FLINDERS UNIVERSITYADELAIDE AUSTRALIA

Faculty of Health Sciences

Nursing&Midwifery

NURS2105 Nursing 4

WorkbookSemester 2 2008

Schoolof

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The information in this Study plan was correct at time of printing. Please refer to https://flo.flinders.edu.au for up-to-date information. School of Nursing & Midwifery, Flinders University 2007 2

ContentsWeek 2: Part 2 - Nursing Management of Musculoskeletal Disorders.............................12 Week 5: Part 1 - Nursing Management of Endocrine Disorders Type 1 Diabetes Mellitus................32 Week 6: Part 2 - Nursing Management of Endocrine Disorders Type 2 Diabetes Mellitus................41 Week 7: Nursing Management of Renal Disorders End Stage Renal Failure................48 Week 8: Part 2 Nursing Management of Urological Disorders UTI & SPC...................54 Week 9: Nursing Management of Gastrointestinal Disorders Large Bowel Obstruction60 Week 10: Nursing management of Hepatobilary Disorders.............................................71 Week 11: Nursing Management of Haematological Disorders ............................... .........80 Week 12: Part 1 - Nursing management of Reproductive Disorders Female Focus.....82 Week 13: Part 2 - Nursing management of Reproductive Disorders Male Focus..........89

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NURS2105: Workbook

Week 1: Part 1 - Nursing Management of Musculoskeletal DisordersThis week focuses on two problems related to the musculoskeletal system. The tutorial will focus on osteoarthritis, resulting total knee replacement and nursing management options. The workshop will involve a number of activities including management of the postoperative patient following total joint replacement Total hip replacement.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the musculoskeletal system describe the aetiology, pathophysiology, clinical manifestations and management of metabolic bone disorders describe the types of reconstructive surgery associated with osteoarthritis and rheumatoid arthritis identify the preoperative and postoperative teaching and collaborative care of the patient having reconstructive joint surgery associated with osteoarthritis and rheumatoid arthritis

What you need to do to meet your learning outcomes1. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 60 Nursing assessment: musculoskeletal system 61 Nursing management: musculoskeletal trauma and orthopaedic surgery 63 Nursing management: arthritis and connective tissue disease (this will be especially useful for this weeks practical session). Consult a pharmacology text regarding:

non-steroidal anti-inflammatory (NSAID), antipyretic and analgesic drugs

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WEEK 1: Workshop activitiesMusculoskeletal focusMrs Bartini (70 years old) is admitted to your ward for a L) total hip replacement (THR) for osteoarthritis (OA) and osteoporosis. Unfortunately, whilst changing into her night attire, she slipped and put out her R) arm to prevent the fall resulting in her sustaining a R) Colles fracture (#). It has been decided to reduce & stabilise her # radius with a cast as well as perform her L) THR. She arrives back from theatre with

her R) forearm in a back slab an IVT in her left arm 2L/24 hrs alternating 4%Dextrose/1/5Normal saline with N/Saline Fentanyl 4/24ly prn Abduction pillow in situ wound drains x 2 patent and draining

You are allocated to provide nursing care for her this shift. You have a year 1 student with you. Below is a copy of the orders from the patient care orders:

routine post op care 2 units of autologous blood to be administered as per medical instructions neurovascular observations to L) leg abduction pillow to turn food and fluids as tolerated chest physio

In your group consider the nursing care required for Mrs Bartini. When you read her care plan and case notes consider what you have to do as a group. There are six major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go. Prioritise the nursing care for Mrs Bartini and give a rationale for the prioritisation.

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2. Activity 1Explanation of THR and Colles # to a year 1 student The year 1 student asks you to explain. o The difference between OA and rheumatoid arthritis.

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Explain how OA has caused her to need a THR.

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Exactly what does a THR entail?

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Outline the pathophysiology of a Colles # including how it is reduced.

In discussion with the 1st year student consider. o Outlining the anatomy of the hip and leg. Draw a picture to augment your explanations.

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Use the x-ray of the hip and the metal wear on display to explain OA and a THR.

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3. Activity 2Pressure area care and pain relief for Mrs BartiniMrs Bartini is reluctant to move in bed because of her L) hip pain. Consider what nursing assessment you would undertake to determine the best choice of intervention to relieve the pain for Mrs. Bartini. Document your findings.

Discuss the main side effect of opioid analgesia and how it may be detected and reversed.

Provide pressure area care for Mrs Bartini, taking special note of: o o o o skin for diathermy burn pressure from wound drain lines wound ooze skin over pressure areas.

Outline how you would document your observations.

4. Activity 3Neurovascular observations of Mrs Bartinis L) legNeurovascular observations: Using the sphygmomanometer, apply the cuff to a group members upper arm just as you would to take a blood pressure reading. Inflate the cuff to 180 mm and leave for 10 seconds (no longer than 30 seconds).

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Ask the person to describe how the arm is feeling distal to the inflated cuff. Note limb: o o o o o colour (C) temperature (W) movement (M) sensation (S) presence of a pulse (P)

This information is known as the neurovascular observation of the limb distal to the fracture. Note the documentation that is completed when neurovascular observations are completed. This demonstration gives you some appreciation of what altered sensation, venous congestion and arterial insufficiency could feel like. Document your findings. Perform neurovascular observations on Mrs Bartinis L) leg. o Outline the reasons for them being done on Mrs Bartinis leg.

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5. Activity 4Plaster care and neurovascular observations of Mrs Bartinis R) arm Plaster care o o From your pre-reading, outline the nursing responsibilities when providing care for the person who has a limb in plaster. Consider the new green cast. Outline the nursing care require for Mrs Bartinis green cast.

Discuss the discharge information you would give Mrs Bartini regarding care of the cast and the affected limb.

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Neurovascular observations of Mrs Bartinis R) arm. o Define compartment syndrome and why it may occur with Mrs Bartinis R) arm.

Discuss how it is detected and also treated.

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Watch the video Nursing care of the patient in traction and discuss what particular nerves need to be assessed with Mrs Bartinis R) arm and L) leg. Upper extremity assessment.

Match the nerve with the appropriate motor and sensory test. Nerve Radial Medial Ulna o Lower extremity assessment. Match the nerve with the appropriate motor and sensory test. Nerve Femoral Peroneal Tibial o Vascular assessment. Dark-skinned people Warm = Cold = Hot = Motor test Sensory test Motor test Sensory test

Fair-skinned people Pink = Red = White = Blue =

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o

Capillary refill should occur in less than ___________ seconds.

6. Activity 5Autologous blood Define autologous blood.

Discuss why autologous blood is preferred to donor blood.

Perform the checking procedure according to the FMC ward procedure manual for blood administration. o Discuss how this procedure is different from checking off medications.

7. Activity 6Dietary modificationMrs Bartinis Colles # was partly due to her osteoporosis. Her husband and daughter ask you to suggest foods, which will increase her dietary calcium. Her daughter is also worried that she may develop osteoporosis because she cannot have any dairy products as she is lactose intolerant and so has been avoiding all dairy products.

Construct a calcium rich diet across life span considering: o o o Lactose intolerant Vegans Teenagers.

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Explain whether you would recommend low fat products.

NURS2105: Workbook

Week 2: Part 2 - Nursing Management of Musculoskeletal DisordersThis week focuses on acute infection problems related to the musculoskeletal system. The tutorial will focus on osteomyelitis and appropriate nursing management options. The workshop will involve a number of activities including management of the patient with osteomyelitis and rehabilitation options.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the musculoskeletal system describe the aetiology, pathophysiology, clinical manifestations and management of metabolic bone infections identify the preoperative and postoperative teaching and collaborative care of the patient having reconstructive surgery associated with acute musculoskeletal injury and subsequent infection. describe the pathophysiology, collaborative care and nursing management of the person with osteomyelitis.

What you need to do to meet your learning outcomes

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8. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapter: 62 Nursing management: musculoskeletal problems. Consult a pharmacology text regarding:

non-steroidal anti-inflammatory (NSAID), antipyretic, and analgesic medications. IV antibiotics. Analgesic medications.

WEEK 2: Workshop activitiesMusculoskeletal focusMr Stephen Cartwright is a 56 year old and living in Adelaide within the eastern suburbs. He is married with three adolescent children and works in an executive banking position in the city. He enjoys weekend home maintenance and landscaping as relaxation activities. He is a committed Jehovah Witness and attends twice weekly services at the local Jehovahs Witness Kingdom Hall. His general health is sound for his age. His wife is committed to a healthy eating and physical lifestyle. They play tennis weekly and walk several kilometres throughout the week. They entertain at their home frequently and consume large amounts of alcoholic beverages mainly wine and spirits. A month ago Stephen was on the roof of his house performing maintenance following discovery of a cracked roof tile. On descending the ladder whilst carrying the replaced tile he slipped and fell to the ground, landing on the rough and much rocky garden edges. His injuries included severe compound fractures of his right tibia and fibula. Numerous cuts and scratches of his face and right and left arms were also evident. Surgery involving debridement of the damaged tissue and reduction of the fractures was performed. A right full length leg cast was applied equipped with windows to enable the surgical sight to be visualised. His facial and body scratches and bruising very treated and some were dressed with gauze and hyperfix. He made sound progress on the orthopaedic ward and was discharged after two weeks. After one week being home he began feeling unwell accompanied with fever, some night sweats, restlessness and general increasing malaise. His surgical sight had become more painful and had increased swelling and erythema. He is currently admitted with the development of osteomyelitis of his right lower leg. The organism Staphylococcus aureus has been identified as the infective agent. Bone ischemia has not yet developed and so vigorous and prolonged IV AB therapy is anticipated, including after discharge from hospital. His care is outlined as follows:

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4/24 vital signs rest in bed (RIB) 4/24 wound checks morphine PCA with purges R) leg cast insitu pending possible further surgical intervention. anti-emetics ordered IV ABs 1g Penicillin 8/24. C&B exercises. Ward diet and fluids. Bowel monitoring and coloxyl and senna when necessary

In your group consider the nursing care required for Mr Cartwright. When you read her care plan and case notes consider what you have to do as a group. There are six major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go. Prioritise the nursing care for Mrs Cartwright and give a rationale for the prioritisation.

9. Activity 1Explanation of osteomyelitis to Mr Cartwright (Patient Education). The patient asks you to explain. o o o What is osteomyelitis. The difference between osteomyelitis and wound infection. What has been the cause of his infection?

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Explain how osteomyelitis has caused the patient to require readmission and further medical interventions.

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Outline precisely what the treatment of osteomyelitis entails.

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Outline the most likely causes of osteomyelitis including how it is pharmacologically treated.

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The patient is unsure why cast windows exist over the operative sight. Outline why this has been done and how it benefits the nursing and medical treatment of osteomyelitis..

10. Activity 2 pain relief for Mr CartwrightMr Cartwright is experiencing and demonstrating severe pain. Consider what nursing assessment you would undertake to determine the best choice of interventions to relieve the pain for Mr Cartwright Document your findings.

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Discuss the reasons for his increased pain there are more than one.

Outline how you would document your observations after each pain assessment.

Outline your choice of pain analgesia and administer. Document procedure.

11. Activity 3Neurovascular observations of Mr Cartwrights R) leg Why are the following components of the neurovascular observations undertaken? What does each component reveal about the physical state of Mr Cartwright? o colour (C) o temperature (W) o movement (M) o sensation (S) o presence of a pulse (P) This information is known as the neurovascular observation of the limb distal to the fracture.

Perform neurovascular observations on Mr Cartwrights R) leg.

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What nursing interventions would you implement should notable neurovascular deteriorations be determined?

12. Activity 4Plaster care and wound management including wound assessment, cleansing, and dressing. Outline the nursing care require for Mr Cartwrights R) leg cast.

Perform a surgical site assessment on Mr Cartwrights R) leg. Document your findings.

Perform a surgical site sterile wound care nursing intervention. What were your experiences?

Discuss the importance of the sterile wound dressing nursing technique.

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13. Activity 5Discharge planning for Mr Cartwright. Outline the major discharge planning requirements for Mr Cartwright.

Should long term IV AB treatment be necessary, how will this be achieved?

What is the important care information and planning information Mr Cartwright and his family require given his long term IV AB therapy?

NURS2105: Workbook

Week 3: Part 1 Nursing management Cognitive and Perceptual DisordersThis week the tutorial will focus on the nursing management required during the acute and rehabilitative phase for the person who has had a stroke. The workshop will focus on the nursing care required for the semi-comatose/concussed patient and the patient with seizures.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the incidence and risk factors for stroke in Australia describe the acute and rehabilitative nursing management for the stroke patient describe the common diagnostic study abnormalities found in patients with a cerebrovascular accident describe age-related changes to the nervous system and differences in assessment findings.

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describe first aid management of the person who is having a seizure and the nursing responsibilities.

What you need to do to meet your learning outcomes14. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 2 Culturally competent care 54 Nursing assessment: nervous system 56 Nursing management: patient with a stroke

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WEEK 3: Workshop activitiesNeurological focusMrs Schofield is a 45 year old married woman who was found in her kitchen by her 18 year old son Peter after he returned home from University. Peter stated that he found his mum on the kitchen floor; she appeared, okay except for a deep laceration on the right side of her forehead. Peter was unable to rouse his mum, so he called an ambulance, he is not sure how long she had been unconscious for, as he left for university at 10.00 am and it was 4.00 pm when he arrived home. When Mrs Scholfield arrived in emergency she was assessed, and was found to have:

A deep laceration to her forehead, requiring seven sutures. A haematoma to the back of her head Slow response to verbal stimuli Pupils were equal and reacting, but sluggish BP of 180/110 Pulse 110 Respiratory rate 32 and shallow No paresis of either limb Smokes20 cigarettes a day Social drinker Has not had any previous admissions to hospital apart from child birth On oral contraceptives.

Whilst in emergency the medical orders include

Skull x-ray CXR CT/MRI of her skull IVT of N/Saline in 24 hours and an IV cannula is inserted, running at 83mls/hr (2L in 24 hours) Blood tests

o o

CBP Electrolytes

No medications

Nursing Orders include:

Hourly neurological observations Nil Orally

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Oral-Pharyngeal suction as necessary Head of the bed not to raised more than 30 Wound to be dressed

She is admitted to your ward, where the MO asks you to check that IV Dexamethasone, Diazepam & Mannitol is available.

In your group consider the nursing care required for Mrs Scholfield. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

15. Activity 1Neurological observationsAccurate nursing assessment of the neurological status of the patient is vital for the patients safe recovery and the early detection of deterioration. With a student assuming the role of Mrs Scholfield, each student is to perform a neurological assessment, using a neurological observation chart. Outline the purpose of the Glasgow Coma Scale (GCS)

Outline the five main components of the GCS

What does a GCS score of 15 indicate?

What does a GCS score of eight indicate?

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As a 2nd year nursing student, who would you notify regarding a change in one or two points in Mrs Scholfields GCS score?

Apart from the Glasgow Coma Scale what other observations are included in neurological observations?

Describe how pupils are assessed.

Explain the acronym PEARL

Outline what may cause differently-sized pupils.

Describe how limb strength is assessed and explain why it is used in neurological observations.

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16. Activity 2Seizure observation and careMrs Scholfield suddenly has a generalised clonic-tonic seizure. Describe the nursing care required for a patient having a seizure in bed.

Outline the observations that you would make of her seizure.

Outline the different forms of seizures.

Her son Peter is scared by this and asks you whether she will continue to have fits when she returns home and what would he do about it including whether he should call an ambulance. Outline the first aid measures for a person having a seizure.

Outline the reasons for calling an ambulance when you are giving first aid for a person having a seizure.

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17. Activity 3IV medicationsThe MO orders IV 5 mg stat of Diazepam. Outline why Diazepam is used in the treatment of seizures.

Describe how you would administer the IV Diazepam.

Outline the major medications used in the treatment of seizures.

18. Activity 4Removal of suturesMrs Scholfield slowly recovers and is able to go home after seven days in hospital, before she goes home; she is to have her sutures removed from her scalp laceration. Explain the appropriate time period before removing sutures.

Outline the procedure for removal of her sutures.

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19. Activity 5Discharge planningAlthough, she is being discharged, the MO has told her and her family that she may have postconcussion syndrome. Outline the major clinical features of post concussion syndrome

Outline the discharge advice that you would need to give Mrs Scholfield and her family to help them cope with Mrs Scholfields post concussion syndrome.

NURS2105: Workbook

Week 4: Part 2 Nursing management of Cognitive and Perceptual DisordersThis week the tutorial will focus on the nursing management required during the acute and rehabilitative phases for the person with raised intracranial pressure (ICP). The workshop will focus on

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the nursing care required for raised intracranial pressure and other trauma following a motor vehicle accident (MVA).

Learning outcomes for this weekUpon the successful completion of this section you should be able to:

describe the incidence and risk factors for raised intracranial pressure. describe the acute and rehabilitative nursing management for the raised intracranial pressure patient describe the common diagnostic study abnormalities found in patients with raised intracranial pressure. describe age-related changes to the nervous system and differences in assessment findings. describe first aid management of the person who is having a seizure and the nursing responsibilities.

What you need to do to meet your learning outcomes20. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 55 Nursing management: intracranial problems 57 Nursing management: chronic neurological problems

WEEK 4: Workshop activitiesNeurological focusMartin is a 28-year-old physical education instructor working in various high schools. His physical fitness is very sound as he undertakes numerous physical activities and he incorporates a considered dietary routine. He is single and spends significant time associating with friends and sporting group clubs. His general outlook on life is that life should always be lived to the fullest. Martin is devoted to his motorcycle and spends weekends riding through the Adelaide Hills and sometimes races at local meetings. Today he was riding through a difficult piece of road in the rain and collided with an oncoming motor vehicle. He incurred serious head, thoracic, and leg injuries and subsequently had to

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sedated and intubated by ambulance paramedics at the crash scene prior to being transported to the emergency department. Medical investigations confirm a closed head injury with an associated fracture of the frontal skull. His right wrist (with severe soft tissue damage) and left tibia are broken transversely and will be set in plaster. No internal organ damaged is confirmed and he has numerous cuts and deep lacerations about his torso and forehead. In emergency the nurses obtain a health history from his father who is quite distressed to see his son this way. At the scene of the accident he was:

Unresponsive with Glasgow Coma Scale of 3. Hypotensive with systolic varying between 55 and 82 mmHg. Diastolic ranged from 35 and 45 mmHg. Tachycardic 120 to 130 bpm. Respirations rapid and shallow 30 breaths per minute. Pupils 3mm and non-reactive. assessed by emergency medical officer who orders a CT scans

In the emergency department:

CT confirms Martin has a frontal skull fracture with right subdural haematoma, subarachnoid haemorrhage. Pronounced cerebral oedema confirmed. X-Ray show right wrist fracture and left femur transverse fracture. Increased Cranial Pressure confirmed at 3 mmHg. Bleeding from numerous lacerations to his leg, torso, and forehead. ?

In your group consider the nursing care required for Martin. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

21. Activity 1Neurological observationsWith a student assuming the role of Martin, each student is to perform a neurological assessment, using a neurological observation chart and taking note of his raised ICP status.

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Outline the most effective measurement scale of neurological status.

Perform and accurately document this ICP neurological assessment.

What does Martins score of 3mm and non-reactive indicate?

What are the most effective nursing responses to Martins Fathers questions regarding his sons neurological state?

As a 2nd year nursing student, who would you notify regarding a change in one or two points in Martins GCS score?

Apart from the Glasgow Coma Scale what other observations are included in neurological observations, given Martins injuries? Perform these other neurological observations on another student. Document these findings appropriately.

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Given Martins conditions, what position should he be placed in? What are the underlying medical reasons for this?

Explain why the MO has asked for dexamethasone and mannitol to be available.

22. Activity 2Laceration wound observation and careMartin has numerous deep lacerations to his torso and forehead: Describe the nursing care required for a patient having these wounds assessed and cared for.

Outline the observations that you would make of these wounds.

Perform the documented and ordered wound care. Document appropriately the nursing actions taken.

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Outline the nursing actions required if a sudden post-operative deterioration in these wounds is assessed.

Given Martins reduced neurological status, does he require communication to him by the nurses about to care for his wounds?

23. Activity 3IV medicationsThe MO orders IV Mannitol (25%): Outline why Mannitol is used in the treatment of raised intracranial pressure.

Describe how you would administer the IV Mannitol (25%). Teach this to other students in the group.

Outline the other major medications which may be used in the treatment of raised intracranial pressure.

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24. Activity 4Assessment of otorrhoea and rhinorrhoea as part of neurological observationMartin has had severe skull trauma and therefore requires cerebrospinal fluid (CSF) monitoring: Discuss how you would assess Martins otorrhoea and rhinorrhoea to be CSF.

Outline the care for Martin should CSF otorrhoea and rhinorrhoea be detected.

Outline the nursing observations to be performed to ensure early detection of any infection to the brain.

25. Activity 5Plaster Care and related neurovascular observationsAs Martin has a fractured right wrist and left tibia, both limbs are placed in casts. Outline the nursing responsibilities when providing care for Martin and his two plaster casts.

Outline the discharge advice that you would need to give Martins Father and family to help them cope when Martin is discharged. Role-play this with members of the group and critique for improvements.

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Neurovascular observations of Martins limbs which have a cast.. Assume Martin is now able to give verbal response to nursing actions: Define compartment syndrome and why it may occur with Martins right arm.

Define how it is detected and treated. Perform this task on Martin and document appropriately.

NURS2105: Workbook

Week 5: Part 1 - Nursing Management of Endocrine Disorders Type 1 Diabetes MellitusThe endocrine system is under study this week. The case study focuses on a six year old girl who has Type 1 Diabetes mellitus and has had a hypoglycaemic episode. The element to be particularly covered in the tutorial around this case study is primary health care. Relevant clinical nursing skills will be covered in your workshop related to the patient with such diabetes.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: 1 apply critical thinking to the case study presented 2 apply primary health principles to the case study presented 3 apply biophysical and pharmacological knowledge to the case study presented 4 develop your application of nursing research to the case study presented 5 extend your knowledge of lifespan development in childhood and the implications for nursing practice

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6 expand on your assessment skills in the area of the endocrine system 7 apply diabetes management principles to type 1 diabetes mellitus 8 develop your knowledge base in the nursing management of a child who has type 1 diabetes mellitus 9 practise and discuss nursing skills relevant to the area under study including: care of skin, feet and eyes in a client with diabetes, mixing of insulin medications, oral hypoglycaemic medications, BGLs, and diabetic diet.

2What you need to do to meet your learning outcomesAttend your lectures, one tutorial and one workshop session as well as the following activities. Read the case study, ask the critical questions and then refer to the relevant pages in the following texts to answer those critical thinking questions. By this stage students should be able to find their own reference material pertaining to the area of study.

1Complete these activitiesPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 46 Nursing assessment: endocrine system 47 Nursing management: diabetes mellitus

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Activity Research the following medications and complete the pharmacology worksheet before coming to class.MEDICATION Trade and Generic Name INSULIN (Include all forms) MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS

GLICLAZIDE

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MEDICATION Trade and Generic Name METFORMIN MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS

ARCABOSE

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WEEK 5: Workshop activitiesDiabetes MellitusRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the workshop Emily is six years old little girl. She has Type 1 diabetes. She loves to go to school and being a very energetic child, likes to participate in active sport activities with her friends at lunchtime. Emily is cared for by her conscientious mother and father. Her mother has informed the teacher about Emilys condition and what should be done if she should suffer from a hypo. To maintain glycaemia management, Emily requires an insulin injection before breakfast, lunch and tea. Her meals consist of a well balanced diet. The problem: Emily has her usual injection before lunch but does not eat all her food that day because the class finishes late and she wants to join in the usual sports activity. Half way through the sports activity Emily suddenly has a hypo and the sports teacher has no idea how to cope with the situation. Emily rapidly becomes drowsy and then becomes unconscious. She is admitted to your ward after she has been stabilised. Her parents Jane 29 and Graham, 27 are very worried about Emilys diabetes especially as it was diagnosed at five years of age. They have decided to not have any more children so that they can devote themselves to Emilys welfare and Jane has reduced her full time employment to part-time so that she can be more readily available to Emily. Jane tells you that she had an aunt who had diabetes and she died at 53 from a heart attack, but before her death she had had one leg amputated, was blind and was in renal failure. In your group consider the nursing care required for Emily and her parents. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

26. Activity 1Patient and Parent educationGiven the understandable concern of Emilys parents regarding Type 1 Diabetes Mellitus; Outline the precise reason for Emilys hypo episode and the most effective steps to prevent this happening again. Are there any special ways of interacting with Emily during this stage?

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Outline the importance of this together with a thorough knowledge base, given Emilys Diabetes Mellitus Type 1 and her age.

Outline the nutritional therapy required for Emilys Diabetes Mellitus Type 1 management when discharged. How does her eagerness for exercise impact upon this?

27. Activity 2Blood Glucose Level (BGL) Monitoring Describe the rationale for frequent monitoring of BSL.

Outline the nursing observations that you would frequently make given the necessity for BGL monitoring.

When are the most frequent times of the day to perform BGLs?

Perform a BGL. Document your findings. What is the range of BGL readings considered within an acceptable range?

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Outline the nursing interventions when performing a BGL reading on a paediatric patient. Suggest strategies which may improve the process if the patient is distressed.

28. Activity 3Administration of Insulin medicationsAssume the MO has determined Insulin administration is required for this activity: Perform a BGL reading and determine the dose of Insulin required.

Describe how you would administer the Insulin. Describe the dosage measurement and state the principles of care when administering of a subcutaneous injection of insulin.

Outline the range of Insulin medications used in Diabetes Mellitus Type 1 management. Detail the difference between short, medium and long acting types of insulin

Outline the injection sites for Insulin administrations.

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Outline the dietary requirements and planning for Emily whist she is admitted and thus requiring close glycaemia monitoring.

Outline the oral medications used for blood glucose maintenance. How do these differ from Insulin?

29. Activity 4Acute assessment and management of a hypoglycemic situationThis activity requires one person of your group to assume the role of the patient undergoing a hypoglycaemic event whilst on the ward. Explain the clinical symptoms of the observed hypo event.

Outline the nursing assessment immediately required.

Detail the nursing interventions required to maintain patient safely and securely. Critique and support the actions of all members of the group advising and acting.

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30. Activity 5Discharge planningAlthough, she is being discharged, the risk of another hypo event is real. Outline the major requirements for Emily and her parents to implement.

Outline the community facilities and Diabetic Mellitus public information available for Emily and her parents.

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NURS2105: Workbook

Week 6: Part 2 - Nursing Management of Endocrine Disorders Type 2 Diabetes MellitusThe endocrine system is under study this week. The Tutorial scenario focuses on a 72 year old man who has Type 2 Diabetes mellitus and relating health conditions. Differences with Type 1 Diabetes Mellitus will be made clearer as well as the nursing interventions required. Relevant clinical nursing skills will be covered in your workshop related to the patient with Type 2 Diabetes mellitus.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: 2 apply critical thinking to the case study presented 3 apply primary health principles to the case study presented 4 apply biophysical and pharmacological knowledge to the case study presented 5 develop your application of nursing research to the case study presented 6 extend your knowledge of lifespan development in childhood and the implications for nursing practice 7 expand on your assessment skills in the area of the endocrine system 8 apply diabetes management principles to type 1 diabetes mellitus 9 develop your knowledge base in the nursing management of a child who has type 1 diabetes mellitus 10 practise and discuss nursing skills relevant to the area under study including: care of skin, feet and eyes in a client with diabetes, mixing of insulin, oral hypoglycaemic medications, BGLs, and diabetic diet.

3What you need to do to meet your learning outcomes

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Attend your lectures, one tutorial and one workshop session as well as the following activities.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 46 Nursing assessment: endocrine system 47 Nursing management: diabetes mellitus

WEEK 6: Workshop activitiesDiabetes Mellitus Type 2Read through this scenario and consider the questions that follow. Please be ready to discuss your answers in the workshop Jean Paul is a 72 year old man living on his own in a small apartment in the suburbs. He was a chief for many years and had a French restaurant for 15 years after immigrating to Australia. He never married but has a son living nearby with his family. He was diagnoses with Type 2 Diabetes Mellitus eight years ago after the development of several foot neurotropic ulcerations and various points of dermopathy around his body. He has begun to develop early signs of diabetic neuropathy in his right hand. Changes in his urinary function were also detected and a diagnosis of nephropathy was confirmed. This renal condition is monitored annually. His father died of diseases related to Diabetes Mellitus aged 82 years. His physical activity is minimal due to lifestyle choices, foot pain, and not having the willingness to do so. Consequently he is obese and weights 127kgs at 5ft 9. He smokes heavily in his apartment and consumes approximately 1 packet daily. His diet is devoted to his love of homeland French cuisine and he consumes large amounts of it. He does not drink alcohol as he thinks it diminishes the taste of his cooking. Despite medical instructions, he takes his BGL reading infrequently and does not incorporate nutritional modifications to his eating habits. He is determined to remain a smoker. Jean Pauls medications include: Enalapril (ACE inhibitor) for his hypertension and kidney conditions. Metformin, for blood sugar level maintenance, which he often forgets to administer. He takes regular Panadol for foot and other bodily pain. His son Michael came to visit him where he found Jean Paul very somnolent and almost unable to move or coordinate. He was immediately taken to the emergency department. A diagnosis of Hyperosmolar Hyperglycaemic Non-Ketotic Syndrome (HHNS) is made and medical treatment is rapidly instigated to manage this life-threatening syndrome. He has not developed this medical condition since his diabetic diagnosis. The findings of the emergency department are: BP: 85/55 Temp: 37.8

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Resps: 26 Pulse: 118 SAO2 91% BGL: 48 mmol/L IV Insulin: immediate treatment for high BGL IV N/S 1000mls 250mls hour then titrated according to fluid volume status. IV 5% dextrose administered when BGL is 12-16 mmol/L to prevent hypoglycaemia. Cardiac irregularity detected by ECG Pronounced dehydration and serum osmolarity frequent urination. Ketoacidosis not present. Routine blood and urine tests for electrolyte balances. Oxygen therapy via nasal cannula commenced at 4L. In your group consider the nursing care required for Jean Paul. When you read his care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

31. Activity 1Cardiac monitoring ECGGiven the understandable cardiac irregularities secondary to HHNS, an ECG is warranted: Outline the precise reason for an ECG for Jean Paul. Link your reasoning to his current medical condition.

Outline the importance of the registered nurse being able to detect cardiac arrhythmias. Discuss the link with cardiac angiopathy and Diabetes Mellitus Type 2.

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Perform an ECG on a consenting fellow student. Explain your nursing actions to other students in the group. Critique and support

32. Activity 2Blood Glucose Level (BGL) Monitoring Describe the rationale for frequent monitoring of BSL in Type 2 Diabetes.

Outline the nursing observations that you would frequently make given the necessity for BGL monitoring concerning Jean Pauls HHNS.

When are the most frequent sights to perform BGLs? Be mindful of Jean Pauls age and physical condition.

Perform a BGL. Document your findings. What is the range of BGL readings considered within an acceptable range? Remember Jean Pauls current diagnosis and Type 2 diabetes.

Outline the nursing interventions when performing a BGL reading on a Jean Paul, when he becomes agitated and refuses the intervention.

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33. Activity 3Administration of hypoglycemic oral medicationsAssume the MO has determined Insulin administration is no longer required for treatment. What are the classes of hypoglycaemic medications? Which class does Jean Pauls medication belong?

Describe how Metformin works. How does it benefit Jean Paul?

Under what circumstances is Insulin prescribed to treat Type 2 Diabetes patients?

Outline why Jean Paul received IV Insulin does? Examine the set-up presented.

Is there a risk of hypoglycaemia through Jean Pauls treatment? How can this be prevented? What signs would you look for?

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34. Activity 4Neurovascular observationsThis activity requires one person of your group to assume the role of the patient undergoing a neurovascular assessment whilst on the ward. Explain the clinical requirements to your group of neurovascular assessments.

Outline the nursing actions required.

Discuss the principles of care regarding the normal findings during a neurovascular assessment including. o o the abnormal findings during a neurovascular assessment the abnormal findings during a neurovascular assessment.

Demonstrate the correct procedure for a neurovascular assessment by examining another student (with their consent) using all equipment available.

Students will discuss the principles of care including neurovascular assessment in the assessment for patients with Diabetes Mellitus Type 2, particularly: o o o diet skin eyes

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o o

feet mobility.

35. Activity 5Discharge planningGiven Jean Pauls self stated less than adequate diabetic management: Outline the major educational requirements for Jean Paul.

Outline the community facilities and Diabetic Mellitus public information available for Jean Paul pay attention to his age group and Type 2 Diabetes.

Outline the required nutritional changes required for Jean Pauls management of his Type 2 Diabetic Mellitus:

36. Activity 5Agitation/ Confusion Management

Outline the nursing interventions to manage Jean Pauls agitation and confusion:

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NURS2105: Workbook

Week 7: Nursing Management of Renal Disorders End Stage Renal FailureThis week will focus on urological/renal diseases culminating in urological/renal failure. The tutorial focuses on chronic renal disease (CRD) leading to end stage renal disease (ESRD). The practical workshop will involve a number of activities including fluid and electrolyte management, blood pressure (BP) management, arterio-venous fistula/graft (AVF or AVG) care and central venous dialysis catheter (CVDC) care.

Learning outcomes for this weekUpon the successful completion of this section you should be able to:

describe the clinical manifestations, complications, collaborative care, and nursing management of a person with CRD leading to ESRD. describe the preoperative and postoperative nursing management for a person requiring AVF or AVG formation prior to haemodialysis. describe the treatment options of a person with ESRD including haemodialysis, chronic ambulatory peritoneal dialysis (CAPD), intermittent peritoneal dialysis (IPD) and renal (kidney) transplantation describe the nursing and collaborative management of a person undergoing haemodialysis.

What you need to do to meet your learning outcomesPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 43 Nursing assessment: urinary system 45 Nursing management: acute renal failure and chronic kidney disease

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WEEK 7: Workshop activitiesESRD and AVF post-surgical careNguyen is a 35 year old female who lives in Fulham Gardens. She is married with two young children (8 and 6 years old). She has lived in Australia for the past two years and her English is limited. She was admitted 2 weeks ago with symptoms of increasing lethargy, nausea, weakness, depression, and recurring gastritis. Following diagnostic tests including blood tests (urea, creatinine, potassium), renal ultrasound and renal biopsy she was diagnosed with ESRD. Nguyen had not previously been diagnosed with (chronic renal disease) CRD. On day 2 after admission Nguyen had a CVDC (often called a Permcath) inserted into her left subclavian vein and haemodialysis was commenced. After 10 days of intermittent haemodialysis (every alternate day) she had an AVF surgically constructed in her left forearm. She returned from theatre 8 hours ago.

Current nursing care includes:

post-operative observations (BP not on operated arm) post-operative neurovascular observations observation of bruit/thrill wound observation RIB IVT FBC Her medications include:o o o o o o o o o o o

Paracetamol or Panadine Forte 1g QID prn IV AB (Two Doses) Cephalothin 1gm 8/24. Alutab 1 TDS Amlodipine 10mg nocte Caltrate 3 TDS Calcitriol 1 mcg non-dialysis days EPO 6000u s/c twice weekly Folic Acid 5mg daily Loperimide 2 nocte Vit C 500mg post dialysis Mega B 1 post dialysis

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In your group consider the nursing care required for Nguyen. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

38. Activity 1Post- Operative Nursing ManagementGiven the understandable concern of Nguyen regarding her ESRD and surgical interventions: Formulate a nursing care plan for Nguyen for the first 24 hours on the ward. Include the following: Look at the statement of Nguyens most significant nursing needs. nursing interventions including rationale. changes that may need to occur to the nursing care plan during the first 24-hrs period. Consider the cultural and language requirements of Nguyen.

Detail and discuss with group members the nursing interventions required to maintain patient safely and securely. Critique and support the actions of all members of the group advising and acting.

39. Activity 2AVF surgical site Describe the new blood flow through Nguyens new left arm AVF.

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Outline the nursing observations that you would frequently make post-operatively.

What is the importance of assessing the Thrill and Bruit of the AVF sight? Describe the meaning of these two terms.

Document your findings of the above AVF assessment accordingly.

Allow one student in the group to assume the role of Nguyen, explain this assessment to her with regard to language difficulties.

40. Activity 3Neurological Assessment Perform a neurological assessment on Nguyens left arm.

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Describe the nursing responsibilities and assessment required.

Outline the pathophsiological reasons for such an assessment.

What are the nursing responsibilities if a sudden decrease in neurological results is detected. Be sure to critique each students suggestions.

Discuss why a BP is not to be done on this arm. Is this now a permanent precaution?

41. Activity 4IVT Management, IV AB administration, and Nguyens IVT flask is due for changing. Explain to the other group members the nursing responsibility for these procedures.

Document the above change in the FBC.

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Detail and discuss the nursing interventions required to administer the medically ordered IV AB.

Administer the IV AB. Other members of the group to provide critique and support.

42. Activity 5Discharge planningAlthough she is being discharged, the need for regular haemodialysis is vital. Outline the major changes for Nguyen and her family to implement.

Outline the community facilities and Haemodialysis public information available for Nguyen.

Outline the considerations which will likely be implemented to enhance the discharge planning process, given Nguyens cultural background and language limitations.

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NURS2105: Workbook

Week 8: Part 2 Nursing Management of Urological Disorders UTI & SPCThis week will focus on permanent urological problems of an elderly man. The tutorial focuses on chronic UTI development due to the use of a permanent SPC. The practical workshop will involve the nursing responsibilities for treating a UTI and the assessment and maintenance of an SPC.

Learning outcomes for this weekUpon the successful completion of this section you should be able to:

describe the clinical manifestations, complications, collaborative care, and nursing management of a person with chronic urological problems chronic UTI development describe the nursing management for a person requiring UTI treatment and SPC monitoring describe the treatment options of a person with urological problems chronic UTI describe the education and public health information able to be give to such patients

What you need to do to meet your learning outcomesPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 43 Nursing assessment: urinary system 44 Nursing management: renal and urological problems

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WEEK 8: Workshop activitiesUTI & SPC nursing interventionsPeter is a 78 year old nursing home resident. He has been resident in the home for ten years following the death of his wife from liver cancer. Peters daughters rarely visit and he insists on remaining in his room alone most of each day. His physical mobility is poor and he remains in his wheelchair rather than walking. He has significant osteoarthritis in his hips and left knee. He has Type 2 diabetes resulting in lower leg ulcerations and hypertension. Peripheral neuropathy is also present in his lower legs. Peter will not take hypoglycaemic medication as he says he doesnt eat enough nor wants to take such tablets. The nursing home RN performs BSL twice weekly. Two months ago he had a suprapubic catheter (SPC) inserted following numerous incidents of urinary tract infections. Medical investigations revealed a neurogenic bladder with associated low bladder wall compliance. His tolerance of having such a urinary catheter has been low and he refuses to be involved in its care and maintenance. Such low involvement has contributed to the numerous cases of (urinary tract infections) UTIs. Three days ago the nursing home staff noticed an increase in his agitation and confusion; he frequently refused to have carers attend to his hygienic needs. An increase in flank pain, discomfort, agitation, and development of a fever led to his emergency department admission where a severe recurrent upper UTI with related urethritis were diagnosed. Misuse and nonhygienic maintenance of his SPC in the nursing home are the determined as causes. A dipstick urinalysis confirmed presence of nitrates and leucocytes. Peter is on your ward undergoing treatment for his infections and the assessment and management of his SPC. You are assigned his care: IVT N/S 1000mls 8 hours Diabetic diet. Encourage fluids IV AB Penicillin 1.2gms 8/24 BSL random daily Panadol 1gm QID prn Oxybutynin 10 mgs prn. Metformin 850mg nocte Metaprolol 25mgs mane Seranace 1.5mg prn SPC maintenance and assessment 2/24

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FBC Agitation and confusion management.

In your group consider the nursing care required for Peter. When you read his care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

43. Activity 1SPC Nursing ManagementRead the medical orders for Peters SPC management and undertake the following tasks: Discuss with other group members the need for an SPC. Describe the placement of an SPC. Describe the flow of urine when an SPC is insitu. Describe the equipment used for an SPC.

Detail and discuss with group members the nursing interventions required to maintain and assess an SPC safely and securely. Critique and support the actions of all members of the group.

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Whilst assessing the state of urine flow, you notice urine has stopped flowing. Peter reports feeling pain in his lower abdomen and it is firm to the touch. Describe the nursing actions taken to try to resume urine flow. Perform these nursing actions. If a medical order for irrigation is obtained, describe how this is done and perform the procedure. Other group members to critique and support.

44. Activity 2IVT management and IV AB administrationDiscuss with group members the requirement for Peters IVT administration. Discuss the benefit to his UTI treatment. Does he have any pre-existing conditions which may be contraindicative?

Assume Peter has removed his IV line and knocked over the IVT. Replace the IVT with new N/S flask and IV giving set. Document the above change in the FBC.

Detail and discuss the nursing interventions required to safely administer the medically ordered IV AB. Outline the class of ABs Penicillin belongs to.

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Administer the IV AB. Other members of the group to provide critique and support.

53. Activity 3 Management of confusionYou have noticed that Peter is becoming agitated and confused and the RN suggests that you conduct a mental assessment. Discuss the responsibility that the nurse has in relation to Peters confusion. o Outline the possible causes for his confusion

Perform both assessments on a fellow student o Reflect on how you felt, both as the administrator and receiver of the test.

Outline the actions that you could take to minimise Mr Rollers confusion

Please ensure that you document this care provided for Peter on your shift.

54. Activity 4Urine analysis and documentation Explain the need for analysis and monitoring of Peters urine?

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Perform a urine analysis with the available equipment.

Detail and discuss the nursing interventions required when undertaking such an analysis and related documentation.

55. Activity 5Discharge planningAlthough, Peter is now being discharged, the need for regular self and nursing maintenance is vital to prevent future incidences of UTI. Discuss the nursing responsibilities that need to be implemented by the RN at Peters nursing home.

Discuss the strategies which can be employed by the RN to promote Peters involvement in the care and maintenance of his SPC.

Outline the considerations in changes to his diet and fluid intake which will assist in the prevention of future UTI incidences.

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Use the space below to document workshop notes:

NURS2105: Workbook

Week 9: Nursing Management of Gastrointestinal Disorders Large Bowel Obstruction1The gastrointestinal system is under study this week. The scenario focuses on a patient who develops a large bowel obstruction from cancer and undergoes a resection with a temporary colostomy. Her consequential clinical nursing care will be covered in the workshop.

Learning outcomes for this week

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Upon the successful completion of this section you should be able to: 1 apply critical thinking to the case study presented 2 apply primary health principles to the case study presented 3 apply biophysical and pharmacological knowledge to the case study presented 4 develop your application of nursing research to the case study presented 5 expand on your GIT nursing assessment skills 6 develop your knowledge base in the nursing management of an elderly person undergoing major GIT surgery 7 extend your knowledge of nursing management of clients with a diagnosis of cancer, major surgery, loss of independence, and a chronic illness 8 practise nursing skills relevant to the area under study including: NG tube drainage and LPS, colostomy/ileostomy care, revision of PEGs, assessment of bowel sounds, faecal impaction, constipation/diarrhoea, nausea and vomiting.

What you need to do to meet your learning outcomesAttend the lectures, one tutorial and one workshop session as well as the following activities. Read the case study, ask the critical questions and then refer to the relevant pages in the following texts to answer those critical thinking questions. 9 Complete these activities

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 38 Nursing assessment: gastrointestinal system 41 Nursing management: lower gastrointestinal problems Research the following medications and complete the pharmacology worksheet before coming to the tutorial.

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Trade and Generic Name

MODE OF ACTION

PRECAUTIONS

SIDE EFFECTS

NURSING IMPLICATIONS

MAXALON

CEPHALOTHIN

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Trade and Generic Name METRONIDAZOLE

PRECAUTIONS N

MODE OFACTIO

SIDE EFFECTS

NURSING IMPLICATIONS

GENTAMICIN

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Workshop activitiesGastrointestinal SystemMrs Carsons is a an 86 year old woman who was admitted to the ward two days ago with mild abdominal pain, anorexia, slight nausea and chronic constipation for investigation via her GP. She has no significant past medical history and is taking no medications. Her GP had done a Haematest on her stool in the surgery and found it to be positive for occult blood. On admission Mrs Carsons seems very anxious. She says she has never been in hospital before and she is frightened that shell never get out. When you ask her why, she says shes sure shes got cancer and shes going to die. She also tells you that she lives alone since her husband died six years ago, but her only daughter, who is 58 and married, visits her every day and they are very close. Her admission observations are T 37.5C, P92 (reg), R22, BP 145/90 On examination, Mrs Carsons tissue turgor is poor, her tongue is dry and coated, her lips are cracked and her skin is dry and frail. Her abdomen is distended and she pulls away when you try to palpate it. On auscultation you hear no bowel sounds in the left upper and lower quadrants but hyperactive sounds in the right upper and lower quadrants. Her admission weight is 50 kgs and she is 160 cm tall. She tells you she used to be quite a big woman, weighing about 10 stone a year ago. She has no explanation for this weight loss, however. About two hours after her admission Mrs Carsons calls you over urgently and says she thinks shes going to be sick. She promptly vomits about 150 mls of green bile into the bowl you offer her. After making her as comfortable as possible you administer the injection of IM Maxalon 10 mgs 4-6 hourly that has been ordered. Unfortunately this has no effect and Mrs Carsons continues to vomit large amounts over the next two hours culminating in a large brown offensive vomit. The total amount she has vomited is 680 mls. Her observations are T 38C, P118 (reg), R 26, BP100/55. You call the RMO, who after examining Mrs Carsons diagnoses a large bowel obstruction. He inserts a NG tube and asks for it to be on free drainage, inserts a Jelco with Normal Saline 1000 mls running over four hours and he asks you to prepare Mrs Carsons for emergency surgery. During surgery Mrs Carsons is found to have Ca BowelDukes Category C. The surgeon goes on to perform a Left Hemi-colectomy and creates a temporary colostomy. During the procedure the bowel was perforated distal to the anastomosis but this was repaired during the operation. She returns to the ward with a NG tube, an IDC and IV line in situ. Her midline abdominal wound is clean and dry and covered by combine and Hyperfix. She is receiving O2 via nasal spectacles and she is drowsy but rousable. When asked, she states she is experiencing pain at a level of 8 out 10. Her post-op orders are: 0 routine post-op obs. 1 naso-gastric tube on free drainage. 2 oxygen @ 2L/min via nasal specs. 3 nil orally 4 measure urine output 2 hourly 5 IVT: 5% Dextrose 1/5 Normal Saline 1000 ml in 8 hours (current bag) 6 normal Saline 1000 mls in 8 hours 7 5% Dextrose and 1/5 Normal Saline 1000 ml in 8 hours. 2 3Medications:

o o o o o o

Morphine 5-10 mgs S/C 24 hourly PRN. Maxalon 10mg IV 6-8 hourly PRN. Cephalothin 1 gm TDS IV. Metronidazole 500 mgs TDS IV. Gentamicin 160 mgs IV daily. Panadine 500 mg-1000 mgs 4 hourly PRN.

In your group, consider the nursing care required for Mrs Carson. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care accurately.

Nursing interventions 56. Pre-activitiesPrioritise the nursing care for Mrs Carson and give a rationale for the prioritisation Priority Rationale

57. Activity 1Assessment of blood loss through wound dressingMrs Carson calls tells you that her dressing feels very wet. When you check the bed and wound, you find it wet with blood Discuss the possible causes of the blood loss. o o What vital sign assessments would you make to assess the degree of blood loss? Should these be adversely changed, who would you notify?

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Outline the observation you could make referred pain at certain anatomical point will assist here.

Mrs Carson does not want the blood soaked dressing changed. What strategies would you employ to help her see the need for this dressing attendance?

One of the group members should redress it after checking the care plan, using the resources at your disposal and implementing an aseptic technique. o The remainder of the group provide guidance and critical feedback to the person implementing the procedure.

58. Activity 2N/Gastric Tube Check Mrs Carsons non-medication orders to determine how frequently you need to aspirate her N/G tube. Aspirate her N/G tube and measure the result. Measure the contents in her drainage bag Add the two amounts together to determine if she needs any replacement fluid and document appropriately on her FBC

Outline the nursing care required for Mrs Carson regarding her N/G tube

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Why is Mrs Carson nil orally? What are the medical reasons for this?

59. Activity 3IV fluid replacement for N/G drainage Check Mrs. Carsons N/G IV replacement fluid orders Follow the IV replacement orders and add the appropriate amount to the side arm burette. Calculate the flow rate and regulate the IV accordinglydocument appropriately on FBC

Discuss whether there should be any IV additives to her IV replacement fluid taking into consideration her electrolyte levels.

Discuss the purpose of the fluid replacement regime in this situation

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Explain the serious complication which could arise if this does not occur

Explain why a burette is essential on the side arm.

60. Activity 4Administration of her IV antibiotics Note which IV ABs are due and administer those for your shift. o Ensure that you sign for the medications that you give

Outline the protocols when administering her IV antibiotics

Outline the factors that are checked in the Australian injectable drugs handbook, 2nd edn, before administering an IV medication

Administer the IV antibiotic having another student assess your performance Document appropriately

61. Activity 5Bowel Sound Assessment What are the nursing responsibilities for bowel sound assessment?

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What medical reasoning underlies the need for bowel sound assessment.

Physically perform a bowel assessment on Mrs Carson. Where quadrant of the abdomen is this performed? How long does an assessment take? Are the findings documented? What is the nurse listening for?

62. Activity 6Pain reliefo Assess Mrs Carsons pain. What would you expect to find and why?

o

Discuss the main side effect of opioid analgesia and how it may be detected & reversed.

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o

Discuss whether the pain relief administered is appropriate for this problem, and Mrs Carsons age.

o

Outline how you would assess the effectiveness of the pain relief

Workshop notes63. OSCE skillsUse this page to note and document nursing skills that you have learnt this week. Take note of pertinent issues, and feedback given to you from your lecturer. This may assist you in revising for the OSCE later in semester.

NURS2105: Workbook

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Week 10: Nursing management of Hepatobilary DisordersThis week involves the study of the hepatobiliary system. The tutorial focuses on a woman who develops acute pancreatitis secondary to cholelithiasis; she is admitted for an open cholecystectomy. The workshop will focus on the nursing skills associated with caring for patients with such hepatobiliary problems.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: apply critical thinking to the scenario presented. apply primary health care (PHC) principles to the scenario. utilise your knowledge of physiology and pharmacology (from 1st & 2nd year) in your analysis of the scenario. appreciate the relevance of cultural safety in the nursing context. plan the nursing management of a patient with pancreatitis secondary to cholelithiasis. Plan and implement the post operative open cholecystectomy nursing management.

What you need to do to meet your learning outcomes64. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 42 Nursing management: liver, biliary tract and pancreas problems 17 Nursing management: preoperative care 19 Nursing management: postoperative care

65. Attend the lecture, tutorial and workshop for this week

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Workshop activitiesHepatic-biliary focusMrs Justine Oliver (aged 32 years) is seen in Accident & Emergency with the following clinical findings

Acute RUQ pain Severe nausea & vomiting T 37.8C P - 108 R 26 BP 110/60 Mild jaundice Some abdominal distension

Her medical history is

She has been having episodes like this for about a month, but none of them have been this bad She cant really say if they have been associated with any particular food intake The only medication that she tales is the Pill which is oestrogen based. Her alcohol intake is an average of 3 Standard Drinks a week

The MO orders the following tests

Serology

o o o o CXR

CBP LFT Electrolyte levels C-reactive Protein

Abdominal X-ray Abdominal Ultrasound ERCP

The results show

Raised White Cell Count Raised creatine Raised SGOT, LDH & ALT Raised BUN Enlarged & swollen CBD & Pancreatic Duct with stones in evidence Raised CRP

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Raised BGL

The provisional diagnosis is acute pancreatitis due to cholelithiasis and she is to be admitted for an open cholecystectomy. She arrives in the ward with the following orders

N/G tube in situ on free drainage IVT 3 Litres in 24 hours alternating Hartmanns with N/Saline N/G tube to be aspirated with IV replacement of N/Saline IV Antibiotics Metronidazole 500mg/100mls TDS & Ticacillin 1g 8/24 Analgesia

o o

S/C Morphine 2.5-5mg 2/24 IM Hyoscine butylbrmide 20mg/ml

Nil Orally

You are assigned to look after her the next day when she has just returned from theatre after her open cholecystectomy with

IVT with 2 lines

o o

the main IV line is running at 3L/24 hrs, this can be reduced once her nasogastric fluids have been reduced & bowel sounds have returned the second line is for replacement of her naso-gastric fluids which you will need to calculate 4/24ly

IV ABs are to continue Wound drain (Haemovac) in situ T-tube in situ S/C Morphine 2.5-5mg 2/24 for pain relief RIB with toilet privileges as tolerated for 1st 24 hours, then mobilise as tolerated N/G tube in situ on free drainage

o o

Aspirate 2/24ly replace with IV fluids if > 50mL an hour To be removed once drainage < 50 mls an hour for 4 hours

Free fluids once N/G tube is removed Light diet once N/G tube removed and bowel sounds are present

In your group, consider the nursing care required for Mrs Oliver. When you read her care plan and case notes consider what you have to do as a group. There are five major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks. The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care accurately.

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Nursing interventions 66. Pre-activitiesPrioritise the nursing care for Mrs Oliver and give a rationale for the prioritisation Priority Rationale

67. Activity 1Assessment of strike through and blood loss and dressing a woundIt is now 10.00 am and Mrs Oliver calls you over and tells you that her dressing feels very wet. When you check the bed and wound, you find it wet with blood Discuss the possible causes of the blood loss.

Outline the observations that you could make to check your hypothesis

Explain to Mrs Oliver why it is so important that the dressing is completely changed rather than reinforced in this situation

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One of the group should redress it after checking the care plan, using the resources at your disposal and implementing an aseptic technique. o The remainder of the group provide guidance and critical feedback to the person implementing the procedure.

68. Activity 2N/Gastric Tube Check Mrs Olivers non-medication orders to determine how frequently you need to aspirate her N/G tube. Aspirate her N/G tube and measure the result. Measure the contents in her drainage bag Add the two amounts together to determine if she needs any replacement fluid and document appropriately on her FBC

Outline the nursing care required for Mrs Oliver regarding her N/G tube

69. Activity 3IV fluid replacement for N/G drainage Check Mrs. Olivers N/G IV replacement fluid orders Follow the IV replacement orders and add the appropriate amount to the side arm burette. Calculate the flow rate and regulate the IV accordinglydocument appropriately on FBC

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Discuss whether there should be any IV additives to her IV replacement fluid taking into consideration her electrolyte levels.

Discuss the purpose of the fluid replacement regime in this situation

Explain the serious complication which could arise if this does not occur

Explain why a burette is essential on the side arm.

70. Activity 4Administration of her IV antibiotics Note which IV ABs are due and administer those for your shift. o Ensure that you sign for the medications that you give

Outline the protocols when administering her IV antibiotics

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Outline the factors that are checked in the Australian injectable drugs handbook, 2nd edn, before administering an IV medication

Administer the IV antibiotic having another student assess your performance Document appropriately

71. Activity 5Wound and T-Tube care Check wound drain for patency and drainage and record o o o Describe and document findings on the Fluid Balance Chart (FBC). Check the patency of the HaemovacTM drain and, if required, recharge it using the instructions from the procedure manual to guide you. If the HemovacTM drain is not patent, outline other signs and symptoms that you might observe in Mrs Oliver

Check T-tube for patency and drainage and record o o Describe and document findings on the Fluid Balance Chart (FBC). Describe a T-tube drain and explain why it has been used in Mrs Olivers case

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o

Explain the procedures which are instigated before removing the t-tube and give the reasons for doing so

72. Activity 6Pain reliefo Assess Mrs Olivers pain. What would you expect to find and why?

o

Discuss the main side effect of opioid analgesia and how it may be detected & reversed.

o

Discuss whether the pain relief administered is appropriate for this problem

o

Outline how you would assess the effectiveness of the pain relief

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Workshop notes73. OSCE skillsUse this page to note and document nursing skills that you have learnt this week. Take note of pertinent issues, and feedback given to you from your lecturer. This may assist you in revising for the OSCE later in semester.

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Week 11: Nursing Management of Haematological DisordersThis week focuses on problems relating to the haematological system. Knowledge of haematology is useful in clinical environments to assess the patients ability to transport oxygen, carbon dioxide, and other blood-borne considerations. The tutorial will focus on various haematological problems and their management options. The workshop will involve a number of activities focussed on the OSCE assessment later in the semester. These will involve wound management, patient education, pain management, and infection control and prepare the student for this item of assessment.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient with haematological problems. Iron-deficiency anaemia, Neutropenia, and Thrombocytopenia will be discussed. Describe the preoperative and postoperative nursing management for the patient with haematological considerations. Explain the essential functions of the haematological system. Describe age-related changes in the haematological system and differences in assessment findings.

What you need to do to meet your learning outcomes74. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 29 Nursing assessment: haematological system 30 Nursing management: haematological problems If you wish to read more widely you may wish to revise these chapters. Galbraith, A, Bullock, S & Manias, E 2004, Fundamentals of pharmacology, 4th edn, Pearson Education Australia, Prentice Hall Health, Frenchs Forest, NSW. Chapters: 46 Anticoagulants, Thrombolytics and Antiplatelet Drugs, pp. 482-496. 50 Antianaemic Drugs, pp. 546-552. 51 Drugs used to Maintain Gas Exchange, pp.553-570.

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75. Attend the lecture, tutorial and workshop for this week

Workshop activities OSCE Practice ScenariosThis workshop involves a number of activities focussed on the OSCE assessment later in the semester. Practice activities involve wound management, patient education, pain management, and infection control. These nursing skills have been focused upon in previous workshops. Each member of the group is to provide support and critique on other group members nursing interventions. In your group, consider the nursing care required for the activity. When you read care plans and case notes consider what you have to do as a group. There are 5 major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

76. Activity 1Plaster care and wound management wound packing activity. 77. Activity 2PCA pain assessment and pain relief. 78. Activity 3 Sterile wound dressing infection control focus. 79. Activity 4Post operative patient care - IVT maintenance and replacement. 80. Activity 5Patient education - Diabetes Type 2 focus.

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Week 12: Part 1 - Nursing management of Reproductive Disorders Female FocusThis week focuses on two problems relating to the female reproductive system. The tutorial examines endometriosis and its management options. The workshop will involve a number of activities related to the post operative management of an abdominal hysterectomy.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient with endometriosis Describe the preoperative and postoperative nursing management for the patient requiring major surgery of the female reproductive system Explain the functions of the major hormones essential for the structure and function of the female reproductive system. Describe age-related changes in the female reproductive system and differences in assessment findings. Describe the nursing and collaborative management of the patient undergoing an abdominal hysterectomy.

What you need to do to meet your learning outcomes81. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 49 Nursing assessment: reproductive system 52 Nursing management: female reproductive problems

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Workshop activities Female Reproductive /urinary focusTracey is 38 years of age and has been in a stable relationship with her partner David for 11 years. They live in Pasadena and both work full time in the hospitality industry. Tracey has been living with endometriosis, dysmenorrhoea and dyspareunia. she was first diagnosed following a diagnostic laparoscopy at 20. She has undergone another two laparoscopies which involved laser surgery to remove the many chocolate cysts found in her peritoneal cavity. Tracey has also tried a six-month course of danazol but was unable to tolerate the acne side effects. Tracey and David have been unsuccessful in becoming pregnant after trying for seven years with IVF. Tracey is now fed-up with the pain and disruption to her life and the lost time from work. Together they have discussed the options and Tracey has decided to have an abdominal hysterectomy so that laser oblation of the endometriosis can occur at the same time. While the nurse is alone with Tracey, she tells the nurse that prior to her relationship with David she become pregnant and had a termination. She does not want David to know about this. Tracey is prepared for theatre and David walks beside her until he reaches the transfer bay. The ward RN walks David back to Traceys room to await her return. Four hours later, Tracey returns to the ward very sleepy with the following postoperative care orders: Routine postoperative vital signs and wound/rain checks:

morphine PCA and purge IVT for hydration 4% dextrose and 1/5 normal saline IDC wound drain wound covered and dry RIB fluids when bowel sounds return and passage of flatus.

In your group, consider the nursing care required for Tracey. When you read his care plan and case notes consider what you have to do as a group. There are 7 major groups of nursing interventions to do, divide them between you. Take time as a group to prioritise these tasks The lead role for each group of activities should be rotated between group members. The remainder of the group are to provide guidance and critical feedback to the person leading the activity. Ensure that you document your care as you go.

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Prioritise the nursing care for Tracey and give a rationale for the prioritisation. Priority Rationale

82. Activity 1IDC maintenance Outline the nursing actions required for a woman with an IDC in situ. o o Complete the FBC. Outline nursing focus when maintaining the IDC

Discuss why Tracey has had an IDC inserted after an abdominal hysterectomy?

Would you alert the medical officer about changes in the urine appearance to blood colour?

Explain whether you would wear sterile gloves to empty the urinary drainage bag

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83. Activity 2Intra-venous therapy Check the IV orders & IVT o o Ensure they are correct and reduce or increase the IV rate as needed. Observe his IV site for any problems Outline the most common problems associated with an IV site Offer solutions for those problems

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Check that his IVT is flowing on time & there is no air in the line Discuss and demonstrate ways to remove air from an IV line

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If the bag is due to run out, ensure that you change the bag as per orders. Calculate the flow rate and regulate the IV accordingly and document on the FBC

84. Activity 3Administration of IV antibiotics Note which IV ABs are due and administer those for your shift. o Ensure you sign for the medications that you give

Outline the protocols when administering his IV antibiotics

Outline the factors that are checked in the Australian Injectable Drugs Handbook 2nd Edn before administering an IV medication

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Administer the IV antibiotic having another student assess your performance

85. Activity 4 Assessing Bowel sounds post operatively. Discuss the reasoning for auscultation of Traceys bowel sounds post operatively.

Explain physical nursing interventions to perform a bowel sound assessment. Perform the bowel sound assessment.

How long is the nursing time devoted to this activity? Which abdominal quadrant is/are concentrated on? Why?

How would you explain this nursing intervention to Tracey when she inquires?

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86. Activity 5Deep breathing and coughing (DB&C), leg exercises (LE) and positioningTracey needs to learn how to perform post-operative exercises. Discuss the common post operative exercises and give a rationale for each

You may wish to use incentive Spirometry for part of these exercises. o Explain to Tracey how to use a TriFlo

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Explain how a TriFlo aids in breathing & coughing exercises

Discuss how you would teach him these exercises and explain the procedures to your group.

87. Activity 6Wound Drain MaintenanceTracey has an abdominal wound drain insitu. Discuss the responsibility that the nurse has in monitoring this wound drain. o Outline the reasoning for drain insertion and maintenance.

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Outline the actions that you could take should the drain begins to collect a sudden and large blood volume.

Outline the actions that you could take should the drain cease to collect blood, combined with increased abdominal swelling and discomfort.

Outline the documentary requirements of a patient with a wound drain. What forms are required?

Please ensure that you document all care provided for Tracey on your shift.

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Week 13: Part 2 - Nursing management of Reproductive Disorders Male FocusThis week focuses on problems relating to the male reproductive system. The tutorial will examine Benign Prostatic Hyperplasia (BPH) and its management options. The workshop involves a number of activities relating to the post-operative management of bladder irrigation following a transurethral resection of the prostate (TURP) secondary to BPH.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient BHP. Describe the preoperative and postoperative nursing management for the patient requiring major surgery of the reproductive system Explain the functions of the major hormones essential for the structure and function of the male reproductive system. Describe age-related changes in the male reproductive system and differences in assessment findings Describe the nursing and collaborative management of the patient undergoing a transurethral resection of the prostate.

What you need to do to meet your learning outcomes88. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 49 Nursing assessment: reproductive system 53 Nursing management: male reproductive problems

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89. Attend the lecture, tutorial and workshop for this week

Workshop activities Male Reproductive /urinary focusMr Roller first went to his GP with a 1 year history of decreased force and amount of urinary stream, difficulty in starting urination and dribbling at end of urination. He also complained of an incomplete feeling on emptying the bladder.