Case study – Mrs Soo Hui –

Case study – Mrs Soo Hui – relates to Q1-19 Mrs Soo Hui is a 46-year-old female ( identifies as she, her) admitted to your ward at St Elsewhere Hospital, following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. The next-door neighbour found her on the ground outside her front door unable to move or speak. She has been diagnosed as having a left sided ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy. Family history Born to Thai parents in Australia Buddhist & speaks Thai & English Lives with husband & 2 children, Ty 13 years old & Grace 5 years old. Also her father who is a frail 82-year-old. Medical history Hypertension, Type 2 Diabetes, Asthma Depression Hearing aid left ear Bi-focal glasses (broken in fall) Upper dental partial plate Medication – Amlodipine, Metformin, Salbutamol. Admission observations BP 150/90 PR 85 regular RR 24 To 36.9 SpO2 96% on room air BGL 8.4 mmol Weight 69 kg Height 162 cm GCS (Glasgow coma scale) = 14 Eyes open to speech Oriented to time, place, and person (speech slurred, but able to be understood) Right hemiparesis PERL (Pupils equal reactive to light) Issues/impacts of the CVA Pain on movement, mainly right hip & shoulder stated as 7 /10 Large haematoma right hip 5cm skin tear right elbow Dysphasia Dysphagia Right sided facial droop Mild Right-side hemiplegia Initial Doctor’s orders and interventions Rest in bed (RIB) 2nd hourly Neurological observations Nil by mouth (NBM) until Speech Therapist review Physiotherapist review Full assistance with hygiene IDC insitu Intravenous Therapy via cannula in left forearm Discharge Information Mrs Soo Hui will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted. Provide an answer for each of the questions below in relation to Mrs Hui. Explain how you would prepare the hospital room for Mrs Hui’s admission to the ward. List 4 pieces of equipment you would need to conduct an assessment on Mrs Hui’s when she is admitted to the ward. …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… Identify 4 components of correct nursing documentation ( this also includes electronic documentation) …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… Why is it important to measure and record a person weight and height on admission? …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… You are required to provide a clinical handover to the Enrolled Nurse and Registered Nurse who are coming onto the next shift. Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui? I S B A R The RN has created care plans for Mrs Hui and identified four (4) assessment and nursing diagnoses based on the Nursing process concept. As the EN contributing to the nursing care plan, please provide the following for each of the four (4) care plans. Two (2) nursing implementations for each care plan. One (1) rational and one (1) evaluation for each Implementation. a) Care Plan 1 Assessment (subjective and objective data) (completed by RN) Rest in bed, Actual identification of limited Immobility due to CVA Nursing diagnosis (Identification) (completed by RN) Risk of impaired skin integrity related to immobility resulting from CVA Planning (goal, expected outcome, what do you hope to achieve) (completed by RN) implement nursing cares to prevent risks of altered skin integrity Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why) One (1) for each implementation Evaluation (did the plan of care work, how will you know) One (1) for each implementation 1. 2. b) Care Plan 2 Assessment (subjective and objective data) (completed by RN) Pain, limited movement, and bed rest Nursing diagnosis (Identification) (completed by RN) Inability to perform self-care hygiene independently Planning (goal, expected outcome, what do you hope to achieve) (completed by RN) Patients personal and oral hygiene needs will be met Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why) One (1) for each implementation Evaluation (did the plan of care work, how will you know) One (1) for each implementation 1. 2. c) Care Plan 3 Assessment (client has/has not, data) (completed by RN) Mrs Hui has been placed on a puree diet by the Doctor, she is noted to have difficulty eating due to Right hemiparesis Nursing diagnosis (Identification) (completed by RN) Risk for aspiration related to impaired swallowing reflex resulting from CVA Planning (goal, expected outcome, what do you hope to achieve) (completed by RN) Nursing staff to provide supervision and assistance with eating and drinking where there is clinical risk To minimise risk of aspiration while maintaining optimal nutritional and hydration status. Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why) One (1) for each implementation Evaluation (did the plan of care work, how will you know) One (1) for each implementation 1. 2. d) Care Plan 4 Assessment (client has/has not, data) (completed by RN) Mrs Hui is expressing feelings of powerlessness and loss of control over her limited mobility due to CVA and being away from her family Nursing diagnosis (identification) (completed by RN) Risk for impaired emotional, psychological, and social function related to depressed mood and impact of major health event (CVA) Planning (goal, expected outcome, what do you hope to achieve) (completed by RN) Reduced feelings of depression and creating adaptive measures Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why) One (1) for each implementation Evaluation (did the plan of care work, how will you know) One (1) for each implementation 1. 2. SCIENCE HEALTH SCIENCE NURSING HLT 54115

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