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Nursig care plan

Case Study

Answer the questions related to the information provided in the case study

Your research must be appropriately referenced using APA guidelines. The total word limit for your responses is approximately1,500 words (+/- 10%).

As this unit is not directly assessed in the clinical workplace, both assessment tasks need to reflect a simulated clinical work environment demonstrating critical thinking applied to clinical conditions.

Case Study

William Smith is a 68 year-old man who was transferred to the Palliative Care ward three days ago from a surgical ward. He was admitted on 26/01/2013 for excision of a sacral abscess which had been causing him a lot of pain.  After surgery his future management was assessed and it was decided that he would be transferred to the Palliative Care ward as he could not be discharged home. 

Social History

·        Mr Smith lives alone in a unit with 23 stairs. He is unable to care for himself and refuses any home help. 

·        According to his daughter who was contacted by the Social Worker, Mr Smith has a past history of domestic violence and abuse towards his former wife and children. His son and daughter are finding it hard to visit him even at this end stage of his life and have stated that they are not willing to care for him at home.

·        Mr Smith identifies himself as an indigenous Australian (a person of Aboriginal or Torres Strait Islander descent).  He was born in Arnhem Land but moved firstly to a rural township in the Northern Territory before settling in his current home in a metropolitan city at age 65 to be nearer to his estranged children.

·        He has a past history of alcohol abuse until his admission to hospital on 26/01/2013.

Medical History

·        Mr Smith has a past history of a primary Ca lung with liver and bone metastases.

·        He also has a past history of COPD as he was a heavy smoker ( > 20 cigs a day for 45 years).

Physical Assessment on admission

·        Mr Smith has dyspnoea, ascites, pruritus and bone pain (moderate to severe at times).

·        He is very thin as he has been anorexic for several weeks. According to a neighbour, he lived on beer and baked beans with an occasional meal at the club when he could be taken there by a friend. 

·        His skin is stretched over his distended abdomen and bony prominences.

·        He is not able to walk unaided further than from the bed to the bedside chair.

·        He requires oxygen at all times.

29/01/2013 – Palliative Care Unit Admission Assessment

·        Mr Smith is receiving regular analgesia for pain.

·        He had not been ordered an aperient for several days and has not had his bowels opened since admission to hospital on 26/01/2013 and he is feeling very uncomfortable.

·        He refuses to eat much as he doesn’t like the food in hospital. His fluid intake is low and he is showing signs of possible dehydration. His urine output needs to be monitored.

·        Mr Smith is also complaining of stomatitis – he has poorly fitting dentures and evidence of mouth ulcers.

·        He also suffers from hiccups which can last for 20 minutes at a time. 

·        He is complaining of nausea and vomiting.  His weight loss is marked (5kg since admission 26/01/2013). 

·        Mr Smith can be incontinent of urine at night.

·        Mr Smith is finding it very hard to sleep at night and falls asleep for long periods during the day.

·        He has been talking a little about his children and speaks about his former behaviour towards his wife and children with regret. He often asks if his children are going to visit him.

06/02/2013

Mr Smith has now been on the Palliative Care ward for a week.  He has deteriorated in the past few days and is now bed bound.

·        He is able to roll from side to side for PAC.

·        His skin is intact apart from a small pressure ulcer (0.2 x 0.1cm) on his sacrum.

·        He is extremely sensitive to soap because of an increase in ascites and consequent pruritus.

·        He needs assistance with personal hygiene (sponge in bed).

·        He refuses to wear his dentures now as his mouth is extremely painful. He has been ordered Nilstat and Bonjela (anaesthetic mouth gel) with limited effect as he doesn’t like the taste.

·        His breathlessness has increased and he is having 4/24 Ventolin nebs.

·        He is ordered soft diet, encourage fluids. Mr Smith likes ginger beer which he says helps his hiccups (next-door neighbour brought some in) 

·        BNO for several days. Microlax enema and Agarol 10ml given with effect. 

·        Can be incontinent of urine at times – pad in situ. 

·        Current analgesia is oral (Oxycontin 100mg bd and Tramadol 50mg bd) – Mr Smith states this regime is “holding pain at present”.  Pain score  2 -3/10.

·        He can be confused and agitated at times.

·        Mr Smith has requested a visit from the Social Worker to try to organise a visit with his children. He is very depressed about the current situation.

·        Daily TPR and BP and girth measurement.

PART A: Analyse the information given in the case study and answer the following questions. NUMBER EACH QUESTION IN YOUR SUBMISSION

Review the following document to assist your responses to questions 1 – 2:

Queensland Health (2011) Sad News, Sorry Business: Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying

http://www.health.qld.gov.au/atsihealth/documents/sorry_business.pdf

.

1.  Could Mr Smith’s culture influence his pain assessment?  Why?  What strategies could you employ to ensure that you are adequately addressing Mr Smith’s pain?

2   Consider Mr Smith’s social and medical history. 

a. Reflect on any judgements and prejudices that you may have when caring for Mr Smith. 

b. Review the following professional Australian nursing standards:

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx

Code of Ethics for Nurses

Code of Professional Conduct for Nurses

EN Competency Standards

Outline the standards / codes that relate to non-judgemental nursing care in this situation.

3.   Compile a list of questions you would ask Mr Smith as part of an holistic health assessment.  These questions should be framed to enable collection of information on:

a. physical health status including pain assessment

b. mental and emotional status

c. social and cultural issues

4.  Mr Smith asks you about planning for his future.  He states that he does not want to be resuscitated. Provide Mr Smith with a brief description (with APA referencing) of the following and apply it to this scenario:

a. Advanced Health Directive

b. Enduring Power of Attorney

c. Organ Donation

5: Suggest alternative strategies (complimentary therapies) other than pharmaceutical pain management that could help Mr. Smith’s pain.

6.List appropriate referrals for Mr Smith to other members of the multi-disciplinary team.  Provide a rationale and a description of the service for each referral.

7: What support / referral could be offered to Mr Smith’s family?

8. Outline the pathophysiology of the following conditions ensuring you relate back to Mr Smith and his clinical presentation and diagnosis. Include within your answer the possible management strategies and rationale for these symptoms:

a. Anorexia related to cancer (NOT Anorexia Nervosa)

b. Ascites

c. Dyspnoea

d. Hiccups

     Note: Pathophysiology is not signs and symptoms. Pathophysiology explains the processes within the body that result in the signs and symptoms of a disease.

9. Consider Mr Smith’s deterioration.  What data provided about Mr Smith’s condition on 06/02/2013 would assist in determining if Mr Smith is at end of life?