful death and wish against having an amputation are being given proper
consideration. Moreover, the fact that she has appointed a power of attorney is also advantageous
as the latter has the comprehensive power of advocating for the rights of Mrs. Elle for her end-
of-life decisions. However, the fact that her current physical condition requires blood
transfusion, which might increase her lifespan, against her wish is a major loss. The power of
attorney also faces a loss that can be attributed to the advantage of blood transfusion in
increasing the life expectancy of the patient, against the wishes. Advocating for the patient will
make the power of attorney fail to consider the benefits of treatment. The physician and hospice
nurse are also at a loss due to the fact that in spite of treatment provisions that will help them
enhance the survival of their patients, they will have to maintain respect towards the autonomy of
the client (Karlsson et al., 2013).
c)
During end of life care ethical dilemma might arise from a range of situations that
involve communication breakdown, compromise with patient autonomy, symptom management
inefficiency and shared decision making. The strategies to be adopted by the hospice nurse for
resolving the ethical dilemma include the following:
 Identifying the ethical concern and defining guiding principles- The nurse will
have to adhere to the plethora of principles for biomedical ethics such as,

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nonmaleficence, autonomy, justice, beneficence, confidentiality, privacy and
veracity.
 The hospice nurse should also advocate for a meeting with the family if the
patient, in addition to the power of attorney, with the aim of clarifying the goals
of care for Mrs. Elle, with the life-limiting condition.
 The nurse should separate all kinds of emotional responses from the primary
objective issue, which in turn will facilitate the decision making process
 Additional information should be gathered from the practice setting, followed by
their review and discussion with the patient Mrs. Elle and her power of attorney
over alternate treatment options.
 The nurse should inform the power of attorney about the probable benefits and
risks of the transfusion therapy
 Efforts must be taken for conflict resolution through collaboration that involves
mutual evaluation of health information and identification of the interest of the
stakeholders
 The values, culture, and beliefs of Mrs. Elle must be recognised, which in turn
will create provisions for honouring the dignity of the client
 The nurse should also take attempts at compromising if all stakeholders are
morally certain about their unique stand on the care
 The ethical dilemma can also be addressed by contacting the healthcare executive,
for ensuring adherence to certain policies that must be followed while guiding the
patient and power of attorney to make informed treatment preferences, by sharing
trustful information and appropriate prognosis of the health abnormality

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 A post-event reflection should also be exercised by the nurse for evaluating the
scenario and assessing the major outcomes of the decision making process.
Case Study, Case Study 4
a)
Further assessments required for Mr. Smith are as follows:
 Systemic collection of subjective data that will involve gathering information
based on his perceptions about his common symptoms and health condition.
 Efforts must be taken to collect data about his health history that will encompass a
holistic assessment of factors that include health status, social life, family history,
cultural background, biographic and demographic data, physical, emotional and
mental data.
 All prescribed and nonprescribed medications taken by him should also be
documented
 The patient must be subjected to a vital signs assessment
 An enquiry should also be made about the past illnesses that require medical
attention or hospitalisation
b)
The topics that will be addressed while providing health education to the patient include
the following:
 Starting with the basics and ensuring that he is performing the simplest of all
infection control practices appropriately

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 Adequate measures should be taken to demonstrate the effectiveness of hand
hygiene practices for infection control
 Effective communication will help Mr. Smith report his concerns on issues of
patient safety
 Delivering safe water guidelines are also essential for this purpose (Johnson et al.,
2014)
c)
The teaching plan will encompass the following objectives:
 Define infection
 Explain the routes of transmission of infection
 Identify infection prevention steps
 Educate on hand hygiene
Objectiv
e
Learning
content
Activity/
teaching method
Resource
s needed and
time allotment
Evaluatio
n method
Define
infection
How are
microorganisms
transmitted?
What
effect do they
create on the
body?
Providing
handouts
3
minutes
Pamphlet
s
Oral
feedback;
appropriate
recognition of the
pathogen
transmission
routes
Enumera When One-to-one 4 Oral

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te the correct
timings of
washing hands
should the hands
be washed?
discussion minutes
Pamphlet
s
feedback; the
client will be
able to correctly
state when he
should wash his
hands
Demonst
rate proper hand
washing
techniques
What
steps should be
followed in hand
hygiene?
Demonstration 5
minutes
Pamphlet
s
Return
demonstration;
the client should
be able to depict
the hand washing
steps in a correct
manner
Correctl
y enumerate the
other steps that
must be followed
for infection
control
All other
infection control
measures that
need to be
followed at
home
One-to-one
discussion
10
minutes
pamphlet
s
Instant
oral feedback;
the client will be
able to accurately
state the different
infection control
measures that he
follows at home
(Source- Johnson et al., 2014)

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Case Study, Chapter 5
a)
As Mrs Varner described herself as overweight (height- 64 inches and weight- 165
pounds) for most of her adult life, it is important to compute her BMI. Moreover, after
calculating her BMI, it is estimated to be 28.2, (BMI = Weight (kg)/Height (m)2) that are more
than the standard scale of 25 being overweight. According to World Health Organization
(WHO), the healthy BMI range is between 18.5 and 24.9 and Mrs. Varner is 28.2 above the
normal range. Therefore, by measuring her BMI, it is easy to know that she is underweight or
obese. Furthermore, by consuming proper nutrients, she can gain ideal weight and reduce the
increased disease risk in overweight conditions.
b)
The ideal body weight (IBW) for females is calculated by adding 45.5 kg and 2.3 kg for
each inch over 5 feet. IBW is considered healthy weight that is considered maximally healthy for
an individual that is based on height and influenced by factors like age, gender and build. Mrs
Varner is 165 pounds and after calculating the ideal weight as per her height (in inches), weight
(in pounds), gender and age, the healthy BMI recommended weight is 54.70 kg or 120.59
pounds. On a contrary, her weight is 165 pounds that is more than the standard ideal body weight
range and BMI and therefore, she is overweight. Height of 64 inches or 5’3” with 141 to 168 lbs
confirms that Mrs. Varner is overweight.
c)