Assessor Instructions

1. Mr Hardy has ‘hypertension’ which means high blood pressure. List the parameters for a ‘normal’ blood pressure range and the ranges for hypertension.
2. The normal blood pressure range parameters are 120/80 mmHG.

The blood pressure range for a person to have hypertension includes higher than 140/90 mmHG.

1. You have performed vital signs on Mr. Hardy, they are;

• BP135/ 90mmHg, RR 26bpm, P 95bpm, T 40^o

If the observations listed below are considered the normal for adults, identify which of these observations are variations from normal levels that have the potential to cause problems with Frank’s health.                              

T: 36.2 – 37.3^oC

P: 60 – 100bpm

RR: 16 – 24bpm

BP: 120/80mmHg

As per the normal and healthy vital signs that have been listed below, the abnormal vital signs of the patient that that can have a potential to cause problems with Frank’s health includes BP being 135/90 mmHG which indicates both systolic and diastolic pressure to be high of the patient indicating that the patient can have hypertension (Wang et al., 2013). The respiratory rate is also slightly high which can lead to pulmonary hypertension and shortness of breath as well. The body temperature of the patient is also high of the patient indicating the patient to be febrile.

1. The term pathophysiology explains the processes and functioning within the body which result in the signs and symptoms of a disease/s. The ‘relationship’ between body systems is the contributing factor/s that work together in our bodies to try and maintain homeostasis. Explain the relationship between Mr Hardy’s respiratory rate and temperature.

There is a significant relation between the temperature and breathing rate of a person. With the rise in the body temperature, the rate of respiration also increases proportionately due to the body heat accelerating the metabolic and physiologic reaction processes indicating at higher kinetic energy; this in turn enhances the cellular respiration rates (Meredith et al., 2012). In this case as well, as the body temperature of Mr Hardy was high it sped up the cellular respiration rate as well.

Identify your scope of practice in this situation. List your role responsibility in comparison to a Registered Nurse (RN) role.

As an enrolled nurse, my scope of practice will be limited to patient assessment, contribution to plan of care, implementation, and evaluation of care under the supervision of the RN. On the other hand, the registered nurse will have the full responsibility of patient care planning and implementation and supervising the ENs. Although, as an EN, I will not be able to administer IV fluids to the patient, which falls under the scope of practice of a registered nurse only.

As an Enrolled Nurse, identify the reporting hierarchy that you would follow in order to ensure that this information is relayed appropriately.

As an enrolled nurse, the reporting hierarchy for me will be first my registered nurse, followed by my nursing supervisor, and then the physician.

1. Explain and discuss the following three (3) health care professionals’ scope of practice/role in the care and management when referred to Mr. Hardy.

• Dietician
• Physiotherapist
• General Practitioner (GP)
• Dietician: As the patient has a risk of stroke and hypertension, the dietician will be able to provide a strict low fat and low sodium diet plan in collaboration with the patient to be able to control the high blood pressure

• Physiotherapist: The physiotherapist will be able to collaborate with the patient to help the patient start a strict exercise regimen that will help the patient lose weight and keep his blood pressure in check as well.

• GP: The general practitioner will investigate the underlying reason behind the high blood pressure and risk of stroke for the patient and decide both pharmacological and non-pharmacological treatment options.
• Hardy has a significant medical and social history. From the case study list four (4) potential factors that could have been responsible for the CVA (stroke). In your answer ensure that for each factor you provide a brief explanation of how/why it could have impacted on Mr. Hardy’s current condition. 

1. Age: with older age, the risk for cerebrovascular accidents are higher, especially over the age of 55. As the patient had been 68, it can be a significant risk for stroke to the patient
2. Gender: Stroke risk factors have been reported to be at least 1.25 times higher in the men which can be for Mr hardy
3. Heredity: genetic predisposition is also a very significant risk factor for stroke (Bandemer et al., 2014)
4. Smoking: a prolonged history of smoking has been identified as a string risk factor for stroke
5. Obesity: obesity is critically linked with coronary arterial diseases and is a significant risk factor for stroke as well.
6. A functional deficit is a sign or a symptom associated with an illness in a body system or a variation from normal. These functional deficits can also be identified as potential risk factors when performing an intervention. Mr. Hardy has several of these risk factors. Using correct medical terminology, list two (2) potential deficits associated with Mr Hardy’s CVA.

1. Mobility restriction 

1. 2. Lack of personal hygiene

1. As per organisational policy you are taking blood from Mr Hardy for his routine tests. When finished you note that you leave his arm with a large contusion (bruise). Identify the term used to describe complications that are caused by treatment from healthcare professionals. 

Any complication to the patient that can be caused by the treatment received from the health care professionals can be broadly classified as medical errors. 

End of section one

Case Study 2

Scenario 2 – Mrs. Heather Bishop  (Questions 10-17 refer to this scenario)

Mrs Heather Bishop is an eighty (80) year old woman who is living in the residential aged care facility you are working in. Before meeting her you quickly review her chart for her medical and social history: Medical History: ·         Weight 50Kg ·         Height 170cm ·         80 years old ·         Menopause at 38yrs of age ·         Osteoporosis   Social History: ·         Widowed (10 years ago) ·         1 Daughter that visits regularly   She is mobile with a walking frame and supervision, however has had difficulty hearing lately. Mrs Bishop is orientated and alert, and she has no cognitive deficits. As Mrs Bishop walks to the shower, she states that she is ‘dizzy’ and loses her grip on her walking frame. She falls on her right side, you call for help, make her comfortable and take a set of observations; ·         BP: 110/60mmHg, T: 36.5oC, P: 100bpm, RR: 28bpm You are assisted by colleagues to move her back to the bed, then the resident doctor arrives. The doctor diagnoses a fractured hip, at the neck of femur (NOF). Mrs Bishop is transferred to a hospital for further treatment and investigations.

1. If the observations listed below are considered the normal parameters (range) for adults, identify Heather’s abnormal observations.

T: 36.2 – 37.3^oC

P: 60 – 100bpm

RR: 16 – 24bpm

BP: 120/80mmHg

As per the vital signs that have been presented in the case study of Heather, her abnormal observations include respiratory rate (high at 28 bpm) and blood pressure or BP (low at 110/60 mmHG indicating hypotension)

1. Consider Mrs Bishop’s recent hearing loss. Identify and briefly explain the pathophysiology of the degenerative ear condition that commonly causes hearing loss. 

The most common cause to degenerative hearing loss in the adult population is due to the presbycusis which is facilitated by a degenerative series of changes or deterioration in the auditory system of the elderly patients associated with age derived deformities observed in the body. This particular condition generally affects the patients within the age group of 55 to 65 and deteriorates gradually further reducing the hearing capacity of the patient with time (Rariy, Ratcliffe & Weinstein, 2012).

1. Mrs Bishop has a significant medical and social history. From the case study list four (4) potential risk factors that could have been responsible her osteoporosis.

1. Age: Age can be considered the first risk factor associated with osteoporosis, as the patient had been 80 year old, the risk is extremely high
2. Gender: women over the age group of 50 are of extreme high risk to osteoporosis
3. Body weight: women with lesser body weight are more at risk with osteoporosis.
4. Early menopause is another great risk to osteoporosis and it is present in case of Heather as well. 

1. Discuss the pathophysiology of osteoporosis and relate this to Mrs Bishop’s fractured Neck of Femur (#NOF). 

Reasonable Adjustment

Reduced skeletal mass that has been facilitated by the imbalance between bone resorption and bone formation is the main pathophysiology of osteoporosis. However, neck of femur or any femoral neck fractures have been reported to be accelerating the development of osteoporosis as well due to impairments in bone mass (Tufail et al., 2015).

1. Mrs Bishop must have a surgical repair of her fracture; this means some care will be referred to other health carers. Explain and discuss the following three (3) health care professionals’ roles, within the multidisciplinary team in regards to Heather’s care and management whilst in hospital.

• Orthopaedic Surgeon
• Physiotherapist
• Radiologist

• Orthopaedic surgeon:

The orthopaedic surgeon could help with further diagnosis and management of the condition of Mrs. Bishop as she had fractured her femur. The method which could be followed by the surgeon over here for treatment of the fractured femur is intermedullary nailing where specially designed metal rod is inserted in the canal of the femur

• Physiotherapist:The physiotherapist could help in restoring the normal movement pattern within the patient after the formative treatment has been provided to the patient.

• Radiologist:

The radiologist helps in accessing bone position followed by dislocation with the help of techniques such as X-rays. The position of the displaced bones or the extent of the fracture is accessed from the X-ray reports

1. A functional deficit is a sign or a symptom associated with an illness in a body system or a variation from normal. These functional deficits can also be identified as potential risk factors when performing an intervention. Using the correct medical terminology identify two (2) main functional deficits in Heather’s body systems necessitating nursing care and or monitoring.

A: The two functional deficits which have been identified for Mrs. Bishop are- Osteoporosis and difficulty in hearing. Therefore, before planning the best next step in the care planning the prevalent health conditions of the patient needs to be taken into consideration.

1. Osteoporosis- The patient already had osteoporosis, which means that she had less bone density along with brittle bones. Hence, the nurses should ensure that they apply sufficient safety features while application of physiotherapy techniques to the patient.
2. Hearing difficulty- the patient also has hearing difficulties which could serve as a barrier in the planning and implementation of the care process. Therefore, the nurses need to ensure that the family members of the patient are involved in the care planning process (Jimenez-Herrera & Axelsson, 2015). This could help in ensuring that the specific loopholes are surpassed while designing the care plan as well as the policies of informed decision making is practised.
3. You assess Heather’s reported pain level and note that it is a 9/10 and she is not due for medication. This is an abnormal result and potentially a very serious issue. Consider your scope of practice as an EN and within organisational requirements. Identify the reporting hierarchy that you would follow in order to ensure that this information is relayed swiftly and action taken.
4. A: It was found that Mrs. Bishop was high on pain and required immediate medication   strategies. She recorded a 9/10 for pain, which was considered as a potentially serious issue. Therefore, as an enrolled nurse I need to abide by the regulations as stated in the Nursing Midwifery Board of Australia.  Hence, before the administration of the prescribed medication to the patient I need to ensure that the matter is followed up by a practising physician. Additionally, I need to ensure that the back history of the patient is taken into consideration for the presence of some form of allergies or the other. This helps in the designing of the effective Medicare plan for the patient.

1. Mrs Bishop is ordered a high dose of a strong pain killing medication to be given orally. Consider your basic pharmacology and pharmacokinetics in Mrs Bishop’s situation. List three (3) factors specific to Mrs Bishop that may affect therapeutic levels.

Some of the factors which could affect the therapeutic levels in Mrs. Bishop are low blood pressure, age, presence of relevant drug allergies. The pharmacokinetics and pharmacodynamics of a medicine are hugely dependent upon the age of the patient.

1. The dosages of the medicines are adjusted as per the age of the patient. Since the patient was an 80 years old lady, she may be having less resilience. Therefore, the pain could become aggrieved within the patient, which calls for the administration of strong painkillers to the patient .

1. The patient also depicts a slightly low blood pressure over here, which could affect the pharmacodynamics of the medicine. The low orthostatic pressure could result in improper distribution of medicines (Jennings, Clifford, Fox, O’Connell & Gardner, 2015). 

1. The enrolled nurse should also take into consideration the presence of any drug allergies within the patient. As suggested by O’Beirne et al. (2018), the plausible reaction caused by particular kind of drugs could initiate a negative feedback where some of the pharmacokinetics of the some of the medications may be affected, as they may not reach full potential.

Case study 3 – Mrs Jane Trenton (questions 18-25 refer to this scenario)

Mrs Jane Trenton is an 85 year old woman who has just returned to the residential care facility from a ten (10) day hospital stay for dehydration caused by gastroenteritis (vomiting and diarrhoea). You review her chart and find the following: Medical History: ·         Weight 65 Kg ·         Height 150 cm ·         Age 85 yrs. old ·         Urinary incontinence Social History: ·         Partner in care also in facility (different area, dementia ward) ·         Five (5) children in different states ·         Enjoys social activities at the facility   On admission you perform a full integumentary assessment and vital signs as per organisational policy. Her vital signs are; ·         BP 110/80mmHg, P 65bpm, R 20bpm, T 36.5oC ·         Urinalysis pH- 5, SG- 1010, Glucose- Neg, Ketone- Neg, Protein- Neg, Leukocytes- Neg, Blood (RBC’s)- Neg   On inspection of Jane’s skin you find an area of erythema (dark red in colour) that does not blanch (go white) when gently pressed. The area, over her left hip is raised but the skin remains intact. This appears to be a pressure injury. Jane appears to be in some pain as you move her and gently touch the red area. Mrs Trenton is not usually independently mobile and requires assistance for transfers and a wheelchair to move around in. When in bed she needs to be frequently turned to prevent pressure injuries.   In consultation with the RN you dress the area to prevent further pressure and Jane’s care plan documentation is adjusted to reflect 2nd hourly turns. You ensure that Jane has a clean, dry continence pad on before settling her into her chair.

 

1. The following are considered normal values for urinalysis:

• pH6- 8, SG-1.015- 1.030, Glucose- Neg, Ketone- Neg, Protein- Neg, Bilirubin- Neg, Nitrites- Neg, Leukocytes- Neg, Blood (RBC’s)- 2-3HPF (Clarke et al, 2016)

Identify which of Mrs Trenton’s urinalysis results are considered a variation of normal and a potential risk for poor skin integrity

A: Some of the features which are highlighted from the urine analysis of the patient   are the presence of pressure injuries. The pressure injuries are mainly developed due to improper filtration of the kidneys.  There is an increased risk of the development of pressure injuries due to urine incontinence. The pressure injuries can also results in poor skin integrity. 

1. The skin is the largest organ in the body and has a surface area of 1.5 -2m² in an adult. Identify four (4) functions of the integumentary system.

A: The integumentary system consists of the following vital parts such as – skin, nails, glands and nerves. They act as the preliminary line of defence which prevents the body from the outside world. It functions to retain body fluids, protect against disease, regulate body temperature and eliminate waste products.

 Some of the functions of the integumentary system are-

• Protect the body’s internal tissues and organs
• Prevention against dehydration
• Prevents the body  against  abrupt changes in temperature
• Helps dispose of waste materials through  

1. When functioning normally the skin comprises of three layers, the epidermis, dermis and subcutaneous tissue. Mrs Trenton has a pressure injury that threatens to progress into her dermal layer. Identify four (4) structures found in the dermis.

A: The four structures found in the dermis are- nerve endings; sweat glands, hair follicles and blood vessels.

1. Nerve endings- the nerve endings help in the reception and the transfer of the stimulus such as touch, pain, heat etc
2. Sweat glands- the sweat glands help in the removal of toxic and nitrogenous waste through sebum secretion. 

1. Hair follicles- the hair follicles are rooted deep into the skin which serves as the growth point 

1. Blood vessels- the blood vessels provide nutrients to the skin and helps regulate the temperature of the body.

1. Pressure injuries can be caused by different factors. In Jane’s case the cause was likely to be pressure from decreased mobility whilst in hospital. Identify two (2) other potential risk factors for Jane that could be responsible for her pressure injury.

A: Some of the other potential risk factors which were responsible for the development of pressure injuries within the patient are- poor blood circulation and kidney disease. For instance, the patient here reported low blood pressure leading to poor blood circulation. In addition, the patient had reported urine incontinence which could be due to poor performance of the kidneys (Rahmqvist Linnarsson, Benzein & Årestedt, 2015).  Some of these could lead to increased chances for the development of pressure ulcers.

1. Mrs Trenton is 85 years old. As people age their bodies change and normal function can be compromised. Explain the degenerative changes that occur to the skin as a result of ageing.

A: Due to ageing a number of changes may be brought about within the skin surface of the patient such as thinning, drying, and wrinkling along with uneven pigmentation. The physiological changes brought about within the skin surfaces include changes in permeability, biochemistry, vascularisation, neurosensory perception may also be changed.  With old age the tenacity and flexibity of the skin is also changed which results in the development of wrinkles.

1. In order for wounds to heal certain conditions need to be met both locally and systemically. Identify two (2) local and two (2) systemic conditions that would delay wound healing. 

Local 

1. Chemical stress- the chemical stress which is caused by prolonged use of iodine, peroxide, alcohol and acetic acid has been shown to damage cells and tissues involved in wound repair. 

1. Infection at the wound site- inflammation at the wound site arrests the healing process in the inflammatory phase. The pathogenic microbes add to further tissue necrosis at wound site. 

Systemic 

1. Medications- some of the medications  such as the  ones which are steroidal in nature have been seen to slow the healing of wounds
2. Inadequate nutrition- the lack of proper nutrition in the diet of the patient has also been seen to slow the recovery process.

1. Mrs Trenton is ordered medication to help with pain (such as paracetomol), to be given orally. Consider your basic pharmacology and pharmacokinetics in Mrs Trenton’s situation. List three (3) factors specific to Mrs Trenton that may affect the therapeutic dose being reached.

A: The three factors which could affect the pharmacokinetics mechanisms within the patient are –

Age of the patient, physical condition of the patient, undertaking of other medications.

• The age of the patient acts as a determining factor where  the full potential of the medicine may be o prevented from reaching based  upon the present physical condition of the patient
• The undertaking of other kinds of medication may also prevent particular medications from reaching their peak potential.

1. Identify the condition that Mrs Trenton has that is considered iatrogenic (a direct impact of healthcare intervention) in this case.

A: The development of pressure injury in the hip region occurs due to movement restrictions within the patient (Edvardsson, Watt & Pearce, 20117). The movement restriction arrests the flow of blood resulting in the development of pressure ulcers within the patient.

References:

Bandemer, S., Merkel, S., Nimako-Doffour, A., & Weber, M. M. (2014). Diabetes and atrial fibrillation: stratification and prevention of stroke risks. EPMA Journal, 5(1), 17.

Edvardsson, D., Watt, E., & Pearce, F. (2017). Patient experiences of caring and person?centredness are associated with perceived nursing care quality. Journal of advanced nursing, 73(1), 217-227.

Jennings, N., Clifford, S., Fox, A. R., O’Connell, J., & Gardner, G. (2015). The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. International Journal of Nursing Studies, 52(1), 421-435.

Jimenez-Herrera, M. F., & Axelsson, C. (2015). Some ethical conflicts in emergency care. Nursing ethics, 22(5), 548-560.

Meredith, D. J., Clifton, D., Charlton, P., Brooks, J., Pugh, C. W., & Tarassenko, L. (2012). Photoplethysmographic derivation of respiratory rate: a review of relevant physiology. Journal of medical engineering & technology, 36(1), 1-7.

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Rahmqvist Linnarsson, J., Benzein, E., & Årestedt, K. (2015). Nurses’ views of forensic care in emergency departments and their attitudes, and involvement of family members. Journal of clinical nursing, 24(1-2), 266-274.

Rariy, C. M., Ratcliffe, S. J., & Weinstein, R. (2012). Osteoporosis in Women. Year Book of Endocrinology 2012-E-Book, 2012, 310.

Spence, J. D., & Hammond, R. (2016). Hypertension and stroke. In Hypertension and the Brain as an End-Organ Target(pp. 39-54). Springer, Cham.

Tufail, A., Naheed, F., Parveen, S., Zahidie, F., & Sultana, A. (2015). Osteoporosis In Women. Journal of Surgery Pakistan (International), 20, 2.

Wang, Y., Xu, J., Zhao, X., Wang, D., Wang, C., Liu, L., … & Wang, Y. (2013). Association of hypertension with stroke recurrence depends on ischemic stroke subtype. Stroke, STROKEAHA-111.