Clinical Reasoing Cycle Textbook Answers Tracy-Levett Jones

Amended January 25, 2014. Copyright © 2013 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781442556621/Levett-Jones/Clinical Reasoning: Learning to Think like a Nurse/1e

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Answers to Clinical Reasoning questions Chapter 2 Scenario 2.2 Changing the scene 1. Right client education, right to refuse, right assessment, right evaluation (effect), right

equipment, right person/s administering. Additionally, the right reason (i.e. indication) and any contraindications should also be checked.

2. Patient ID (name, address, DOB, medical record number); time, date, month and year of prescription; generic drug name (spelt accurately and written clearly); dose/strength/amount of drug; route of administration; directions for administration (including frequency); prescriber’s name and signature; approved abbreviations only.

3. Check the label when getting the drug from storage; check the drug label with the drug order; recheck the drug order and drug again before administration.

4. Yes, it is important to monitor patient’s responses to medications prior to and following administration. This is particularly important when administering digoxin, as pulse rate, rhythm and regularity can indicate toxicity. Vitals signs can be used as keys to decision making related to medication administration.

2. Collect cues/ information (b) Gather new information 1. To determine whether Giuseppe had postural hypotension, as this may be a reason for his

dizziness; postural hypotension can be caused by cardiac arrhythmias and dehydration (as well as a number of other factors).

2. Manual blood pressure measurements are more reliable and accurate than electronic blood pressure devices, which need to be calibrated regularly for accuracy. Additionally, electronic blood pressure devices cannot tell you the ‘feel’ of the pulse (e.g. weak and thready or full and bounding) and rarely identify an irregular pulse rate.

3. Giuseppe’s blood pressure recording indicated postural hypotension, that is, a 20 mm Hg (or more) drop of systolic BP, a 10 mm Hg (or more) drop of diastolic BP (or both) at 1–3 minutes after standing up from supine position.

4. The apical pulse should be checked when an irregular pulse is found. 5. b, c, h 6. and 7. Examples of cues and questions: When did Giuseppe start feeling dizzy? Had he felt

dizzy before? When? Did he know what caused it? How much is he able to drink now? Does he feel thirsty? Is his mouth dry? Is his tongue furrowed? How much has he been voiding? Does he have any other symptoms? Can he describe what he means by ‘his eyes are shot’? Has he had any falls in the past from dizziness (has a fall risk assessment been done)? Who will he be staying with when he is discharged? Has he had any blood taken for pathology? If

Copyright © 2013 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781442556621/Levett-Jones/Clinical Reasoning: Learning to Think like a Nurse/1e

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so, when? Is there anything he is worried about, or anything else he would like to report about how he is feeling?

(c) Recall knowledge (Quick quiz) 1. those who prescribe (doctors), dispense (pharmacists), administer (nurses), and consume (i.e.

patients/clients) 2. b; 3. c; 4. b; 5. c; 6. c; 7. b; 8. b; 9. b; 10. c 11. Anorexia, nausea (vomiting and diarrhoea have

settled), blurred vision, dizziness, irregular pulse but needs to be confirmed by ECG 3. Process information (a) Interpret – a, d (b) Discriminate – a, c, e, f, g, h, j, k (c) Relate – T, F, T, F, F, T, F, T (d) Infer – a, d (e) Predict – c, d 4. Identifying the problem/ issue That Giuseppe may be having a reaction to one of his medications (he had some of the symptoms of digitalis toxicity, in particular an irregular pulse; side effects of enalapril include hypotension and dizziness when standing, and this medication and frusemide should not be given to dehydrated or hypovolaemic patients); that he may still be dehydrated; that his postural hypotension puts him at risk of falls; that he was due to be discharged shortly. 5. Take action I Identify Self: name, position,

location. Patient: name, age, gender.

Can I talk to you about Giuseppe Esposito in room 14B, please.

S Situation Briefly explain the reason for the call.

I am concerned about his condition. He is feeling dizzy. I checked his BP and it was 120/70 sitting and 110/65 standing. I think this is postural hypotension. His pulse is 64. It’s weak, thready and irregular. I checked his apical pulse to be sure.

B Background Patient’s diagnosis, relevant history, investigations, what has been done so far.

As you know, he is meant to be discharged this morning as his gastro is much better.

A Assessment Summarise the patient’s current condition or situation. Explain your assessment of the problem.

He is not drinking a lot and his mouth is dry. His fluid balance chart was ceased yesterday, so it is hard to determine his fluid balance. His temp and resps are normal. I am not sure what is wrong with him, but I wonder whether it could be one of his medications, perhaps the digoxin or enalapril.

R Request/ recommendation

State your request. Can you please come with me to see him?


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Chapter 3 Scenario 3.1 Day of admission 1. Mr Barrett is considered to be at high risk because of his age, co-morbidities and type of

surgery. 2. Other information needed is his management of COPD, and that Mr Barrett uses a salbutamol

puffer occasionally. He gave up smoking four years ago but started again last year when his son died. He smokes 25 cigarettes a day. Baseline oxygen saturation level? 96 per cent on room air. Results of his routine pre-operative urinalysis? haematuria ++; specific gravity 1016. Weight: 82 kg Height: 1.67 m Management of diabetes: Type 2 diabetes (diet controlled) diagnosed 24 years ago. Mr Barrett does not pay particular attention to his diet, nor does he check his blood glucose regularly. Currently his BGL is 7.8 mmoL. Pre-operative pathology results: haemoglobin (Hb) 9.5 g/L; sodium (Na) 140.0 mmol/L; potassium (K) 3.9 mmol/L; serum albumen 26 g/L. 3. Assessments required: falls risk, pressure area and nutrition assessment. 1. Consider the patient situation (Quick quiz) 1. b; 2. c; 3. b; 4. a; 5. c; 6. b; 7. a; 8. a 2. Collect cues/ information (b) Gather new information: b, c, e, g, h (c) Recall knowledge (Quick quiz): 1. d; 2. b; 3. d; 4. d; 5. c; 6. a; 7. c; 8. d 3. Process information (a) Interpret: 1. a, c; 2. d; 3. a (As Mr Barrett is an older person, his body’s compensatory mechanisms are less effective at excreting excess fluids. For this reason, 35–40 mL per hour is considered adequate, but his hourly urine output should still be monitored very carefully; 4. a (b) Discriminate – a, d, g, j (c) Relate – F, F, T, F, T, F, T (d) Infer – d, g (e) Predict – a, c, e, f


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4. Identify the problem/ issue – 1. e 2. Factors that may have contributed to Mr Barrett’s deterioration: • Mr Barrett was given two picopreps on the night before his surgery. Picopreps cause

osmotic diarrhoea and many litres of fluid can be lost from the circulating volume through the wall of the intestine as the bowel is evacuated. The major electrolytes sodium and potassium are also lost in this way.

• Following routine protocol, Mr Barrett was nil orally from midnight on the day of surgery to prevent the risk of aspiration during surgery. Being nil orally for this extended period of time contributed to his hypovolaemia.

• Mr Barrett was unable to tolerate the clear fluid diet he had been ordered to offset the fluid losses from the picoprep.

• The first stage of wound healing is the inflammatory stage. During this stage there is increased capillary permeability to allow fluid and molecules that assist in haemostasis, prevent infection and promote healing of the wound to leave the bloodstream and surround the site of trauma. A large surgical area such as Mr Barrett’s results in significant third-space fluid shift which further depletes the intravascular volume.

• Blood loss during surgery and through drainage from the bellovacs further depleted the intravascular volume.

• Mr Barrett’s hypotension caused decreased glomerula filtration rate and resulted in decreased urine output.

• A hypovolaemic stage is not unusual after major surgery. For most people this lasts 24–72 hours or until IV fluid replacement and the body’s own compensatory mechanisms have been effective in increasing circulating volume. During this stage, it is essential to monitor your patient’s condition carefully as any deterioration could be critical.

5. Establish goals – c 6. Take action – 1. a, d, f, g, I, j, k Explanation for incorrect responses: (b) Monitor Mr Barrett’s level of consciousness. [The cues provide no evidence of cognitive impairment (at this stage).] (c) Monitor Mr Barrett’s pain score. [Important, but not related to current signs and symptoms.] (e) Monitor the condition of Mr Barrett’s drain, stoma and wound. [Important; however not an immediate action.] (h) Check that the urinary catheter is not kinked or blocked. [Catheter blockage is not likely as there is some urine output.]

2. Nursing action Rationale Document all nursing observations and actions accurately and contemporaneously.

To ensure clear, accurate and timely communication between all health professionals caring for Mr Barrett.

Daily weight (same scales, same This is the best indication of fluid status.


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clothes). Check cognitive status regularly. Anxiety and restlessness may indicate

worsening fluid status. Check UEC (urea, electrolytes and creatinine) as ordered.

Sodium, potassium, urea and creatinine are important indicators of fluid status and renal function.

Regular position change.

To prevent pressure areas due to dry skin.

Maintain patent IV access and monitor IV site regularly.

To ensure fluids are administered as ordered.

Encourage oral fluids as ordered/ tolerated by patient.

To increase fluid intake.

Maintain oxygen therapy via nasal prongs or Hudson mask and hourly oxygen sats.

To ensure adequate oxygen delivery.

Monitor haemodynamic status closely.

To identify improvement or deterioration in Mr Barrett’s condition.

Reassure patient. To maintain psychosocial wellbeing. Provide regular oral care. To manage dry mouth and tongue and to

promote patient comfort. Check specific gravity of urine. To monitor changes in fluid status.

7. Evaluate 1. Cognitive status – unchanged

Level of thirst – improving Pulse – improving Urine output – improving Oral mucosa – unchanged Oral intake – unchanged BP – improving Colour – unchanged Skin condition – unchanged

2. d Scenario 3.2 2. Collect cues/ information (b) Gather new information – 1. a, d; 2. c, e, g, I, l, m, n (c) Recall knowledge (Quick quiz) – 1. b; 2. T, F, T, F; 3. b, d, e, g, h, j, k, l, m; 4. d; 5. a; 6. c 3. Process information (a) Interpret – 1. positive balance; 2. b; 3. c; 4. b, c, e, f, h; 5. a, c, d; 6. b, c, e, f, h, j, k; 7. c (b) Discriminate, (c) Relate, and (d) Infer – b, d, e, i (e) Predict – a, c, e, f


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4. Identifying the problem/ issue – 1. b, e, f; 2. d 3 factors that contributed to Mr Barrett’s hypervolaemia:

1. His age, weight, history of hypertension, smoking and diabetes may have caused impaired renal function, and thus the IV fluids that he has been having for the last 24–36 hours may not have been excreted effectively (indicated by the fact that his urine output is not excessive).

2. The IV rate should have been reduced once his fluid status had initially improved. 3. Usually after 24–48 hours, when the inflammatory stage of wound healing resolves,

plasma typically returns to the circulating blood volume. This can cause a significant increase in blood volume adding to the likelihood of hypervolaemia.

4. c 5. Establish goals – b, e, f, h 6. Take action – 1. a, d, f, h, m 2. I Hello ……….. This is ………….I am .........., an RN working on .... ward.

I am calling about Mr Barrett. S I am concerned about his deteriorating fluid status. His condition is serious. His

oxygen sats are 90%, resps 31 per minute, he is confused, his BP is 150/90, pulse rate 102, and it’s irregular, full and bounding. He is confused and is reporting a headache.

B Mr Barrett is a 74-year-old man who is day 3 following a colorectal resection. He has a history of diabetes type 2. His IV was 125 mL/hour but I’ve reduced it to TKVO pending your orders. I’ve increased the oxygen to 6 L per minute and an ECG is being done now.

A His sodium is 128 mmol/L and potassium (K) 3.3 mmol/L. Urine output is low: 15–30 mL/hour. He is afebrile.

R I need you to see him immediately. Will you come now? 3. b, d, f 7. Evaluate

1. Decreased BP 2. Increased urine output (as a results of the diuretic) 3. Increased oxygen sats (> 94%) 4. Decreased pulse and respiratory rate 5. Normal cognitive status 6. Headache resolved 7. Normal ECG 8. Normal electrolyte levels


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Chapter 4: Caring for a person experiencing respiratory distress Scenario 4.1 Admission to the ED – 1. a, e, f 1. Consider the patient situation (Quick quiz) 1. Diaphoretic Sweaty Febrile High temperature Tachycardic Increased heart rate Tachypnoeic Increased respiratory rate Sats A test of the oxygen-saturated haemoglobin ABGs A test of gases and pH in arterial blood Coarse rales A series of short low popping sounds, also called crackles Haemoptysis Coughing bloody sputum Cyanosis Bluish tinge around lips due to lack of oxygen in blood Consolidation Increased areas of density due to fluid, mucous and oedema on a CXR 2. c; 3. FiO2 0.44 or 44% (approximately 4 x rate + 20); 4. d; 5. b 2. Collect cues / information (a) Review current information – Q. b (b) Gather new information – 1. b, f, g, i, j; 2. a; 3. b; 4. B and d; 5. b; 6. hypoxia, hypoventilation, ventilation and perfusion mismatch, diffusion abnormalities; 7. b; 8. a; 9. closed; 10. yes or no (c) Recall knowledge (Quick quiz) – 1. a, c, e, h 2. Build up of fluid in the space between the lung and chest wall

Pleural effusion

Pockets of pus that form in the space between the lung and chest wall

Empyema

Sputum material coughed up from the lungs Productive cough Pockets of pus that form in the lung itself Lung abscess Secondary bacterial lung infection after a viral infection Secondary infection due to

medication Bacteria in the bloodstream or throughout the body Bacteraemia or septicaemia Clinical sign of hypoxia, manifested by a feeling of breathlessness

Dyspnoea

Subjective sensation of a patient reporting loss of endurance

Fatigue

Generalised feeling of being unwell Malaise


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3. Process information (a) Interpret 1. a; 2. 80 and 100; 3. 35 and 45, 7.35 and 7.45; 4. b; 5. b (b) Discriminate – 1. c, f, k, i; 2. a (c) Relate - 1. T, T, T; 2. c (d) Infer – 1. c, e; 2. a, c, j, k, i; 3. b, d (e) Predict – 1. c, d; 2. c 4. Identify the problem/ issue – 1. a; 2. a, b, c; 3. b 5. Establish goals – Q. c; immediate resolution of Trent’s symptoms is the desired goal 6. Take action 1. Nursing action Rationale Monitor oxygen saturations and ABGs regularly.

Changes may indicate worsening hypoxia.

Check cognitive status regularly. Anxiety and restlessness may indicate worsening hypoxia.

Position in semi- or high Fowler’s.

To reduce oxygen demand.

Teach patient deep breathing and coughing.

To aid in removal of secretions.

Keep patient well hydrated. To help loosen secretions. Maintain oxygen therapy via nasal prongs or Hudson mask.

To increase partial pressure of oxygen in alveoli and increase diffusion into capillaries.

Instigate chest physiotherapy. To reduce lung consolidation and prevent chance of atelectasis.

Reassure patient and reduce anxiety. To maintain psychosocial wellbeing. Give patient paracetamol. To reduce and pain and increase comfort.

2. c, d, e; 3. b, c, d, e, j, k, l; 4. b, c, f

5. Oxygen delivery device Flow rate FiO2 Nasal prongs 2–4 litres per minute 0.24-0.36 Hudson mask 6–15 litres per minute 0.4-0.6 Non-rebreather mask 10–15 litres per minute 0.6-0.9

7. Evaluate 1. a


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2. Changing Hudson mask to a non-rebreather mask to increase available oxygen to improve Trent’s oxygenation.

SpO2 increases from 94% to 97%.

Position Trent in a high Fowler’s to assist lung expansion.

Trent is able to expectorate secretions effectively.

Monitor Trent’s vital signs every hour. Changes in condition are identified early and associated actions initiated.

Promote adequate rest to support Trent’s recovery.

Trent reports adequate sleep and rest.

3. b, c, d Scenario 4.2 1. Consider the patient situation – 1. c; 2. a, b, e, k; 3. a, c, e, g 2. Collect cues/ information (a) Review current information – 1. Pulse, respirations, SpO2, wheezing; 2. b (b) Gather new information – Q. d, e, f, h, i, j, k, (c) Recall knowledge (Quick quiz) – 1. c; 2. c; 3. b; 4. b; 5. a 3. Process information (a) Interpret, (b) Discriminate, and (c) Relate – 1. d; 2. a; 3. c; 4. b, c, e, h (d) Infer True False Presence of coarse rales √ Worsening symptoms after taking aspirin or beta-blockers

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Worsening signs and symptoms after exposure to an identified allergic trigger

√

A previous allergic reaction of any kind √ (e) Predict – Q. a, c, e, f 4. Identifying the problem/ issue – Q. c, e, f 5. Establish goals – 1. a, b, f, i; 2. c 6. Take action Place in high Fowler’s position. To reduce the work of breathing and increase

lung expansion Administer oxygen. To reduce hypoxaemia


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Administer nebuliser/spacer treatments as ordered.

To aid in bronchodilation

Provide humidification as ordered. To help loosen secretions Monitor vital signs and laboratory results. To detect increasing tachynoea, tachycardia,

and increasing respiratory distress Assist with ADLs as needed. To converse energy and reduce fatigue Provide rest between scheduled activities and reduce excessive environmental stimulus.

To promote rest

Assess level of anxiety. To decrease the chance of panic attacks Assess level of understanding of asthma and management.

To promote self-management in the recovery and rehabilitation phase

7. Evaluate – 1. oxygen saturations > than 95%, respiratory rate >10 and < 20, heart rate 60, < 100, signs of anxiety absent or decreased; 2. a, c, d, f, g Chapter 5: Caring for a person with a cardiac condition Scenario 5.1 Admission to the ED (Quick quiz) – 1. d; 2. b. 3. There is a window of time (6 hours) for thrombolytics to be given to maximise the potential for them to reduce myocardial damage from the ischaemia. 1. Consider the patient situation (Quick quiz) – 1. c; 2. a; 3. b, c; 4. b; 5. a 2. Collect cues / information – 1. a, c, d, e, g; 2. d; 3. a (b) Gather new information – 1. d; 2. c; 3. a (c) Recall knowledge (Quick quiz) – Q. a, d, e, g, h 3. Process information (a) Interpret – 1. a; 2. c; 3. d, a; b, c; 4. c; 5. c (b) Discriminate – 1. d; 2. a (c) Relate – 1. T, F, T, F; 2. d (d) Infer – Q. b (e) Predict, and (f) Match Outcome Condition Mr Parker may gradually improve over the next few days and have no adverse effects

if his myocardial demand can be reduced through oxygen supply, medication and bed rest

Mr Parker’s vital signs may if he experiences no further


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continue within normal parameters

arrhythmias

Mr Parker may experience signs of heart failure

if his heart has not suffered damage and the pumping ability of the left ventricle is not compromised

Mr Parker may experience more chest pain as a result of his anxiety about his farm

unless his family can identify a management strategy to address his concerns

4. Identify the problem/ issue – 1. b; 2. e 5. Establish goals – Q. a, b, c, e, g, i 6. Take action: Short-term nursing goal Nursing action For Mr Parker to have no pain within 20 minutes

Assess for pain using a visual analogue scale (1 to 10). If any pain does occur, include location, intensity, duration and factors that affect it in the reported description. Administer morphine as required.

For Mr Parker’s to be euvolaemic

Monitor IV and complete an accurate fluid balance chart and daily weight. Maintain average hourly urine output > 30 ml/hour.

For Mr Parker to have no evidence of impaired gas exchange

Maintain oxygen saturation levels of greater than 95% and a respiratory rate < 20 on exertion and < 16 at rest. Administer oxygen as ordered or by protocol.

For Mr Parker to be normotensive and have a pulse rate in acceptable parameters

Monitor vital signs continuously keeping his blood pressure within his normal levels and continue his preadmission antihypertensive therapies. Maintain his pulse rate > 60 bpm and < 100 bpm. Maintain a restful, supportive environment, enabling rest periods and freedom of strain during elimination.

For Mr Parker’s ECG to show no signs of ishcaemia on his next ECG

Monitor rhythm continuously using rhythm strips and obtain a 12-lead ECG during any symptomatic event. Continue post thrombolytic regime of aspirin and LMWH.

For Mr Parker to be alert and orientated

Monitor his LOC when doing vital signs.

7. Evaluate Sign or symptom Desired observation e.g. BP Stable with no postural drop Pulse > 60 bpm and < 100 bpm


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Respirations < 20 on exertion and < 16 at rest. Temperature Normal range Oxygen saturations > 95% Level of consciousness Alert and orientated Pain level Nil Urine output > 0.5 to 1.0 mL/kg/hr Scenario 5.2 1. Consider the patient situation (Quick quiz) – 1. b; 2. a; 3. a; 4. b; 5. c; 6. a, c, f 2. Collect cues / information (a) Review current information – 1. b, c, h; 2. d (b) Gather new information – Q. f (c) Recall knowledge (Quick quiz) – 1. b; 2. a; 3. d; 4. b; 5. c; 6. b; 7. lungs; 8. peripheries 3. Process information (a) Interpret, (b) Discriminate, and (c) Relate – 1. d; 2. b, c, e, f; 3. b; 4. b; 5. weigh; 6. a, d, e (d) Infer True False Smoking cessation √ Maintenance of a low-salt diet √ Appropriate activity and rest periods √ A decrease in stress, through stress-management programs

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Compliance with diabetic and healthy heart diet

√

(e) Predict – Q. a, c, d 4. Identifying the problem/ issue – c, d, f, h 5. Establish goals – Q. b, d, f, h, j 6. Take action Long-term nursing goal Nursing action For Mr Parker to maintain his daily fluid restriction

Continue his daily weigh.

For Mr Parker to participate in education and adhere to a self-care program

Commence an education program to provide information on nutrition to manage type 2 diabetes mellitus and a cardiac condition.

For Mr Parker to be free from anxiety by Include in Mr Parker’s education program


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using stress-reduction techniques

how to recognise and manage stress through relaxation/meditation techniques. Referral to an appropriate therapist for ongoing support.

For Mr Parker to understand the rationale for all his medications

Educate him in rationale for his cardiac medications, including recognition and management of possible side effects.

For Mr Parker and his family to obtain support from the community

Provide Mr Parker and his family with information on cardiac rehabilitation programs, local support groups and Heart Foundation.

7. Evaluate – Q. Outcomes should focus on managing stress, maintaining fluids through adhering to restriction, maintaining daily weighs within his normal weight, managing his diabetes, maintaining glucose levels between 4 and 8 mmol/L, adhering to medication schedule, maintaining a healthy heart diet. Chapter 6: Caring for a person with an acquired brain injury Scenario 6.1 On admission to the ward – Q. b, c, d, h, i 1. Consider the patient situation (Quick quiz) – 1. b; 2. d; 3. c; 4. b; 5. d; 6. a; 7. a; 8. c; 9. b; 10. F, T, T, T, F; 11. b; 12. d; 13. Myocardial infarct and ischaemic stroke are due to blockage of an artery by the build-up of atherosclerosis and resulting clots. tPA is a thrombolytic agent; it can lyse a clot, break it up, and hence help to restore circulation and reperfuse tissue. Nurses should be aware of the important side effects of tPA, mainly bleeding and severe hypotension if an allergic reaction occurs. Monitor for signs of bleeding and for hypotension. 2. Collect cues / information (a) Review current information – 1. c; 2. c; 3. d; 4. 3; 5. Pulse pressure has increased, pupil reaction has become sluggish on the left side and pupil size on left has increased; other vital signs not noticeably different. (b) Gather new information – Q. a, e, f, k (c) Recall knowledge (Quick quiz) – 1. (a) increased arterial pressure; (b) increased hydrogen ions from increased carbon dioxide; (c) a fall in PaO2; 2. Cerebral, vertebral; 3. d; 4. c (raised/widening pulse pressure, f (decreased pulse) and h (abnormal breathing pattern); 5. a; 6. brain, CSF, blood; 7. Monroe-Kellie; 8. c 3. Process information (a) Interpret – 1. a, b, c, e, f; 2. Higher blood pressure may increase blood flow through stenosed or partially occluded blood vessels and help maintain perfusion to the brain tissue. 3. c


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(b) Discriminate – 1. a, b, d, h, I; 2. d, e, m; 3. Assess patient for any underlying conditions known to cause confusion, full history where appropriate, blood tests taken and vital signs; cluster information to rule out possible causes. (c) Relate – Q. d (d) Infer – 1. b, c, e, g; 2. b, c, f; 3. c (e) Predict – Q. If Mr Apulu’s increasing confusion is not considered and actions taken to determine the cause, he may die. His increasing confusion may be an early sign of increasing intracranial pressure. If left untreated, his intracranial pressure may continue to rise, putting pressure on his brainstem which may herniate. This can lead to a cardio-respiratory arrest. 4. Identify the problem/ issue – Q. d 5. Establish goals – Q. a, b, d, g, i 6. Take action Nursing action Rationale Notify Mr Apulu’s doctor or rapid response team of his condition.

The medical officer should be notified immediately of a change of 2 points in the GCS; the Rapid Response Team (if available) can also be called.

Reassure Mr Apulu.

Emotional distress can raise ICP.

Check that the IV cannula is not kinked or blocked.

To ensure patency and delivery of IV fluids.

Administer IV mannitol as ordered. This osmotic diuretic draws fluid out of the brain cells by increasing the osmolality of the blood.

Raise the head of Mr Apulu’s bed to 30° and keep his head in midline.

Facilitates venous drainage, and prevents obstruction of the jugular veins which could raise ICP.

Maintain a quiet environment.

ICP can be elevated by noxious stimuli including noise and emotional upset.

Strictly monitor Mr Apulu’s input and maintain hourly urine measures.

To ensure patient is not retaining more fluid and/or dehydrating after the osmotic diuretic-aim for normovolaemia.

Cluster nursing care activities.

Care procedures and frequent patient interruptions can raise ICP.

Monitor Mr Apulu’s level of consciousness. Vital signs and changes in behaviour can indicate a further rise in ICP and further deterioration.


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Monitor Mr Apulu’s pain score.

Severe headache can indicate worsening condition and can also cause anxiety, raising ICP.

Monitor Mr Apulu’s vital signs, oxygen saturation level and behaviours.

Establish baseline observations; sudden changes in neurological condition can indicate deterioration.

Monitor Mr Apulu’s ABGs and electrolytes.

Excess carbon dioxide and hypoxaemia can cause vasodilation and further raise ICP.

Instigate seizure precautions.

Patients experiencing raised ICP can suffer from seizures and need to be kept safe from injuring themselves if they have a seizure.

Monitor bladder distention and bowel constipation.

Constipation and bladder distension can raise ICP and impair venous drainage.

7. Evaluate

unchanged Cognitive status improving GCS unchanged Pulse unchanged Urine output improving Pupil size improving Pupil reaction unchanged BP unchanged Speech unchanged Oxygen saturation level

Scenario 6.2 2. Collect cues/ information (a) Review current information – 1. Term Definition

1. Hemiplegia e. Paralysis of the left or right half of the body 2. Aphasia/dysphasia g. difficulty speaking/incomprehensible speech or inability to

understand speech 3. Dysarthria d. difficulty speaking/pronouncing words 4. Hemianopia h. loss of half of the visual field of one or both eyes 5. Unilateral neglect c. unaware of and inattentive to one side of the body 6. Agnosia a. the inability to recognise previously familiar objects 7. Diplopia b. unilateral or bilateral double vision 8. Dysphagia f. difficulty swallowing

2. b, c, d, h, k, I, m, n, o, p 3. The nurse seems to have assumed that if she talks louder Mr Apulu will be able to understand her better, even though he is not deaf or does not have hearing difficulties. This tends to be a


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common response when someone does not understand what is said. It is an example of ascertainment bias. (b) Gather new information – Q. c, e, f, h, j, l, n, o (c) Recall knowledge (Quick quiz) – 1. c; 2. c; 3. a; 4. c; 5. b; 6. F, T, T, F, T, F; 7. b; 8. Speak in single sentences, use gestures or communication aids, allow him time to respond, remain calm. (a) Interpret – 1. T; 2. F; 3. F; 4. T; 5. T (b) Discriminate, (c) Relate, and (d) Infer – 1. b; 2. c; 3. b; 4. b, e (e) Predict Complication At risk Not at risk Shoulder dislocation x Bleeding X Aspiration pneumonia X Seizures X Pneumothorax X DVT (deep vein thrombosis) X Hepatic coma X Pulmonary oedema X Further stroke X 4. Identify the problem / issue – Q. a, b, c, e, f, h, I, j 5. Establish goals – Q. b, d, g, I, k, m, n, o 6. Take action 1. Health professional Role and responsibilities Social worker

Help patient organise such things as finance, vocational aspects, referrals

Psychologist

Help assess cognitive abilities of patient and emotional state

Dietician

Help determine right food choices for patients and also right food consistency

Speech pathologist

Help patients with aphasia relearn how to communicate, and assess ability to swallow

Physiotherapist

Help patients retrain motor and sensory impairments, and assess strength and endurance

Occupational therapist

Help improve motor skills and such things as grooming, preparing meals and house cleaning

Physicians: neurologist, general practitioners

Primary responsibility for managing and coordinating care


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Rehabilitation nurse Help patients to relearn to carry out activities of daily living and educate patients about routine self-care

2. Action Rationale Pulmonary care, chest physiotherapy. To prevent chest infections such as aspiration

pneumonia Anti-embolic stockings and early mobilisation. To revent thrombophlebitis and contractures Monitor vital signs and respiratory status. To detect early developing complications such

as pneumonia, bleeding Assess for warmth, redness and increase in size of calves.

To monitor for development of thrombophlebitis

Face patient, speak slowly and allow time for answers.

To maintain patients dignity and decrease frustration with communication

Encourage fluids and high fibre diet (high fibre nasogastric feeds were appropriate).

To prevent constipation

Mouth care, including suctioning on affected side.

To keep mouth clean and prevent infections and aspiration pneumonia

2nd-hourly turns. To prevent pressure areas developing Use picture boards, gestures, writing boards and computers.

To assist in communication

Instigate range of motion exercises and support joints and limbs at rest.

To maintain and improve muscle strength and joint flexibility

Encourage patient to void on schedule, every 2 hours using positive reinforcement.

To help promote bladder tone and retraining

7. Evaluate Q. Actions has been effective if Mr Apulu remains free of infections, does not become constipated, has reduced frustration in communicating, does not develop pressure areas, maintains muscle strength and joint flexibility within the constraints of his disability, does not develop thrombophlebitis, and begins to regain bladder tone and control of urination. Chapter 7: Caring for a challenging patient Scenario 7.1 1. Consider the patient situation 1. The tone and content of the handover is likely to adversely affect the care Shawn receives.

Nurses will be attuned to the negative aspects of his behaviour and are likely to interpret all of Shawn’s behaviour in a negative light (this is called ascertainment bias). This in turn will affect the way Shawn interacts with them, which sets up a vicious cycle. The nurses may also fail to look after his clinical needs adequately.

2. No. With regard to the ANMC’s Boundaries of Practice, the nurse’s ‘under involvement’ lies to the left side of the continuum; this includes attributes such as ‘distancing, disinterest, coldness


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and neglect’. No. With regard to the Code of Ethics value statement, nurses value access to quality nursing and health care for all people: ‘Nurses valuing non-harmful, non-discriminatory care provide nursing care appropriate to the individual that recognises their particular needs and rights. They seek to eliminate prejudicial attitudes concerning personal characteristics such as race, ethnicity, culture, gender, sexuality, religion, spirituality, disability, age and economic, social or health status.’

3. Check all observations, conduct a full assessment, talk with Shawn about how he is feeling,

and work out a mutually agreeable plan. 2. Collect cues / information (a) Review current information – If Shawn was withdrawing from alcohol, his temperature, heart rate and respiratory rate are likely to be raised. (b) Gather new information – 1. Assess for nausea, tremor, increased blood pressure and pulse, agitation, sweating, vomiting and headache. Assess whether there are perceptual disturbances. Ask about past episodes of severe alcohol withdrawal including delirium and seizures, other medical or psychiatric problems or benzodiazepine dependence. 2. a (c) Recall knowledge (Quick quiz) – 1. a; 2. The missing word is alcohol in every case. 3. a; 4. a T, b F, c T, d T, e F, f T, g T; 5. c; 6. a; 7. c 8.

i. Drowsiness c. Alcohol, benzodiazepines, opiates ii. Agitation a. Sedative withdrawal, or stimulant

toxicity iii. Tremor f. Alcohol, benzodiazepine withdrawal iv. Diaphoresis b. Alcohol and opioid withdrawal v. Slurred speech, ataxia d. Alcohol, benzodiazepines intoxication vi. Pinpoint pupils e. Especially opiates

9. a F, b T, c T, d T, e F, f T 3. Process information (a) Interpret – Q. a, c, d, e (b) Discriminate – 1. a, b, f, h, I, m, n (c) Relate – Q. a F, b F, c F, d F, e F, f T, g T

(d) Infer – Q. d (f) Predict

(a) high likelihood (b) possible (c) possible (d) low likelihood (e) high likelihood


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(f) high likelihood

4. Identify the problem/ issue – Q. f, h 5. Establish goals – Q. b, c, d 6. Take action – Q. b, d, f, h, j, k Which of these actions could be counterproductive? c and e. They are likely to make him more anxious and possibly frustrated; g. crosses a professional boundary. 7. Evaluate – Q. c, e, f, g 8. Reflect – 1. clinical reasoning errors: ascertainment bias, confirmation bias, fundamental attribution error. 2. full assessment at the beginning, being aware of transference issues, stigma and stereotyping Scenario 7.2 2. Collect cues / information (b) How common are anxiety disorders? – Q. a, d, e, f, g, h, k (c) Recall knowledge – 1. a F, b F, c T, d T, e F, f T, g T, h F 2. Stress is a normal reaction to a situation where a person feels under pressure, whereas an anxiety disorder involves more than just feeling stressed; it affects people’s wellbeing and day-to-day function. 3. An anxiety disorder involves more than just feeling stressed and anxious; it affects people’s wellbeing and day-to-day function. 4. Fear is a feeling of agitation and dread caused by the presence or imminence of danger. It differs from anxiety in that it is a response to a known and specific threat. 5. Medication side effects, hyperthyroidism, asthma, cardiac problems, withdrawal from alcohol, anaemia 3. Process information (a) Interpret

Predisposing factors

Precipitating factors

Perpetuating factors

Prognostic indicators (including protective)

Biological Family history of anxiety

Misuse of alcohol Misuse of alcohol and nicotine

Intelligent

Psychological Anxious personality Anxiety Poor relationship with father

Low self-esteem Avoidance of situations that made him anxious

Smart and keen to access help Contemplative

Social Peer pressure Leaving school/leaving

Mother has not always been able

Support from mother


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home to assist in the most useful way

(c) Relate – Q. a F, b T, c F, d T, e T (d) Infer – Q. a, b, c, d (e) Predict – Q. a, b, d 4. Identifying the problem/ issue – Q. f 5. Establish goals – Q. a, b, c, e, i 6. Take action – Q. a, e, f, g, h, l 7. Evaluate – Q. Evaluation might be about whether you used Shawn’s crisis as a catalyst for change by relating to him in a therapeutic way and using the ‘teachable moment’. People using substances do often change their behaviour when faced with increasing consequences such as job loss, relationship problems, financial difficulties and physical deterioration. Emergencies related to drug and alcohol abuse can serve as learning experiences. You might also consider whether Shawn’s long-term prognosis is improved because of your intervention. Chapter 8: Caring for a person with an autoimmune condition Scenario 8.1 Setting the scene (Quick quiz) – 1. b; 2. a; 3. c; 4. b; 5. a 2. Collect cues / information (b) Gather new information – 1. a, b, c, d, g (c) Recall knowledge – 1. a, b, c, d; 2. a; 3. e; 4. b, c, e; 5. d; 6. c; 7. a, b, d; 8. b, c, d 3. Process information (a) Interpret – 1. a; 2. b; 3. b; 4. a (b) Discriminate – Q. b, e, f, h, j (c) Relate – Q. a F; b T; c T; d F; e T; f F; g T; h F; i T (d) Infer – Q. a, c, e (f) Predict – Q. a, c, d, e, g 4. Identify the problem/ issue – 1. a, c, d 2. Potential factors contributing to inadequate management to date:

• Lack of continuity of medical and nursing care. • Elsie has had limited education to assist her in managing her symptoms.


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• Coexisting Sjögren’s syndrome had not been diagnosed. • Health professionals may have been unaware of the impact of what appear to be minor

symptoms such as dry eyes and oral dryness. 5. Establish goals – Q. a, c, f (subject to time available, or schedule follow-up appointment) 6. Take action – Q. After reviewing with Elsie the issues you have identified, it is important to check with Elsie about which issue she would like addressed first. This discussion will then inform the prioritising of the rest of the activities. 7. Evaluate Symptom Unchanged Improving Deteriorating Nocturnal cough and choking X Quality of sleep X Ulcerated finger X Oral dryness X Eye irritation X Raynaud’s phenomenon X Scenario 8.2 2. Collect cues/ information (b) Gather new information 1. Questions that might help you understand more about her distress:

• Are you still sewing and going out with your friends? • Is there anything that has happened since we met last that is upsetting you? • Have you been worried about what has been happening with your health? • You said you don’t see the point of going on. Have you been perhaps thinking of killing

yourself? 2. Other factors that could be contributing to her sadness:

• The still-birth of Nicholas on Christmas Day many years ago and the silence between Elsie and her husband regarding this has been a source of chronic sorrow for Elsie.

• Since the death of Nicholas, Doug has not once participated in Christmas celebrations with the rest of the family. Over the years, Elsie, her daughters and now her grandchildren have celebrated Christmas together without Doug.

3. Screening questions:

• Over the past two weeks, have you felt down, depressed or hopeless? • Over the past two weeks, have you felt little interest or pleasure in doing things? (Arroll, Goodyear-Smith, Kerse, Fishman & Gunn (2005, p. 884).

(c) Recall knowledge – Q. a T, b F, c F, d F, e T, f T, g T, h F, i T, j F 3. Process information (b) Discriminate, and (c) Relate – Q. c, e, h, k, l


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(d) Infer, and (e) Match – Q. b, d, g (f) Predict – Q. b, d, e, g 4. Identify the problem/ issue – Q. c, d, f 5. Establish goals – Q. b, c, e 7. Evaluate • Ask Elsie about her appetite and her sleep and how she would describe her mood now

compared with how she was feeling when you last met. • Have Elsie’s symptoms that prompted referral to the mental health nurse been resolved?

Also review Elsie’s capacity to manage her physical symptoms related to scleroderma and whether she has returned to previously enjoyed activities.

Chapter 9: Caring for an older person with impaired cognition Scenario 9.1 Setting the scene 1. Vietnamese names are traditionally written using the surname first then the given name. Vietnamese people often prefer to be addressed using their title followed by their given name. For example, Mr Dang Tien would be referred to as Mr Tien. 2. Fever in older people with pneumonia is frequently absent. Person-centred care Q. Negative stereotypes about and illness trajectories for older people both contribute to the increased risk of them being treated as cognitively incompetent. It is widely accepted by society that any cognitive decline with increasing age is seen as expected, irreversible and untreatable. It is poorly recognised that both acute and chronic illnesses contribute to a temporary alteration in the cognition of an older person. Therefore, when a nurse encounters an older person in hospital they may incorrectly assume that the person is not able to make decisions or be actively involved in their own care. 1. Consider the patient situation (Quick quiz) – 1. c; 2. a; 3. c; 4. b 2. Collect cues / information (a) Review current information

1. Mr Tien’s vital signs and oxygen saturation level 2. Blood and sputum culture results 3. Mr Tien’s prior cognitive abilities 4. Social (cultural) history 5. Hydration/nutritional status

(b) Gather new information 1. Mini mental status (MMSE) – The night nurse’s report suggested issues with cognition that required further investigation. She thought Mr Tien had dementia, yet he did not have a history of dementia. Tricia, the day nurse, would be thinking she would need to assess his cognition and the MMSE is a tool for this.


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But she also was told he had not slept much, was agitated and there were difficulties with Mr Tien’s communication. Tricia chose the AMTS as it is shorter and the questions and tasks are less complex than the MMSE and therefore there was more likelihood of Mr Tien being able to respond. The AMTS delivers information about memory, attention and calculation. Glasgow coma scale (GCS) – Mr Tien has not suffered a head injury. Geriatric Depression Scale (GDS) – He does not have a history of depression and his condition deteriorated during the night, which suggests a short duration not consistent with depression. 2. f, h (c) Recall knowledge 1. Alteration in cognition

Onset Level of consciousness

Mood Self- awareness

Activities of daily living

Dementia Chronic; months–years

Alert Fluctuates Unaware of deficits

Early: intact but impaired as disease progresses

Delirium Acute; hours–days

Fluctuates Fluctuates Fluctuates May be intact or impaired

Depression Weeks–months

Drowsy Low, apathetic

Aware of cognitive change

May neglect basic self-care

Cognitive decline

Chronic; Months–years

Alert No change Aware of cognitive changes

No change

2. d; 3. c; 4. a; 5. c; 6. d 7. Cultural aspect Mr Tien Example: Language Speaks Vietnamese and French. Usually

speaks Vietnamese with family and English outside the home.

Food and diet He rarely eats western food. Eats Vietnamese food. Uses chopsticks.

Attitudes to illness and pain

Stoicism: suffers in silence, does not complain.

Cultural beliefs Use of alternative medicines: acupuncture and herbal medicines.

Family (living arrangements)

Lives with daughter. Eldest son is the family spokesperson. He lives around the corner from sister.

3. Process information (a) Interpret Temperature: 36.9°C (normal) Abnormal results for Mr Tien: Pulse rate: 95 beats per minute (normal 60–90) Respiratory rate: 23 breaths per minute (normal 16–20) Blood pressure: 175/90 (normal blood pressure < 140/< 90) SaO2: 92% room air (normal SaO2 is above 95%) Lung sounds: Crackles in left lower lung bases (lungs should have no crackles)


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(b) Discriminate 1. d, e, h, i (The g response if also important, but only in establishing that Mr Tien probably does not have a urinary tract infection which could be contributing to his alteration in cognition.) 2. a, b, c, d, f, i, j, k 3. F, F, T, F, F, F 4. If Tricia has an understanding of what is normal for older people, then any alterations in cognition noted will be explored thoroughly. This will lead to an accurate diagnosis and appropriate person-centred care. (c) Relate, and (d) Infer 1. T, F, F, F, T, T, F, T, T 2. Yes 3. a, c, d (f) Predict – Q. b, e, f, h 4. Identify the problem/ issue – Q. b, c, f, g, h, i, j, k 5. Establish goals – Q. b, c, h, j, k, l, m 6. Take action

(a) Notify Mr Tien’s doctor of his condition. 1 (b) Educate Mr Tien about how to breathe deeply. 2 (c) Physically restrain Mr Tien so that he does not climb out of bed and hurt himself. 3 (d) Check that the IV cannula is patent. 2 (e) Lower the bed rails on Mr Tien’s bed. 1 (f) Monitor Mr Tien‘s level of consciousness. 2 (g) Regularly orientate Mr Tien to the hospital environment. 2 (h) Chemically restrain Tien so that he does not climb out of bed and hurt himself. 3 (i) Administer inhalers as charted. 2 (j) Ensure Mr Tien is wearing his nasal prongs. 1 (k) Communicate via phone with Mr Tien’s daughter. 2 (l) Maintain Mr Tien’s fluid balance chart. 2 (m) Engage the interpreter service to assist with communication strategies. 2 (n) Adjust bed to lowest position. 1 (o) Leave the television on in Mr Tien’s room so that he does not feel lonely. 3 (p) Ask daughter or other family member to sit with Mr Tien. 2 (q) Administer IV antibiotics as charted. 2 (r) Prompt and assist Mr Tien with drinking and eating. 2 (s) Monitor Mr Tien’s vital signs and oxygen saturation level. 2 (t) Transfer Mr’s Tien to a residential aged care facility until he recovers. 3 (u) Move Mr Tien to an area where he can be closely observed. 1 (v) Communicate with family to start discharge planning. 2 (w) Ask Mr Tien’s family to bring in his favourite foods for each meal. 2 (x) Ensure Mr Tien is not disturbed once he settles for the night. 2 (y) Schedule the taking of observations when Mr Tien is awake during the night. 2

Explanation for incorrect responses:

• Physically restrain Mr Tien so that he does not climb out of bed and hurt himself. and

• Chemically restrain Tien so that he does not climb out of bed and hurt himself.


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Both forms of restraint are not considered appropriate treatment strategies for an older person who is experiencing delirium. Both can exacerbate a delirium and are associated with adverse outcomes: pressure area development, incontinence, falls and death.

• Leave the television on in Mr Tien’s room so that he does not feel lonely.

This is the opposite of what is required when nursing Mr Tien at this time. A quiet, calm and comfortable environment is what is recommended when nursing an older person with delirium. It is important for Mr Tien to be monitored closely and continuously and, where appropriate, to use validation or reality orientation communication strategies.

• Transfer Mr Tien to a residential aged-care facility until he recovers.

Mr Tien’s delirium will improve as he recovers from pneumonia. A diagnosis of delirium does not lead to a transfer to a residential aged-care facility.

2. Nursing action Rationale Document all nursing observations and actions accurately and contemporaneously.

To ensure clear, accurate and timely communication between all health professionals caring for Mr Tien

Reassess using the CAM.

To identify the progress of the delirium

Engage interpreter service to assist with the other cognitive assessments.

To determine Mr Tien’s level of cognition

Prompt and assist Mr Tien with toileting.

To prevent episodes of incontinence

Prompt and assist Mr Tien with oral fluids.

To ensure adequate fluid intake and prevent dehydration

Monitor psychomotor activity. Restlessness and lethargy are indicators of continuing acute confusional state.

Encourage family to stay with Mr Tien.

To assist with communication, to improve safety and provide comfort for Mr Tien

Communicate Mr Tien’s progress to his family.

To ensure clear, accurate and timely updates are received by family from all health professionals

Encourage gentle ambulation and regular position change.

To prevent pressure areas due to reduced mobility

Monitor oxygen saturation levels. To ensure adequate oxygen delivery 7. Evaluate

Fluctuating Language ability Not speaking


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Fluctuating Psychomotor activity Lethargic Fluctuating Mood Withdrawn Improving Pulse 88 Improving BP 150/70 Improving Respirations 18 Improving Oxygen sats 96% Improving Urinary incontinence Using a urinal with prompting and assistance Improving Oral intake Eating and drinking food brought in by daughter

Scenario 9.2 2. Collect cues / information (a) Review current information – Q. b, d e, g, h, k, l, m The incorrect responses, a, i and j, contain information that is currently not available for Kristy to review. All this information is required, but she will have to conduct a series of assessments to gather this new information. The incorrect responses, c and f, although both are very important information, are not essential for Kristy to come to an understanding of Mr Tien’s current problems/issues. (b) Gather new information 1. Level of cognition; level of consciousness; degree of orientation; ability to be attentive, concentrate and to recall recent events; level of psychomotor activity; language ability; comprehension and calculation abilities. Urinalysis Vital signs, respiratory assessment Duration of cognitive alteration Regularity of bowels Mood 2. h 3. Process information (a) Interpret – Q. d, g, h, I, j, k, l (b) Discriminate – Q. d, e (c) Relate, and (d) infer – Q. F, F, F, F, T, F (e) Predict – Q. f 4. Identify the problem/ issue – Q. a, c, e, f 5. Establish goals – Q. b, d, g, i 6. Take action (a) Ring Mr Tien’s eldest son. 2 (b) Discuss the results of the assessments with Mrs Qui. 1 (c) Explain to Mr Tien that he is not to speak to his daughter in a negative way. 3 (d) Suggest some strategies for Mrs Qui to help with Mr Tien’s personal hygiene. 1 (e) Plan for readmission to hospital. 3 (f) Make a referral to Aged Care Assessment Team. 2 (g) Arrange for Meals on Wheels. 3


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(h) Suggest communication strategies to help Mrs Qui receive positive responses from Mr Tien. 1 (i) Discuss the need to organise Mr Tien’s admission to a residential aged-care facility in the near future.

3 (j) Suggest strategies that Mrs Qui can use to ensure Mr Tien is eating and drinking adequately. 1 (k) Notify Mr Tien’s GP of his condition. 1 Explanation for incorrect responses: Explain to Mr Tien that he is not to speak to his daughter in a negative way. Traditionally, Vietnamese women will submit to their father’s wishes and obey their husband. Despite some moderation of this cultural value occurring when Vietnamese people move to a Western culture, there is still the expectation that Mrs Qui will obey and respect her father. It is not appropriate for Kristy to discuss with Mr Tien his behaviour towards his daughter. Plan for readmission to hospital. Mr Tien is not acutely ill and does not require admission to hospital. Arrange for Meals on Wheels. Mr Tien is forgetting to eat. He does not have an issue with access to food as it is being provided. Discuss the need to organise Mr Tien’s admission to a residential aged-care facility in the near future. A decline in cognition such as Mr Tien’s does not signal admission to residential aged care. Even as Mr Tien declines, his family will take care of him at home. They will require help and this can be provided by aged-care community services. 7. Evaluate 1.

• Unchanged MMSE: 19/30 • Unchanged CAM: Negative • Improving Mood: Calm • Improving Pulse: 86 • Improving Respirations: 16 • Improving BP: 150/75 • Improving SaO2: 96% • Improving Personal hygiene: Family successfully assisting • Improving Communication: Mrs Qui has not been called a bad daughter • Improving Nutrition/hydration: Mrs Qui reports Mr Tien is eating and drinking

2. b, c, f, I, j Chapter 10: Caring for a person experiencing pain Scenario 10.1 2. Collect cues/ information (a) Review current information – Q. c (b) Gather new information – 1. a, c; 2. b; 3. a, b, c, e, g, h, j, k, m (c) Recall knowledge (Quick quiz) – 1. c; 2. , , no change, , , , no change, , ; 3. d; 4. b


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3. Process information (a) Interpret – Q. infrequently, T, infrequently, T, T, infrequently, T, T, F, F, infrequently (b) Discriminate, and (c) Relate – Q. T, F, F, F, T, F, F, F, F, F, F, T, T (d) Infer – Q. c (f) Predict – Q. a, b, c, e, f, g, h, j, l, m 4. Identify the problem/ issue – Q. b, c, f, g 5. Establish goals – 1. b, e; 2. b, d, e 6. Take action 1. P = Provokes

What is causing the pain? What has made it better previously? Does anything make it worse? Does it hurt on deep inspiration? What was the patient doing when it started?

Q = Quality

What does it feel like? Ask your patient to describe the pain. Is it sharp, dull, aching, stabbing, burning, crushing? How does it affect ADLs, sleep, concentration, relationships, mood?

R = Radiates

Where is the pain? Does the pain radiate or is it in just one place? Did it start elsewhere and is now localised to one spot?

S = Severity How severe is the pain on a scale of 1 to 10? T = Time What time did the pain start? How long has it lasted?

2. e, g, c, f, d, a, b 3. b, d, f 7. Evaluate – Q. a, d, e, f, g Scenario 10.2 (b) Gather new information – 1. a, c, e, g; 2. b, d, e, g, j (c) Recall knowledge (Quick quiz) – 1. d; 2. F, T, F, T, F, F, F, F; 3. a; 4. a, c, d, f, h, I, j; 5. a, c, e, g, j; 6. d 7. Acute pain Persistent pain Diagnosis Usually clear

Unclear


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Duration Temporary (few days or weeks)

Persists for indefinite period > 3 months

Pain descriptors

Sharp, stabbing

Aching, burning, sometimes sharp

3. Process information (a) Interpret – 1. F, T, T, F; 2. a (b) Discriminate, and (c) Relate – Q. a, d, f, g (d) Infer – Q. b (f) Predict – Q. a, b, d, e, h, j, k 4. Identify the problem / issue – Q. Mrs Simpson is no longer interacting with her family as she once did; Mrs Simpson is finding it difficult to sleep due to pain; Mrs Simpson is receiving sub-optimal relief from her medications. 5. Establish goals and 6. Take action GOAL Review

date Mrs Simpson’s actions

HCP actions

Short term – 1. Sitting for up to five minutes without flaring pain 2. Hanging out the washing without flaring pain 3. Making breakfast without flaring pain

2 weeks Daily stretches Daily strength exercises Timing activities and recording results Taking regular paracetamol

Medication review Review pain diary Investigation of available Tai Chi groups

Medium term – 1. Sitting for up to 20 minutes without flaring pain 2. Joining local seniors Tai Chi club and attending once a week 3. Spending more

2 months Continue daily stretches and strengthening exercises Attend Tai Chi

Review pain diary Physiotherapy review Organise transport to social club


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time with grandchildren

Review plan and goals

Long term – 1. Sitting for up to 40 minutes without flaring pain 2. Attending the local library’s genealogy classes 3. Attend Christmas dinner at daughter’s house

[6 months] Increase physical activity

Monitor progress Review plan and goals

7. Evaluate – 1. a; 2. d Chapter 11 Caring for a child with type 1 diabetes Scenario 11.1 Family-centred care – Why is it necessary for Haley to monitor her carbohydrate intake? Understanding that carbohydrates convert to glucose after digestion and knowing which foods are high in carbohydrate will enable Haley and her family to calculate her carbohydrate intake and adjust her insulin requirements accordingly. The flexibility of this management system improves Haley’s quality of life significantly and helps to remove the label of being different. Patient education – How would you explain to Hayley why she needs injections when her grandmother doesn’t? There are two types of diabetes. Both result in patients having too much glucose in the blood. Type 1 is caused when the pancreas doesn’t make any insulin. Insulin is a ‘special messenger’ that lets the glucose through to give energy to the working parts of your body. Because you don’t make any insulin you need to have it replaced and the only way we can do that is by injection. Nanna also has diabetes and high glucose in her blood but the reason is different. Although her body makes some of the ‘special messenger’ insulin, it isn’t always enough and the target tissues are not always receiving the message. So, she needs a tablet that will wake up the pancreas to make more insulin and wake up the cells so they pick up the message from the insulin. How could you help Haley openly discuss her fears and frustrations? Children and adults react differently to illness. Children may regress slightly and be less articulate then they are at home and often find a new diagnosis confusing and annoying. The development of a therapeutic relationship requires the nurse to provide individualised attention to the child. Elements of a therapeutic relationship include development of trust, demonstrating nonjudgmental communication, and being open to discussing concerns. Eye contact, getting down to the level of the child and speaking in simple terms that the child can understand are all important strategies. A key element in gaining cooperation is the use of positive language, where the goal of working towards helping the child feel better is stated clearly. It’s also vital that no false promises are made. Using puppets or dolls is an effective way to distract the child during


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uncomfortable procedures and also to teach the child in a relaxed and fun way. Practical initiatives to promote understanding and diminish isolation include introducing Haley and her mother to a support network for children and parents with diabetes and initiating the use of social media support groups to decrease the risk of Haley being isolated from support when she returns home. Ensuring that Haley and her mother develop a sound understanding of the disease and its management will establish confidence and independence. Simple strategies such as the provision of suitable reading material and connection with members of the interprofessional team are all part of achieving this goal. Haley asks you why she has two different types of insulin in the morning and evening but only one injection prior to meals. What explanation will you give Haley for this? Explain that Haley is being given two sorts of insulin that have different jobs. One of them is ‘intermediate’ insulin and acts over a longer period of time. Its job is to manage the amount of glucose that is released from the liver into the body so that glucose levels stay at a constant or ‘good’ level. The liver releases extra glucose when you are stressed or when the levels of insulin get too low. So having a steady release of insulin stops the blood glucose going up and down throughout the day. The insulin you receive each morning and evening does this job. The other is short-acting insulin. Haley’s body needs basal insulin to help maintain a steady blood glucose level that is not too high or too low, but it also needs additional doses of insulin through the day. When she eats carbohydrate foods her body converts the carbohydrate into glucose and absorbs it into the bloodstream. Haley needs extra insulin to process this additional blood glucose when she eats. To process the glucose, the insulin either moves it into the cell to be used now or stores it away to be used when you are exercising. The insulin Haley receives before each meal does this job. 2. Collect cues / information (b) Gather new information – Q. Full set of vital signs including pain assessment, BGL, AVPU to check conscious state (c) Recall knowledge (Quick quiz) – 1. a; 2. b; 3. a; 4. c; 5. b; 6. a; 7. b; 8. T, T, T, T, F 3. Process information (a) Interpret – Q. Normal: f, h, k; all others are abnormal (respiratory rate marginally raised) (b) Discriminate – Q. f (c) Relate, and (d) Infer – Q. F, T, F, T, T, F, T, T, F, F (e) Predict – Q. b, d, e 4. Identify the problem/ issue – Q. e, g 5. Establish goals – Q. d 6. Take action – Q. e, h 7. Evaluate – 1. b, e; 2. outdated test strips, poor skin preparation (i.e. dirt, sugar, alcohol or other substances on skin), lack of calibration of device to test strips, insufficient


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blood, battery problems; 3. Ascertainment bias and fundamental attribution error; 4. Haley and her family have demonstrated that they have a strong commitment to understanding her illness and to ensuring that Haley receives the best care possible. There is no evidence to substantiate such a statement. This type of comment can impact on the objectivity of other staff and so diminish the quality of health delivery to the client. This type of comment is therefore a breach of the professional codes of conduct and code of ethics. Scenario 11.2 2. Collect cues/ information (b) Gather new information – Q. a, b, g, m (c) Recall knowledge (Quick quiz)– 1. a; 2. b; 3. a; 4. b; 5. b; 6. b and d; 7. d; 8. d; 9. a; 10. b; 11. b 3. Process information (a) Interpret – 1. f; 2. a, d, g, h, i (b) Discriminate (a) Temperature 2. Important (b) Pulse rate 2. Important (c) BP 1. Greatest importance (d) Respiratory rate and depth 1. Greatest importance (e) Smell of sweet breath 2. Important (f) SpO2 3. Not of concern at this time (g) Capillary refill 1. Greatest importance (h) Hb 3. Not of concern at this time (i) pH 1. Greatest importance (j) CO2 2. Important (k) Na+ 3. Not of concern at this time (l) pO2 3. Not of concern at this time (m) BGL 1. Greatest importance (n) Ketones 1. Greatest importance (o) K+ 2. Important (p) Urea 2. Important (q) Condition of oral mucosa 1. Greatest importance (r) WBC 2. Important (s) Sleepy, requiring loud stimuli to wake her 1. Greatest importance (c) Relate, and (d) Infer – Q. F, F, T, T, F, F, T, F, F, T, F, T, T, F (e) Predict – Q. a, b, d 4. Identify the problem/ issue – 1. a; 2. infection or illness, omitted or inadequate insulin; poor understanding of carbohydrate intake; failure of insulin administration device


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5. Establish goals – Q. Establish rehydration within 24 hours; stabilisation of serum glucose within 6 hours; stabilisation of electrolytes within 6 hours; resolution of ketosis and acidosis within 12 hours 6. Take action – 1. b, d, e, g, h, i 2. Medical order / Nursing action Rationale Document all nursing observations and actions accurately and contemporaneously.

To provide effective communication between the health team and facilitate the delivery of appropriate individualised care; to provide an accurate and contemporaneous documentation of Haley’s condition and progress

Check neurological status hourly. To identify improvement or deterioration in Hayley’s cognitive state

Monitor fluid status closely. To determine hydration status and enable administration of appropriate IV fluids

ECG and cardiac monitoring. Hyperkalaemia may cause peaked T waves and cardiac dysrhythmias


To ensure cannula remains patent

Maintain oxygen therapy via Hudson mask and hourly oxygen saturations.

To ensure adequate oxygen delivery

Reassure Haley and her family. To promote a therapeutic relationship and maintain psychosocial wellbeing

Set up an insulin infusion to be commenced once K+ improves, then titrate with Se.Glucose and Se.Ketone levels according to doctors orders.

To provide adequate insulin to clear ketones and correct acidosis

Hourly capillary BGL and ketones. To monitor response to insulin treatment and to identify appropriate management strategies

Commence IV with N/Saline 0.9% with 20 mmol/KCL as per written fluid orders.

To correct fluid and electrolyte imbalances

Repeat ABGs in 2 hours. To monitor respiratory and acid–base balance and adjust management appropriately

Check glycosylated haemoglobin (HbA1c). To determine the average plasma glucose concentration over a period of time and so gain insight into how well controlled the disease is

Prepare IV of 5% dextrose but do not commence unless ordered.

To enable the titration of intravenous dextrose so that BGL is maintained between 5 and 10 mmols/L (within acceptable parameters)

Ensure patent airway at all times. To ensure adequate oxygen delivery Transfer Hayley to ICU. To ensure appropriate expertise and resources are

allocated to Haley Hourly vital signs. To identify improvement or deterioration in Haley’s

condition Repeat U & Es in 2 hours. To identify electrolyte imbalances so that an ongoing

titration of treatment to Haley’s condition can occur


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7. Evaluate 1. Improved cognition: Haley becomes more alert and aware. BGLs and Se Ketones return to normal parameters. Skin turgor improves. Capillary refill returns to < 2 secs. Vital signs are within normal parameters: afebrile, pulse rate < 100 bpm, respiratory rate < 20, normotensive. Respiratory pattern becomes less deep. Acetone on breath no longer detectable. 2. Hypoglycaemia, hyperglycaemia, hypokalaemia, fluid overload, cerebral oedema Chapter 12: Caring for a person receiving blood component therapies Scenario 12.1 1. Consider the patient situation (Quick quiz) – 1. b; 2. a; 3. c; 4. a 2. Collect cues/ information

1. (a) bedside, (b) compatibility label (in an emergency group O transfusion of PRBCs, will only be able to identify that the donor group is O and this is compatible as the universal donor), (c) patient, (d) patient identification, (e) full name and DOB, (f) special requirements, (g) expiry date 2. (a) leaks, (b) turbidity or haemolysis, (c) colour difference 3. documentation, signatures, printed names

(b) Gather new information – 1. a, e, f, g 2. Check skin for a rash or hives which may indicate anaphylaxis; check for back pain and colour of urine to rule out ABO incompatibility; check that the right pack has been given to the right patient to rule out ABO incompatibility. (c) Recall knowledge (Quick quiz) – 1. d; 2. b; 3. a, b; 4. d; 5. b; 6. e 3. Process information (a) Interpret 1. Blood pressure and oxygen saturation. A ‘normal’ oxygen saturation level for Mrs Ayman would be 95–100%; a ‘normal’ blood pressure for Mrs Ayman would be 100/60 with NO postural drop. 2. This is not of concern with regard to ABO compatibility. During an emergency, O-ve blood is chosen as this is the universal PRBCs donor and there are no RhD antigens present. However, as this is un-crossmatched blood, there is the possibility of a reaction to other antigens outside the ABO grouping system. (b) Discriminate – Q. b, d, g (c) Relate, and (d) Infer – Q. F, F, F, T, F, F


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(e) Predict – Q. a 4. Identify the problem/ issue – Q. a, d (as a febrile episode may be the first sign of a possible antibody/antigen reaction or a possible bacterial contamination) 5. Establish goals – Q. b (Immediate resolution of Mrs Ayman’s symptoms is the desired goal; however, bacterial contamination may become evident days after the transfusion has been completed.) 6. Take action – 1. a, b, d, f, I (j and k are correct, but these are not immediate actions.) Explanations for incorrect responses are: (c) The IV cannula from the transfusion should not be flushed but a new IV line should be commenced. (e) Raise the foot of Mrs Ayman’s bed [Not indicated at this time as her blood pressure has stabilised] (g) Monitor Mrs Ayman’s level of consciousness [The cues provide no evidence of cognitive impairment (at this stage)] (h) Monitor Mrs Ayman’s pain score [Important, but not an immediate action] 2. Nursing action Rationale Document all nursing observations and actions accurately and contemporaneously.

To ensure clear, accurate and timely communication between all health professionals caring for Mrs Ayman

Check cognitive status regularly. Anxiety and restlessness may indicate worsening antigen/antibody reaction

Monitor haemodynamic status closely.

To identify improvement or deterioration in Mrs Ayman’s condition

Regular skin examination. To immediately identify an urticarial rash or any unexplained bleeding


To ensure cannula is patent and as pain along the IV line may indicate haemolysis

Maintain oxygen therapy via nasal prongs and hourly oxygen saturation.

To ensure adequate oxygen delivery as deterioration may indicate laryngeal oedema, bronchospasm or TRALI

Reassure patient. To maintain psychosocial wellbeing Check colour in each specimen of urine. Dark-coloured urine may indicate haemolysis

7. Evaluate

Unchanged Cognitive status Improving Pulse rate Deteriorating Blood pressure Deteriorating Respiratory rate Unchanged Oxygen saturation level Unchanged Skin condition


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Improving Shivering Improving Temperature

Scenario 12.2 2. Collect cues / information (b) Gather new information – 1. b, f; 2. d (c) Recall knowledge (Quick quiz) – 1. e; 2. b; 3. a; 4. c; 5. g; 6. c; 7. b; 8. d; 9. d; 10. b; 11. a; 12. g 3. Process information (a) Interpret – Q. e (b) Discriminate, and (c) Relate – Q. a, d (d) Infer – Q. restlessness, scratching, dyspnoea, headache (e) Predict – Q. a Warning signs of adverse reaction Allergenic reaction –antibodies to proteins including IgA

Febrile non-haemolytic reaction – possible contamination with pyrogens and/or bacteria

Both

puritis flushing restlessness urticaria rigors anxiety palpitations fever tremor mild dyspnoea headache tachycardia 3 (f) Match Q. In Scenario 12.1 Mrs Ayman experienced a febrile non-haemolytic transfusion reaction (FNHTR). This is the most frequent adverse event following transfusion and is typified by a rise in temperature greater than or equal to 1ºC above the pre-transfusion baseline that cannot be explained by the patient’s condition. The pathogenesis of this type of reaction is multifactorial but in most cases fever is the only clinical finding. It is thought to occur as a result of an antibody reacting with a white cell antigen in the patient’s blood, or a white cell fragment in the blood product, or to cytokines accumulated in the blood product during storage. Typically this type of reaction is not life-threatening; there are no specific tests to confirm an FNHTR, so diagnosis involves a process of exclusion. In Scenario 12.2 Mrs Ayman is experiencing an urticarial (allergic) reaction. Mild allergic/urticarial reactions are more frequently encountered than severe allergic (anaphylactic) reactions, which are extremely rare. It is thought that the contributory factors in mild allergic reactions are cytokine release or an immune reaction causing complement activation. Urticarial reactions with no other signs and symptoms may not require investigation. In the more severe reactions, development of an immunoglobulin E (IgE) antibody to a previously encountered allergen results in the release of


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leukotriene and cytokine. This may result in stridor, dyspnoea and bronchospasm together with hypotension, with the bronchospasm leading to chest tightness. 4. Identifying the problem/ issue – Q. c. Hypersensitivity (allergic) reactions may result when antibodies in the patient’s blood react against proteins (e.g. immunoglobulin A) in the donor’s blood. 5. Establish goals – Q. b. If Mrs Ayman’s symptoms can be controlled and her vital signs improve, continuing her transfusion may be possible. 6. Take action – Q. a, b, e, g, h, I, k, m, p, q 7. Evaluate Sign or symptom Desired observation e.g. BP stable with no postural drop Pulse no evidence of tachycardia from compensatory mechanisms or as a result of

anxiety Temperature normal Respiratory rate normal with no signs of dyspnoea Skin normal with no evidence of urticarial rash Pain absent with no pain along IV line, back or chest Urine normal in colour and amount with no evidence of blood due to DIC Chapter 13: Caring for a person requiring palliative care Scenario 13.1 2. Collect cues/ information (b) Gather new information

1. Pain assessment 2. Assessment of nausea/vomiting 3. Medication history 4. Assessment of abdo distention and bowel (elimination) assessment 5. Assessment of fatigue 6. Respirations 7. Family/carer/social supports 8. Mobility assessment 9. Falls assessment 10. Vital signs

(c) Recall knowledge (Quick quiz) 1. f, 2. True; 3. Morphine; 4. Metabolites, 5. T, F, F, T, F, T; 6. b; 7. b, d, h, I, k; 8. e; 9. a; 10. b 3. Process information (a) Interpret – 1. b; 2. a; 3. c (b) Discriminate – Q. g, h, j, k, l


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(c) Relate – Q. T, F, T, F, T, T, T, F, T (d) Infer – Q. b (e) Predict – 1. a, b, c, e; 2. b, e, f, g 4. Identify the problem/ issue – Q. c, e, g 5. Establish goals – 1. a, c; 2. d, f 6. Take action 1. Administer two glycerine suppositories to soften hard rectal stools. 2. Ensure the glycerine suppositories are against the wall of the bowel. 3. Contact Sally’s doctor to discuss her condition and for an order for an enema as

well as oral aperients or laxatives. 4. Administer an enema to clear the faecal impaction. 5. Educate Sally about the importance of adequate fluids, mobility and use of

aperients. 6. Negotiate an action plan in case of further episodes of constipation. 7. Evaluate 1.

Cognitive status Pulse Bowels Oral mucosa Oral intake BP Colour Pain Nausea Vomiting

Patient restless and anxious 90 Good result but sticky stools Mouth is dry and tongue furrowed Tolerating sips of water 110/70 Pale On scale of 10, Sally reports 2 Slight nausea Nil

Unchanged Improved Improved Unchanged Improved Improved Unchanged Improved Improved Improved

2. c Scenario 13.2 1. Consider the patient (Quick quiz) – 1. T; 2. e; 3. c; 4. subcutaneous; 5. terminal restlessness 2. Collect cues/ information (a) Review current information – Q. f (b) Gather new information – 1. b; 2. b


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(c) Recall knowledge – 1. e; 2. False – Advance Care Planning is best implemented early in a patient’s illness when they are able to clearly state what they would like to be done in regards to healthcare when they are no longer able to speak for themselves. 3. Process information (a) Interpret (Quick quiz) – 1. e; 2. F; 3. T; 4. T; 5. F; 6. T; 7. F; 8. T; 9. T; 10. T (b) Discriminate – Q. d, h, k, m (c) Relate – Q. a T, b F, c T, d T, e T (d) Infer – Q. a (e) Predict – 1. b, c, d, e; 2. b, c, d 4. Identify the problem/ issue – Q. b. The provision of medically administered nutrition and hydration (MN&H) for the end-of-life patient is a controversial issue and there has been much debate in the literature concerning it. 5. Establish goals – Q. a 6. Take action – Q. b, c, f

Chapter 14: Ethical and legal dimensions Responses to questions for consideration 2. Collect cues/ information (b) Gather new information Question 1 Your response to this will very likely depend on your skills and experience, and a number of other factors. There is a subtle but significant difference between actually making a no-CPR decision and being involved in the decision-making process. It is important not to conflate the two. Some of the research (Palmer 2007) that has been conducted on this question has shown a disparity between the degree of involvement in the process that nurses feel they should have and that which they actually do have (the latter being much lower). On the other hand, Kerridge, Pearson, Rolfe & Lowe (1998) point out that in some cases patients will not want to be involved themselves, or not want nurses to be involved either. The ideal is a skilful, collegial, multidisciplinary approach – which fully includes the patient (if that is their preference) and family (if that is the patient’s preference) – that is sufficiently able to respond to situations in which the patient’s views about who should be making the decision may not reflect those of the health professionals. Question 2 A reluctance to discuss death and dying is not limited to hospital contexts. A 2011 survey commissioned by Palliative Care Australia found that the majority of Australians had not discussed dying with their loved ones, and despite the fact that most would prefer to die at home the opposite is the reality – most will die in a hospital. Acute hospitals are in the business of treatment and cure, and death can be seen as an admission of failure. It is only relatively recently that health professionals’ education has included skills such as how to communicate appropriately when discussing difficult and sensitive issues with patients. Research has consistently shown over decades that healthcare practitioners are not well trained in discussing advance care planning and do not feel well prepared to do so (Wilkinson, Wenger & Shugarman 2007). Unless a patient raises the issue, the health professional will have to broach it first; and


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this is not by any means an easy thing to do. The difficulties with this conversation aren’t just about needing to know the right things to ask; they are also about when and how best to do the asking. In George’s case there wasn’t a private, quiet place for this to happen, or indeed much time. For a more detailed discussion of the Palliative Care Australia survey, and the issues arising from it, see the MJA insight website <http://www.mjainsight.com.au/view?post=scott-blackwell-let%25e2%2580%2599s-talk-about-death&post_id=6731&cat=comment>. The ACP review by Wilkinson et al. (2007) is a thorough and comprehensive analysis of all the major issues and difficulties associated with making the process of advance care planning actually work in practice. A review of ACP processes in Australia is also available (Street & Ottman 2006). Their first two recommendations are for values-directed discussions among health professionals, patients and families to begin early in the patient’s illness and be embedded in clinical routines; and for there to be a transformation of attitudes and processes in healthcare organisations. Both of these would have been of great help to George and given guidance to Greg and Dr Jones about best practice in situations such as these. Question 3 The barriers identified in this document are time, discomfort in talking about death, patients not wanting to make these kinds of decisions, fears (such as not being able to change one’s mind), lack of knowledge about the process and the implications of particular decisions, and lack of knowledge about the legal standing of an advance care directive. Question 4 This document identifies such things as having detailed, ongoing, timely, focused discussions, in a relaxed, unhurried environment. It advocates having a multi-disciplinary approach, involving someone who really knows and cares about the person, discussing the person’s values and goals as well as prognostic information. It also details standards for documentation, including the fact that a witness, while recommended, is not required. Question 5 This is a complex question that on the face of it looks straightforward. After all, the ‘informed’ part of a valid consent is regarded as crucial. But it is not always as clear that a refusal must also be ‘informed’ and, if so, to what standard? The Victorian Medical Treatment Act (2008) stipulates that the patient must have been informed about ‘the nature of their condition to an extent which is reasonably sufficient to enable them to make a decision’. This accords with a judgment in 2009 in the case Brightwater Care Group (inc) v Rossiter in Western Australia, where the judge placed a great deal of emphasis on the need for Mr Rossiter’s refusal of treatment to have been demonstrably and thoroughly informed. However, in another 2009 case in New South Wales, Hunter and New England Area Health Service v A, Justice McDougall found that ‘it is not necessary, for there to be a valid advance directive, that the person giving it should have been informed of the consequences of deciding, in advance to refuse [treatment]’. In other words, some jurisdictions in Australia require that refusal of treatment be informed, presumably to a standard that the healthcarers are satisfied with, and in New South Wales it appears that patients have the right to be ‘uninformed’ if they so wish, and a specific refusal by a competent adult overrides the common law duty to inform. The common law in New South Wales appears then to support George in saying that healthcarers cannot override his refusal of CPR on the grounds that he has not yet been sufficiently informed of the consequences of doing so. (c) Recall knowledge Question 6 The answer to this is ‘yes… but’. The ‘yes’ arises from legislation in states that have it, or the common law in states that do not. The ‘but’ arises from the complexity of the process and the lack of clarity and organisational support for it. How to first get the decision made (involving everyone who should be involved) then have it communicated to everyone who needs to know, then to have it followed through, and also to be able to change or reverse it if needed … you can see the difficulty. It becomes even more

http://www.mjainsight.com.au/view?post=scott-blackwell-let%25e2%2580%2599s-talk-about-death&post_id=6731&cat=comment

http://www.mjainsight.com.au/view?post=scott-blackwell-let%25e2%2580%2599s-talk-about-death&post_id=6731&cat=comment


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so when the person concerned may not or does not have the legal capacity to decide. For a case involving just such a dilemma, read the incredibly involved case of Mrs AB in Kerridge, Lowe & Mitchell (1995). Question 7 This is another complex question. The doctrine of necessity (allowing treatment without consent in an emergency) theoretically applies only when the person’s wishes about treatment are unknown. However, when a patient has a cardiac arrest, the nurse has only seconds to decide what to do and the consequences of not doing CPR are irrevocable. So it is difficult to see how this doctrine could not be invoked in situations where the person’s wishes were still in the process of being determined. There is also a theoretical conflict between the common law duty of health carers to adhere to the ordinary reasonable standard, and their duty not to commit a battery. The practical reality is that it would be extremely difficult for a patient to sue for battery or negligence arising from surviving unwanted CPR. There have been no wrongful resuscitation law cases thus far in Australia, and only one in the United States (where a nurse instigated CPR on a patient who had a formal no-CPR order) and in that case the judge found in favour of the hospital (Anderson v St. Francis–St. George Hospital). This was on the grounds that the patient had suffered no physical damage from the battery. Therefore, while not impossible, it is highly unlikely that legal consequences would ensue from either performing or withholding CPR in a situation such as this. The question of how clinicians’ fears and perceptions about the possible legal consequences of their actions affect their decisions is quite a different one, however. The epidemiology of in-hospital cardiac arrest Question 8 This issue is essentially about futility and the balance of potential risks and benefits. Futility can be conceptualised in terms of mathematical probabilities, but applying these to individual cases is subjective. Two things are needed: first, a good understanding of the statistical risks and benefits related to CPR, and, second, the ability to assess how these might apply to the unique situation at hand. Not everyone’s concept of what is futile will be the same, no matter what the statistics are. It is also important not to conflate instigating or withholding CPR with other treatments. No-CPR does not mean all treatment can or should be withheld. In this situation, it might be perfectly reasonable for George to have continued treatments for a range of conditions, including prostate cancer, but not have CPR. What the CPR epidemiology does indicate, though, considering his risk factors and co-morbidities, is that George is at the low end of probability of survival to discharge should he have a cardiac arrest, and this should be taken into account when considering his request not to have CPR. 3. Process information (a) Interpret Question 9 They are likely to be highly influential. Exactly how is difficult to determine specifically without gaining direct and honest insight into each person’s thought processes. This is something that we rarely do, even for ourselves, let alone with others. Rather, we espouse the principle that personal values should not unduly influence decisions, and presume that they do not, and that only professional values do. However, there is considerable evidence from the work of Haidt and others that values, culture, strong emotions (and innate intuitions) do have a considerable, but unacknowledged, impact on moral reasoning and decision making. Question 10 This question is for you to consider.

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Clinical Reasoing Cycle Textbook Answers Tracy-Levett Jones