PLEASE LOOK AT ALL FILES attached case study etc

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PLEASE LOOK AT ALL FILES attached case study etc


Set the scene: You are the new grad RN on nightshift in the acute medical unit. The patient was transferred from the emergency department (ED) to the acute medical unit at 06:00 this morning. You have completed the first set of observations and assessments (recorded on the electronic charts attached). Meet your patient: Maria Smith, 79-year-old-female. Maria presented to ED last night with worsening dyspnea, fatigue, dizziness and orthopnea for the past five days (5/7). The working diagnosis is suspected Heart Failure. Maria takes levothyroxine 100mcg daily to treat Hashimoto’s, which she was diagnosed with in 1995, around the same time as her older sister. She takes perindopril 5mg daily to treat her hypertension, metformin XR 1000mg nocte to treat her type 2 diabetes mellitus and Crestor 5mg to treat her high cholesterol, which was diagnosed in 1998. Citalopram for depression. Maria had three elective caesarean sections in the 1970s and her gall bladder removed in 2005. Around the same time, she went through menopause and gave up smoking cigarettes. She reports no allergies to food or medication. Maria lives at home with her elderly husband, Bill. Their youngest daughter, who lives nearby, brought Maria to the hospital as Bill called her and told her Maria was feeling crook. They manage the cooking and cleaning between themselves, but Maria admits she does it for the most part. She walks with her daughter three times per week but has not tolerated this in the past few weeks. On appearance this morning, Maria sits upright in the bed, propped up on two pillows. She speaks to you in full sentences but reports feeling ‘puffed’ and having a ‘bothering cough’. Maria is using her accessory muscles to breathe. However, she is alert and responds appropriately to all your questions. She is worried about how Bill will cope at home without her. The team has ordered Transthoracic echocardiogram and Chest x-ray today. The doctor has written a pathology order for Urea, creatinine and electrolytes (EUC), Full Blood count (FBC), Blood urea nitrogen (BUN), Liver function test (LFTs) and Thyroid stimulating hormone. Assessment requirements  digital presentation Relevance  Nurses need to demonstrate effective and appropriate communication skills with clinical handover to provide high quality patient-centred care.  This assessment provides the opportunity to demonstrate your understanding of clinical handover, patient assessment and care planning. Task instructions Create a narrated PowerPoint presentation of a clinical handover based on the clinical case scenario below. Your presentation should include 1. the ISBAR handover structure 2. Five evidence-based nursing recommendations for a plan of care Look at all scenarios and files ECG file look at all 06:00hrs 12 lead ECG on arrival to the ward:. Suggested procedure 1. Review your course content and any extra materials on managing a patient with heart failure. 2. Read the clinical case scenario and electronic charts. 3. Formulate the ISBAR handover based on the case scenario, electronic charts chest auscultation and ECG. Create one slide for each component of the handover. ISBAR stands for · Introduce yourself & Identify the patient · Explain the situation · State the medical/surgical/psychosocial history · Systematically state your assessment findings (use the A-H approach) · Make recommendations for the patient care plan 4. Record your handover using PowerPoint (record your voice only). Support your five (5) nursing recommendations for the care plan with citations of evidence-based literature. Add a Reference list slide. Presentation guidelines Time: 5 minutes +/- 10% (30 seconds) Submission: Use the 'Turnitin' submission point to submit a MP4 file of your recording this should include PowerPoint slides with your voice embedded. Only a recording of a MP4 file will be accepted. Referencing: use CDU APA 7th Referencing Style 2023  You must use scholarly sources each for your nursing recommendations. Do not use websites. You will be deducted marks in academic convention and argument. Minimum 5 references. Support for this assignment Research: contact a CDU librarian for guidance. Review the content of the Nursing Libguides on the Library website. Academic Skills: contact a Language and Learning Advisor for support ) co ADULT(� 12 YEARS) OBSERVATION CHART Modifications in Use □ Date: Neurological □ Obervations Required Time: Write> 40 40 Respiratory Rate 35 (breaths/ min) 30 ( . ) 25 20 If respiratory rate > 40 or 15< 5="" write="" value="" in="" box="" 10="">< 5="" 5="" 02="" saturations="" (%)="" 98="" (%)="" 96="" 94="" (="" .="" )="" 92="" if="" 02="" saturation="">< 88="" 90="" write="" value="" in="" box="">< 88="" 88="" 0="" 2="" delivery="" oxygen="" delivery="" mode="" ra="Room" air="" np="Nasal" prong="" �="" hm="Hudson" mask="" vm="Venturi" mask="" oxygen="" flow="" rate="" nrb="Non-Re-breather" hf="High" flow="" (l="" per="" min/="" fio2)="" write=""> 200 200 Blood Pressure 190 (mmHG) 180 Score Systolic BP 170 160 t 150 140 I 130 ( I ) 120 I 110 I 100 90 ' 80 70 If Systolic BP > 200 or 60< 50="" write="" value="" in="" box="">< 50="" 50="" write=""> 140 140 Heart Rate 130 (beats I min) 120 110 100 ( . ) 90 80 70 If heart rate > 140 or 60< 40="" write="" value="" in="" box="" 50="">< 40="" 40="" write=""> 39 39.0 Temperature 38.5 ( oc) 38.0 37.5 ( . ) -----------------37.0 - If temperature> 39.0 or 36.5 36.0< 35.5="" write="" value="" in="" box="">< 35.5="" 35.5="" urine="" output="" (="" •="" )="" hpu="">< 6hrs=""> 30 mis/hr HNPU > 6hrs / < 30="" mis/hr="" awake="" alert="" level="" of="" conscious="" asleep="" responds="" to="" stimuli="" easy="" to="" rouse="" (="" .="" )="" cannot="" remain="" awake="" difficult="" to="" rouse="" pain="" score="" at="" rest="" with="" activity="" o="" none="" 10="" worst="" lntervention(s)="" write="" number="" e.g.="" 1="" comments="" principal="" name="" other="" name(s)="" d.o.b.="" hrn="" sex="" v="" --="" -="" -="" v="" -="" --="" -="" v="" ----="" v="" ---="" page="" 1="" of="" 6="" patient="" label="" address="" must="" be="" documented="" if="" patient="" details="" hand="" written="" v="" ----="" v="" ----="" v="" v="" ---="" i/="" ----="" i/="" ----="" i/="" ----="" i/="" iv="" -="" -="" --="" v="" ---="" v="" ----="" v="" ----="" v="" ----="" v="" --="" --="" iv="" i="" ;�="" l="" -="" -="" -="" i/="" ii="" ii="" l'="" show="" the="" trend:="" plot="" t1="" np="" 4l="" xx/xx="" 06:00="" l="" y="" i="" n="" g="" s="" t="" a="" n="" d="" i="" n="" g="" case="" study="" for="" isbar="" maria="" smith="" 4/254="" president="" avenue="" sutherland="" nsw="" 2232="" 07/11/1944="" hrn="" 222222="" ^="" i="" i="" v="" i="" i="" v="" ^="" principal="" name="" other="" name(s)="" d.o.b.="" patient="" label="" hrn="" adult(�="" 12="" years)="" sex="" observation="" chart="" address="" must="" be="" documented="" if="" patient="" details="" hand="" written="" pivc="" insertion="" record="" instructions:="" the="" pivc="" must="" have="" a="" vip="" assessment="" and="" patency="" check="" a="" minimum="" of="" once="" per="" shift="" (i.e.="" 3="" times="" in="" 24="" hours).="" for="" patency="" document="" yes="" or="" no="" (y="" or="" n).="" for="" vip="" score="" refer="" to="" the="" guide="" below.="" for="" removal="" code="" refer="" to="" guide="" below.="" insertion="" record="" insertion="" record="" date="" inserted:="" name:="" date="" inserted:="" name:="" time="" inserted:="" signature:="" time="" inserted:="" signature:="" insertion="" site:="" number="" of="" attempts="" 1="" 2="" 3="" 4="" insertion="" site:="" number="" of="" attempts="" 1="" 2="" 3="" 4="" cannula="" size:="" reason:="" cannula="" size:="" reason:="" date:="" date:="" shift="" m="" l="" n="" m="" l="" n="" m="" l="" n="" m="" l="" n="" shift="" m="" l="" n="" m="" l="" n="" m="" l="" n="" m="" l="" n="" l="" y="" i="" i="" i="" i="" i="" i="" i="" i="" i="" i="" i="" v="" l="" y="" v="" v="" i="" v="" v="" v="" i="" i/="" i="" v="" v="" vsign:="" sign:="" removal="" record="" removal="" record="" date="" i="" time="" i="" removal="" code:="" date="" i="" time="" i="" removal="" code:="" name:="" i="" signature:="" name:="" i="" signature:="" insertion="" record="" insertion="" record="" date="" inserted:="" name:="" date="" inserted:="" name:="" time="" inserted:="" signature:="" time="" inserted:="" signature:="" insertion="" site:="" number="" of="" attempts="" 1="" 2="" 3="" 4="" insertion="" site:="" number="" of="" attempts="" 1="" 2="" 3="" 4="" cannula="" size:="" reason:="" cannula="" size:="" reason:="" date:="" date:="" shift="" m="" l="" n="" m="" l="" n="" m="" l="" n="" m="" l="" n="" shift="" m="" l="" n="" m="" l="" n="" m="" l="" n="" m="" l="" n="" l="" ;y="" i="" i/="" i="" i/="" i="" i="" v="" v="" v="" i="" v="" v="" l="" 1cy="" i="" i="" v="" v="" i="" i="" i="" v="" v="" i="" i="" i="" sign:="" sign:="" removal="" record="" removal="" record="" date="" i="" time="" i="" removal="" code:="" date="" i="" time="" i="" removal="" code:="" name:="" i="" signature:="" name:="" i="" signature:="" visual="" phlebitis="" score="" observation="" pivc="" site="" appears="" healthy="" 1="" of="" the="" following="" is="" evident="" •="" mild="" discomfort="" at="" iv="" site="" •="" mild="" erythema="" at="" iv="" site="" 2="" of="" the="" following="" is="" evident="" •="" discomfort="" at="" iv="" site="" •="" erythema="" •="" swelling="" (induration)="" 3="" or="" more="" of="" the="" following="" are="" evident:="" •="" pain="" along="" path="" of="" cannula="" •="" erythema="" •="" swelling="" i="" pus/discharge="" •="" pyrexia="" (="">37.8°C) I 4 Severe local signs of Phlebitis • Pain along path of cannula • Erythema • Swelling • Palpable venous cord • Pus/discharge Pyrexia (>37 .8°C) Score 0 2 3 4 Management No Signs of Phlebitis Continue to observe and document every shift Possible first signs of phlebitis Continue to observe and document every shift Early stages of phlebitis • Remove and replace cannula to an alternate site • Complete Riskman Phlebitis • Remove and replace cannula to an alternative site • Send pus swabs for MC&S • Commence wound chart • Complete Riskman ____ ___;=======;;;;___, Advance Stage of Phlebitis • Immediate removal of cannula • If pyrexic above 37 .8°C take blood cultures • Send pus swab for MC&S • Inform Medical Officer• Complete Riskman • Commence Wound Chart Page 6 of 6 PIVC Removal Codes E Removal@ 72 hours V VIP Score �2 B Blocked Other, 0 Please Document Reason D Dislodged N No Longer Required XX/XX/XX XX:XX L)ACF 18G E.DELAHUNTY TODAY 0 ED Highlight Maria Smith 4/254 President Avenue Sutherland NSW 2232 07/11/1944 HRN 222222 ADULT(� 12 YEARS) OBSERVATION CHART Principal name Other name(s) D.0.8. HRN Sex Patient Label Address must be documented if patient details hand written Date: T ime: 40 35 30 25 20 15 10 5 98 96 94 92 90 88 Wri te > 40 Write< 5="" wri="">< 88="" oxygen="" delivery="" mode="" oxygen="" flow="" rate="" (l="" per="" min/="" fio2)="" 200="" wri="" te=""> 200 190 -----------i 180 - - -----I 170 -----------i 160----------1 150 --------1 140 --------1 130 - - ----- 120 --------1 110 --------1 l----+---+----l--+------1---+---+---+--+------1f----+--+---+---t-----if---t---+---+--+------if---t---+---+ 100 --------1 90 80 70 60 50 Wri te< 50="" 1------1-----1-----1---+---1----1-----1-----+--+---1------t="" --+---+--+---t----+="" --+---+--+--t----+--+---+-="" 140="" _="" _="" w_ri="" t_e_="">_14_0 _ _____. r---+----1----1--+--1----+----l---+--+--i-----+--+---+--+--l----+--+---+--+--I-----+--+---+ 130 -----------i f---l-----l-----4----l--l----1-----1-----+--+---1----l---+---+--+---t----+--+---+--+--I----+--+---+- 120 -----------i r---+----+---+----< 40="" :!..---+----1----1---1--1----+--+--+--+--1----+--+---+--+--t----+--+---+--+--t----+--+---+="" 39_0="" __="" w_r_i="" t_e_="">_3_9 _.0 _ ___. ;..._----1-----l----l--+--l----+--+--+--+--l-----+--t---+--+--i----+--+---+--+--I----+--+---+ 38.5 - - ------t '-----+---+----l--+------1---+---+---+--+-----if---t---+---+---t-----if---+--+---+---t-----i--+--+--+ 38.0 --------t '----1-----l-----+--+---l----1-----1-----+--+---l----+--+---+--+---t----+--+---+--+---I----+--+---+ 37 .5 ----------< 37.0="" -------------------="" ----1---+--+----+----+---+--+----+----+----+--t---+--+--+-----il---+--+--+------i--t---+--+---+="" 36.5="" -------="" ---1-----1-----4--+---l----+--+---+--+---l----+--+---+--+---t----+--+----+--+---t-----+--+---+="" 36.0="" -="" -------1="" 1---+----1----1-="" -="" +--1--="" --+--+--+--+--1-----+="" --+---+--+--="" 1---+="" -="" ---+-="" --+--+--f---+="" -="" -+-="" -="" -+="" 35·5="" --="" w-r="" -i="" t="" _=""><_3 _="" 5="" _="" _="" _="" 5_----i="" he="" dot="" -="" join="" the="" line="" page="" 2="" of="" 6="" hpu="">< 6="" hrs="" �="" 30="" mis/hr="" hnpu=""> 6 hrs / < 30 mis/hr awake / alert asleep responds to sti muli easy to rouse cannot remai n awake diffi cult to rouse at rest / wi th acti vi ty 0 = none 10 = worst wri te number e .. 1 principal name other name(s) d.o.b. patient label hrn adult(� 12 years) observation chart sex address must be documented if patient details hand written modifications (maximum duration 24 hours) respiratory rate (breaths / min) rat call *** clini cal review no res onse start date & time duration si nature 0 2 saturation(%) art call *** cli ni cal revi ew no res onse start date & ti me durati on si nature blood pressure mmhg rrt call *** cli ni cal revi ew no res onse start date & ti me durati on si nature heart rate (beats/ min) rrt call cli ni cal revi ew no res onse start date & ti me duration si nature temperature ( 0c ) cli ni cal revi ew no res onse start date & ti me durati on si nature level of conscious rrt call *** cli nical revi ew no res onse start date & ti me durati on si nature comments action required rapid response team call * * * response criteria • any observation in a purple area • 3 or more observati ons i n pink area at the same time • you or fami ly members are worried about the patient but 30="" mis/hr="" awake="" alert="" asleep="" responds="" to="" sti="" muli="" easy="" to="" rouse="" cannot="" remai="" n="" awake="" diffi="" cult="" to="" rouse="" at="" rest="" wi="" th="" acti="" vi="" ty="" 0="None" 10="Worst" wri="" te="" number="" e="" ..="" 1="" principal="" name="" other="" name(s)="" d.o.b.="" patient="" label="" hrn="" adult(�="" 12="" years)="" observation="" chart="" sex="" address="" must="" be="" documented="" if="" patient="" details="" hand="" written="" modifications="" (maximum="" duration="" 24="" hours)="" respiratory="" rate="" (breaths="" min)="" rat="" call="" ***="" clini="" cal="" review="" no="" res="" onse="" start="" date="" &="" time="" duration="" si="" nature="" 0="" 2="" saturation(%)="" art="" call="" ***="" cli="" ni="" cal="" revi="" ew="" no="" res="" onse="" start="" date="" &="" ti="" me="" durati="" on="" si="" nature="" blood="" pressure="" mmhg="" rrt="" call="" ***="" cli="" ni="" cal="" revi="" ew="" no="" res="" onse="" start="" date="" &="" ti="" me="" durati="" on="" si="" nature="" heart="" rate="" (beats/="" min)="" rrt="" call="" cli="" ni="" cal="" revi="" ew="" no="" res="" onse="" start="" date="" &="" ti="" me="" duration="" si="" nature="" temperature="" (="" 0c="" )="" cli="" ni="" cal="" revi="" ew="" no="" res="" onse="" start="" date="" &="" ti="" me="" durati="" on="" si="" nature="" level="" of="" conscious="" rrt="" call="" ***="" cli="" nical="" revi="" ew="" no="" res="" onse="" start="" date="" &="" ti="" me="" durati="" on="" si="" nature="" comments="" action="" required="" rapid="" response="" team="" call="" *="" *="" *="" response="" criteria="" •="" any="" observation="" in="" a="" purple="" area="" •="" 3="" or="" more="" observati="" ons="" i="" n="" pink="" area="" at="" the="" same="" time="" •="" you="" or="" fami="" ly="" members="" are="" worried="" about="" the="" patient="">
Answered 2 days AfterAug 28, 2024

Answer To: PLEASE LOOK AT ALL FILES attached case study etc

Dilpreet answered on Aug 30 2024
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Introducing new grad RNs and identifying patient
The patient who was transferred from the emergency unit to the acute medical unit, is Maria Smith, a 79-year-old female, with a critical history of medical condition. She was diagnosed with dyspnoea, dizziness, and fatigue in the medical unit which suggested that she had a heart failure (Albert et al., 2010). Apart from that, during this medical assessment and thorough check-up, it has been identified that she has a much longer list of some critical medical conditi
ons such as high cholesterol, hypertension, type 2 diabetes mellitus, Hashimoto’s thyroiditis and depression over the years. It has also been assessed that due to her past medical conditions, the suggestion of her heart failure can be worsened in nature. As a newly appointed registered nurse, I have already completed assessing Maria’s condition and past medical records in a well-mannered way. In this regard, I think I must take care of Maria effectively. Though she is admitted to the medical unit for her health, she is constantly worried about her husband Bill in managing household chores. As a nurse, it is my responsibility to provide her comfort, and assurance along with monitoring her condition to plan an effective care system for Maria.
Situation
Maria Smith, a 79-year-old elderly female, was transferred from the ED (Emergency Department) to the acute medical unit at 6 AM sharp this morning. For context, Maria was presented to the emergency unit last night for her worsening fatigue, dyspnoea (sudden shortness of breath), orthopnoea (facing difficulty in breathing while lying down, flat) and dizziness (Mebazaa et al., 2010). It was also recorded that she has been struggling with these burdening conditions for the last five days. These heightened symptoms critically hurt her ability to be involved in daily activities, such as managing household chores and walking. The initial working diagnosis made at her admission was suspected of heart failure. Though not confirmed this condition needs careful and immediate management to eliminate any possible deterioration.
On her arrival at the acute medical care unit, Maria was seated upright, supported by two pillows, in bed. This indicates she was quite comfortable in that semi-upright position due to having problems breathing (i.e., especially when lying flat). This also reduced the discomfort caused by orthopnoea, which is common in patients with heart failure (Mebazaa et al., 2010). It is critical to mention that Smith was able to respond in full sentences. However, she also reported a feeling of ‘puffiness’ and trouble with ‘bothering cough’. This indicates a fluid overload, common with heart failure condition. As a newly graduated Registered Nurse (RN), I observed that Maria was using her accessory muscles to breathe properly. This clear sign of respiratory distress can be an indication of worsening heart failure, encouraging pulmonary congestion, which eventually causes breathing difficulties. However, Maria was oriented and alert as she was responding to primary assessment questions. This suggests the adequate oxygen level in her cerebral.
Apart from this primary clinical situation, Maria expressed anxiousness about Bill, her husband. As an elderly husband, Bill was dependent on Maria for most of the household tasks. Their youngest daughter brought Maria to the hospital last night and at present the father-daughter duo is managing to complete the household chores on their own, including cleaning and cooking. This sudden burden concerns Maria as she is worried about how they will cope without her. Mari also added that she used to walk with her daughter thrice a week; however, it has been tough for her to continue the walk for the last few weeks. I also found that this tension of not being able to help her family is adding extra psychological distress to her situation, impacting her overall recovery and well-being.
In summary, the present situation of Maria presents a complex and suspected case of risky heart failure. This primary concern is coupled with respiratory distress which also suggests underlying chronic medical conditions that need urgent care, monitoring and management. Judging these, the medical team has advised a series of tests. First, a chest X-ray and “transthoracic echocardiogram”, to rule out potential causes and severity of heart failure (Siew et al., 2022). Second, some pathology tests to monitor her electrolyte balance, renal function, thyroid status and liver function.
Medical/Surgical/Psychosocial history
Being a 79-year-old woman, Maria Smith possesses a complex surgical, medical and psychological history that contributed to her present health status. Diagnosed with different chronic conditions Smith has been under strict medication routine and lifestyle adjustments. This demonstrates her commitment and resilience toward maintaining health.
Medical History: Maria Smith has a very critical and complicated medical history as she was diagnosed with certain health issues that worsened her physical health simultaneously. First and foremost, Maria has Hashimoto's thyroiditis which is a rare kind of autoimmune disease. The symptoms of this disease are extreme fatigue, dizziness, uncontrollable weight gain and slow rate of heartbeat (Yuan et al., 2023). While conversing with her, it has also been known that her sister also has the disease. Previously, to reduce the symptoms of this disease, doctors have prescribed her to take levothyroxine in terms of maintaining her daily physical...
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