Case Study: Elderly Patient with Several Concerns

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12th Feb 2020 Nursing Case Study Reference this

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Daniel Littlewood 
Case study

Mrs Hiruni Jupangati

You are an Enrolled Nurse working in the small public hospital in Cattelanbaa, rural QLD. This is your first job since completing the Diploma of Nursing and you have been working here for the past month.

Mrs Hiruni Jupangati (born 20/05/1929) was admitted by her GP last night with exacerbation of asthma. She was born in Sri Lanka but migrated to Australia with her Australian Aboriginal husband whom she met during the 2nd World War. He worked as a stockman for a nearby cattle station until he retired to their small house in town 25 years ago. Their eldest son left home as a teenager and hasn’t maintained contact with the family. Mrs Jupangati has 2 other children – a daughter who lives on a sheep station just out of town, and a son who is a remote Aboriginal health worker in the NT.

Mrs Jupangati has lived alone since her husband of 68 years died suddenly from a stroke 9 months ago. Although she is eligible for a place in a nursing home in Bigganbad, the regional centre 650km away, she is determined to see out her days at home. She receives support from the community nurse for wound care and her daughter who visits weekly to help with housework etc. She enjoys pottering in her vegetable and herb gardens, cooking Sri Lankan food, watching cricket and making robes for the Katina ceremony. Hiruni likes to spend time every day meditating, chanting from the Pali canon, and burning incense. The Buddhist monk visits once a month from Bigganbad and she attends the annual Poson and Katina festivals in Brisbane with her daughter.

Mrs Jupangati has some mild short term memory loss and her GP noted she seemed somewhat confused during his visit. While she is normally independent in performing her ADL’s, Hiruni attends to them once or twice per week. She wears a light pad for some urge urine incontinence. After 45 years of smoking heavily she stopped 5 years ago. Mrs Jupangati had excision of cataracts and insertion of IOL 2 years ago and wears glasses for reading. She can mobilise short distances independently with a walking frame.

Mrs Jupangati has Osteoarthritis in her back, right hip and both knees. She had a left total hip replacement 6 months ago and is on the waiting list for the other joint replacements. She was diagnosed with Type 2 Diabetes Mellitus (DM) 5 years ago and has required insulin for the past 3 years. Her BGL’s have been reasonably stable over that time.

Along with Asthma and Diabetes, Mrs Jupangati’s medical history includes Rheumatic fever as a child, Ischaemic Heart Disease (she had CABG 25 years ago), Congestive Cardiac Failure (CCF), and Chronic Obstructive Pulmonary Disease (COPD). At age 67 Mrs Jupangati had a left mastectomy and axillary clearance for breast cancer. Treatment included radiation and chemotherapy. There has been no apparent reoccurrence although she has not complied with follow-up mammograms which can only be done in Bigganbad.

Mrs Jupangati has had four admissions to the local hospital in the past 6 months. One was for a fall and the other 3 for exacerbation of COPD and respiratory tract infections. She has a small skin tear on her right forearm, a diabetic ulcer on her left foot, and 2 small scratches from gardening on her right lower leg, all of which are being managed by the community nurse & GP. Mrs Jupangati has several missing and decayed teeth. She is complaining of painful areas on her coccyx and red right heel since watching the recent cricket test series on TV. She wears hearing aids though needs reminding to use them.

Patient observations on arrival to the hospital were as follows:

Height – 150cm

Weight – 87kg

BP 160/90

Pulse 108 irregular

Respirations 32

Temperature 37.8C

O2 saturations 84% room air

BSL 8.2mmol/l

Urinalysis – pH 6.0, SG 1010, Nitrates +, Leukocytes ++, Blood ++, urine cloudy and offensive

Current Medications:

  • Lantus
  • Actrapid
  • Seretide and Ventolin inhalers
  • Panadol Osteo
  • Voltaren Gel (her daughter gave this to her last week to help with arthritic pain)
  • Oxycodone PRN
  • Frusemide
  • Enalapril
  • Prednisolone
  • Atorvastatin
  • Coloxyl and Senna
  • Pending investigations:
  • Chest X-Ray
  • Blood tests
  • Spirometry
  • Mid-stream urine (MSU)

Other orders:

TED stockings

Bed rest with toilet privileges

Oxygen @ 2L/min via nasal prongs

Fluid balance & bowel charts

 


Q2:Identify, list and briefly outline the use for the equipment required to obtain all of Hiruni Jupangati’s observations and complete the assessment form.

A2: As written in (Tollefson, J., Watson, G., Jelly, E., Tambree, K., & Bishop, T, 2015, pp.10-30, 66-98) the equipment required to carry out the observations for Mrs Jupangati are:

Gloves and hand wash aid in preventing spread of infection.

Height and weight scales needed to find BMI.

Calculator to work out BMI.

Blood Pressure and sphygmomanometer with BP cuff to take blood pressure.

Stethoscope to listen to heart beat.

Pen torch to check if PEARL.

Watch for RR and pulse rates.

Thermometer with probe covers – take temperature.

Pulse oximeter to get Mrs Jupangati SpO2 level.

Urinalysis

Commode, bedpan as required/ PPE/ specimen container/ urinalysis bottle with regent strips/ paper towel/ perineal care equipment/ watch/ pen and paper.

BGL

Glucometer/ cotton balls or gauze/ lancet/ sharps container/ testing strip/ diabetic chart/ warm water.

Computer / relevant forms and pen to document data collected.

Satisfactory Needs revision


Q3:List five (5) strategies you could implement to enable Heroin to meet her emotional, psychosocial and spiritual needs. Identify 3 ways you would ensure both her privacy and confidentiality are maintained while she is an inpatient.

A3: Understanding how Mrs Jupangati culture belief view health care will help to tailor questions and treatment plans to the Mrs Jupangati needs. By asking Mrs Jupangati about her religious and spiritual practice, you can learn something about Mrs Jupangati health care choices and preferences. Get to know Mrs Jupangati health problems will help you to develop a care plan for Mrs Jupangati, also involve Mrs Jupangati in her care plan. Anticipate Mrs Jupangati needs this will show Mrs Jupangati that you do care and that you want to provide Mrs Jupangati with the best plan of care possible. Gain Mrs Junpangati trust by providing consistent, respectful and patient-focused care, follow through on commitments and have an accepting attitude rather than being judgmental (Crisp, Douglas, Rebeiro, & Waters, 2016 pp 447- 449 ). Three ways you would ensure Mrs Junpangati privacy are environment which is drawing curtains, closing windows and doors. No gossiping about her to staff members and patients. Do not post anything about her on social (Crisp et al., 2016 p225).

Satisfactory Needs revision


Q4What communication techniques would you use when interviewing/assessing Hiruni and explain briefly how they would assist you.

A4: Active listening is taking an interest in what Mrs Junpangati has to say through verbal signal, nonverbal gestures, and body language. Using active listening will help build trust with Mrs Junpangati(Crisp et al., 2016 p222 ) .

Using body language and gestures is important in making a connection with Mrs Junpangati, by taking the time to make eye contact, smiling, leaning forward and focusing my attention on Mrs Junpangati will help make a connection with her(Crisp et al., 2016 p223).

Asking open end questions will require Mrs Junpangati to expand on her answer. English is Mrs Junpangati second language Junpangati may have difficult communicating, then closed questions may be required. Mrs Junpangati cultural difference and ESL may require me to prompt her, using clarification/validating techniques to build trust(Crisp et al., 2016 p224 ).

Satisfactory Needs revision


Q5:Review Mrs Jupangati’s vital signs and observations. Identify whether they are within the normal range. If they are not within normal range state what the normal range and variance is and what the variance may indicate. Discuss your relevant duty of care expectations as an EN.

A5: An EN duty of care expectations are to document, ensuring confidentiality of all vital signs and observation’s immediately after they are done. Any abnormalities of the vital signs and observations should be reported immediately to the RN so further action can be taken (Crisp et al., 2016 p173).

Satisfactory Needs revision


Q9:Identify four (4) potential risks in collecting the MSU and discuss what you, as the EN, would do to minimise these risks. Briefly state what relevance an environmental policy/procedure would have to Mid-Stream Urine collection/testing.

A9: Four potential risks are contamination, infection, urine spill and incorrect labelling. These risks can be minimise by making sure the container is sterile, not touching the inside of the container, the specimen is taken mid-stream as required. Wear gloves to avoid infection and contamination and follow hand hygiene policy. Use ppe such as gloves, apron and glasses in case it splashes everywhere. To avoid incorrect labelling fill out the label before you give the container to Mrs Junganati, verify with Mrs Junganati details as the label is fill out and make sure the correct test procedure is written on the label as well (Crisp et al., 2016 pp 648-658 ).The relevance an environmental policy/procedure would have to a mid-Stream Urine collection/testing is it would tell you how to dispose of the urine and container correctly (Crisp et al., 2016 pp 132-133).

Satisfactory Needs revision


Q10:Explain good documentation standards/principles you would use as an EN caring for Mrs Jupangati.

A10: Good documentation standards/principles are making sure all documents are focussed, accurate. Complete, timely, understandable, always objective and legible. On every document must be the unique identifier or medical record number, patient’s full name, DOB, gender. For good documentation entries must be neat, legible and English, must have proper grammar and spelling, must be accurate and clear, use black ink which is easily reproducible, use approved symbols and abbreviations, use the 24hr clock time sequenced, all entries from students must be countersigned by clinician who is supervising, all entries must be signed by author, followed by name and designation, make sure all entries are factual (Crisp et al., 2016 pp178-181).

Satisfactory Needs revision


Q13:Using your knowledge of anatomy and physiology identify and discuss three (3) possible causes of Mrs Jupangati’s collapse.

A13:

Mrs Jupangati has osteoarthritis in her back, right hip and both knees. She also had a total left hip replacement 6 months ago and is on the waiting list for other joint replacements. She has also been admitted to hospital in the last 6 months with a fall. Mrs Jupangati has arthritis along with osteoarthritis which cause the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling. Mrs Jupangati may have fell because her joints gave way or they lock up (Nazarko, 2015).

Mrs Jupangati has type 2 Diabetes, she is taking insulin injections for her type 2 diabetes. Mrs Jupangati is obese which may be the cause she has type 2 diabetes. With Type 2 diabetes, the pancreas usually produces some insulin. But either the amount produced is not enough for the body’s needs, or the body’s cells are resistant to it. Symptoms of diabetes may include fatigue, blurred vision and loss of consciousness (rare). Type 2 diabetes also increases your risk of a stroke. Mrs Janpangati might have miss her insulin medication, which means glucose cannot make it into the cells to provide energy to the body, which may have cause Mrs Janpangati to have fatigue, blurred vision and loss of consciousness which cause her to fall (Nazarko, 2015).

Mrs Jupangati was admitted last night with exacerbation of asthma. She was admitted with a very high respiratory rate. Mrs Jupangati use to smoke for 45 years. Mrs Jupangati has COPD and asthma which cause narrowing of the airways. Mrs Jupangati is not able to get the required amount of air into her lungs because she unable to take a full breath. Mrs Junpangati is tachycardia which means her heart is working hard to supply the body with more oxygenated blood, which means the lungs have to work faster to oxygenate the blood as well. Mrs Jupangati may have had an asthma attack which may cause her unable to breathe and lose consciousness, which cause her to fall and hit her head (Nazarko, 2015).

Satisfactory Needs revision


Q15:List Mrs Jupangati’s analgesic medications. Outline the process you would use to assess the need to give the opioid. Is an [E]EN authorised to administer the opioid? If so, explain how legislative and regulatory standards support this practice and how the EN would ensure these requirements are met whilst performing this activity.

A15: Mrs Jupangati’s analgesic medication is Oxycodone and Panadol Osteo. To assess to see if Mrs Jupangati needs her Oxycodone PRN a pain assessment will be required. A pain assessment consists of provoking/palliative factors what makes the pain better or worst. Quality what the pain feels like in the patient words. Region and radiation, where is the pain, does it radiate, does it occur anywhere else, have the patient point to where the pain is. Severity, have the patient rate their pain using a pain rating scale, ask the patient how much pain they have at rest and how much pain they have at movement. Time, when the pain began and how long did the pain last. Patients understanding of the cause of pain and what treatments have they tried to relieve it (Crisp et al., 2016 p1336). An EN can administer the opioid because it is a control drug. For a EN to administer Mrs Jupangati’s opioid they must have written in instruction from one of the following dentist, doctor, nurse practitioner, physician assistant or surgical podiatrist and a doctor, dentist or registered nurse supervise, or they can give control drug to a person if has been dispense for that person doctor, dentist or registered nurse supervise (Queensland Government, 2016).

Satisfactory Needs revision


Q16:Review Mrs Jupangati’s medical history & medications. Identify urgent patient education needs, describe how you would go about this and who you would involve.

A16: Diabetes, Mrs Jupangati needs to lead a heathier lifestyle I would involve the following doctor, dietician or nutritionist, accredited exercise physiologist/physiotherapist and her daughter. Blood glucose Mrs Jupangati needs to check her blood glucose levels at home to making sure she is within normal limits and Mrs Jupangati must take the required medication so the following people should be involve the RN, her community nurse and Mrs Jupangati daughter to ensure she carry out this.

Pressure Area Care, Mrs Jupangati needs education on pressure injuries, how her diabetes will increases the risks, what can Mrs Jupangati do to minimise these risk and how Mrs Jupangati can care for her pressure injury. People to get involved doctor/RN speak to her and her daughter and community nurse. Wound care, involve Mrs Jupangati, daughter and community nurse. Nutrition – get the following people involved nutritionist and her daughter. Advise them of what Mrs Jupangati should be eating and avoiding. Oral hygiene Mrs Jupangati needs to be refer to a dentist, educate Mrs Jupangati, community nurse and daughter, educate them on steroid medication’s effect on Mrs Jupangati teeth and educate them on mouth care. ADL’s/hygiene involved Mrs Jupangati , community nurse and her daughter, explain to them why hygiene is so important when you are a diabetic because it can cause sores to become infected a lot easier. How to use puffers/spacer, involve Mrs Jupangati, community nurse and her daughter. Explain the process with them and show them as well.

When teaching Mrs Jupangati reduce environmental distractions, to compensate for Mrs Jupangati hearing loss and with Mrs Jupangati attention and concentration. When talking to Mrs Jupangati use a low-pitched voice, speak clearly and slowly, and face Mrs Jupangati while talking. Encourage Mrs Jupangati to use her hearing aid. Ask the Mrs Jupangati questions to verify that she has understood what been said, and give written information as backup to what you’ve presented orally to Mrs Jupangati. Mrs Jupangati has impaired vision, use adequate diffused light, and avoid having Mrs Jupangati face a direct source of light. Make sure Mrs Jupangati has her prescription glasses, make sure she is wearing them, and use large print for labels and instructions. Keep teaching sessions short for Mrs Jupangati between 10 to 15 minutes and schedule them to allow Mrs Jupangati to rest as needed. When teaching Mrs Jupangati any activity or skill, the pace must be set Mrs Jupangati(Crisp et al., 2016 pp 26-7) .

Satisfactory Needs revision


Q17:Identify potential causes of Mrs Jupangati’s poor oral condition and describe how you could assist her in maintaining proper oral health.

A17: Cause of Mrs Jupangati poor oral condition are diabetes if Mrs Jupangati poorly managed her diabetes she is at an increased risk of tooth decay and gum infections (Diabetes Victoria, 2016). She is a former smoker which can cause mouth decay. She is taking Prednisolone which may lead to bone loss in her mouth. She is taking steroids which can cause oral thrush. Mrs Jupangati has medicine for high blood pressure, analgesics and ACE inhibitors which cause insufficient saliva which cause gum disease because saliva keeps the mouth healthy (NPS MedicineWise, 2016). While Mrs Jupangati is in hospital I will help her with her oral care by assisting her with oral care twice a day. By assisting Mrs Jupangati I will educate Mrs Jupangati on why it is importance to do her oral care and it will get her in a routine. Educate Mrs Jupangati about diabetes and gum disease that she needs to have her BGL at the right level, needs to take her medication correctly and is to test her BGL regularly.

Satisfactory Needs revision


Q18:Discuss the potential cause of Mrs Jupangati’s painful coccyx & reddened right heel and explain why this might have occurred. Outline how the EN will manage this concern effectively.

A18:

Mrs Jupangati is 87years old, has diabetes, and limited mobility. As people age their subcutaneous fat diminishes and their skin texture flatten out. The loss of skin texture allow the epidermis to peel away, increasing the likelihood of skin tears. Mrs Jupangati has lost her skin texture and has poor blood flow to her extremities, especially legs and feet due to her diabetes. Mrs Jupangati poor glucose levels may result in a reduced blood supply which makes them more prone to infection, ulcers and pressure injuries As Mrs Jupangati has been watching the cricket sitting down for a long period of time without moving, she would be applying pressure on her coccyx and her heels on the couch. This would have interfere with her circulation because she was applying pressure which would have cause tissue death. The EN will need to do a waterlow risk assessment Mrs Jupangati must be move every two hours, the EN will need to put a mepilex INSITU on Mrs Jupangati heel and coccyx . Mrs Jupangati must have a wedge pillow under her shins and be given an air bed. The EN can wash and dry the area as well. The EN must educate Mrs Jupangati on pressure injury care and prevention, advising Mrs Jupangati to move every couple of hours. Informing Mrs Jupangati to use non-cosmetic moisturisers on her skin, check regularly for red or sores areas, and about hygiene (Crisp et al., 2016 pp724-736).

Satisfactory Needs revision


References    

Crisp, J., Douglas, C., Rebeiro, G., & Waters, D. (2016). Potter & Perry’s fundamentals of nursing (5 ed.). Australia: Harcourt Publishers Group Pty

Diabetes Victoria. (2016). Diabetes – long-term effects. Retrieved 2 19, 2017, from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diabetes-long-term-effects

Nazarko, L. (2015). Modifiable risk factors for falls and minimizing the risk of harm. Nurse Prescribing, 13(4), 192-198. Retrieved from CINAHL database http://web.ebscohost.com

NPS MedicineWise. (2016). Prednisolone (corticosteroids (oral and injectable)). Retrieved 2 19, 2017, from http://www.nps.org.au/medicines/hormonal-and-metabolic-system/corticosteroids-oral-and-injectable/prednisolone-corticosteroids-oral-and-injectable

Queensland Government. (2016). Health (Drugs and Poisons) Regulation 1966. Retrieved from https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HealDrAPoR96.pdf

Tollefson, J., Watson, G., Jelly, E., & Tambree, K. (2015). Essential clinical skills: Enrolled/division 2 nurses. (3 ed.). Melbourne, VIC, Australia: Cengage Learning Australia.

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