ASSESSMENT TASK 1: Case Study Part A
Answer the questions related to the information provided in the case study
Your research must be appropriately referenced using APA guidelines. The total word limit for your
responses is approximately 1,500 words (+/- 10%).
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As this unit is not directly assessed in the clinical workplace, both assessment tasks need to
reflect a simulated clinical work environment demonstrating critical thinking applied to clinical
conditions.
Case Study
William Smith is a 68 year-old man who was transferred to the Palliative Care ward three days ago
from a surgical ward. He was admitted on 26/01/2013 for excision of a sacral abscess which had
been causing him a lot of pain. After surgery his future management was assessed and it was
decided that he would be transferred to the Palliative Care ward as he could not be discharged
home.
Social History
- Mr Smith lives alone in a unit with 23 stairs. He is unable to care for himself and refuses any
home help.
- According to his daughter who was contacted by the Social Worker, Mr Smith has a past
history of domestic violence and abuse towards his former wife and children. His son and daughter
are finding it hard to visit him even at this end stage of his life and have stated that they are not
willing to care for him at home.
- Mr Smith identifies himself as an indigenous Australian (a person of Aboriginal or Torres
Strait Islander descent). He was born in Arnhem Land but moved firstly to a rural township in the
Northern Territory before settling in his current home in a metropolitan city at age 65 to be nearer
to his estranged children.
- He has a past history of alcohol abuse until his admission to hospital on 26/01/2013.
Medical History
- Mr Smith has a past history of a primary Ca lung with liver and bone metastases.
- He also has a past history of COPD as he was a heavy smoker ( > 20 cigs a day for 45 years).
Physical Assessment on admission
- Mr Smith has dyspnoea, ascites, pruritus and bone pain (moderate to severe at times).
- He is very thin as he has been anorexic for several weeks. According to a neighbour, he lived
on beer and baked beans with an occasional meal at the club when he could be taken there by a
friend.
- His skin is stretched over his distended abdomen and bony prominences.
- He is not able to walk unaided further than from the bed to the bedside chair.
- He requires oxygen at all times.
29/01/2013 – Palliative Care Unit Admission Assessment
- Mr Smith is receiving regular analgesia for pain.
- He had not been ordered an aperient for several days and has not had his bowels opened
since admission to hospital on 26/01/2013 and he is feeling very uncomfortable.
- He refuses to eat much as he doesn’t like the food in hospital. His fluid intake is low and he
is showing signs of possible dehydration. His urine output needs to be monitored.
Mr Smith is also complaining of stomatitis – he has poorly fitting dentures and evidence of
mouth ulcers.
- He also suffers from hiccups which can last for 20 minutes at a time.
- He is complaining of nausea and vomiting. His weight loss is marked (5kg since admission
26/01/2013).
- Mr Smith can be incontinent of urine at night.
- Mr Smith is finding it very hard to sleep at night and falls asleep for long periods during the day.
- He has been talking a little about his children and speaks about his former behaviour
towards his wife and children with regret. He often asks if his children are going to visit him.
06/02/2013
Mr Smith has now been on the Palliative Care ward for a week. He has deteriorated in the past few days and is now bed bound.
- He is able to roll from side to side for PAC.
- His skin is intact apart from a small pressure ulcer (0.2 x 0.1cm) on his sacrum.
- He is extremely sensitive to soap because of an increase in ascites and consequent pruritus.
- He needs assistance with personal hygiene (sponge in bed).
- He refuses to wear his dentures now as his mouth is extremely painful. He has been ordered
Nilstat and Bonjela (anaesthetic mouth gel) with limited effect as he doesn’t like the taste.
- His breathlessness has increased and he is having 4/24 Ventolin nebs.
- He is ordered soft diet, encourage fluids. Mr Smith likes ginger beer which he says helps his hiccups (next-door neighbour brought some in)
- BNO for several days. Microlax enema and Agarol 10ml given with effect.
- Can be incontinent of urine at times – pad in situ.
- Current analgesia is oral (Oxycontin 100mg bd and Tramadol 50mg bd) – Mr Smith states
this regime is “holding pain at present”. Pain score 2 -3/10.
- He can be confused and agitated at times.
- Mr Smith has requested a visit from the Social Worker to try to organise a visit with his
children. He is very depressed about the current situation.
- Daily TPR and BP and girth measurement.
PART A: Analyse the information given in the case study and answer the following questions. NUMBER
EACH QUESTION IN YOUR SUBMISSION
Review the following document to assist your responses to questions 1 – 2:
Queensland Health (2011) Sad News, Sorry Business: Guidelines for caring for Aboriginal and Torres Strait
Islander people through death and dying
http://www.health.qld.gov.au/atsihealth/documents/sorry_business.pdf
QUESTIONS:
- Could Mr Smith’s culture influence his pain assessment? Why? What strategies could you employ to ensure that you are adequately addressing Mr Smith’s pain?
2 Consider Mr Smith’s social and medical history.
- Reflect on any judgements and prejudices that you may have when caring for Mr Smith.
- Review the following professional Australian nursing standards:
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx
Code of Ethics for Nurses
Code of Professional Conduct for Nurses
EN Competency Standards
Outline the standards / codes that relate to non-judgemental nursing care in this situation.
- Compile a list of questions you would ask Mr Smith as part of an holistic health assessment. These questions should be framed to enable collection of information on:
- physical health status including pain assessment
- mental and emotional status
- social and cultural issues
- Mr Smith asks you about planning for his future. He states that he does not want to be resuscitated.
Provide Mr Smith with a brief description (with APA referencing) of the following and apply it to this scenario:
- Advanced Health Directive
- Enduring Power of Attorney
- Organ Donation
5: Suggest alternative strategies (complimentary therapies) other than pharmaceutical pain management that could help Mr. Smith’s pain.
6.List appropriate referrals for Mr Smith to other members of the multi-disciplinary team. Provide a rationale and a description of the service for each referral.
7: What support / referral could be offered to Mr Smith’s family?
- Outline the pathophysiology of the following conditions ensuring you relate back to Mr Smith and his clinical presentation. Include within your answer the possible management strategies and rationale for these symptoms:
- Anorexia
- Ascites
- Dyspnoea
- Hiccups
Note: Pathophysiology is not signs and symptoms. Pathophysiology explains the processes within the body that result in the signs and symptoms of a disease.
- Consider Mr Smith’s deterioration. What data provided about Mr Smith’s condition on 06/02/2013 would assist in determining if Mr Smith is at end of life?
Clinical Assessment of Mr. Smith’s Health Case
QUESTIONS
- Could Mr Smith’s culture influence his pain assessment? Why? What strategies could you employ to ensure that you are adequately addressing Mr Smith’s pain?
Mr. Smith is a patient with a disturbing social and medical history. His social culture is such that he lives alone and does not like any person helping him out at home. These factors would interfere with his pain assessment since he would not want to reveal that he is in pain because it would mean that a caregiver would be assigned to him. One of the strategies that would ensure that I address Mr. Smith’s pain is regular monitoring of his health condition. In this way, I will be able to know if there is any improvement in the pain therapy that is being administered.
2) Consider Mr Smith’s social and medical history
- Reflect on any judgements and prejudices that you may have when caring for Mr Smith
The social history of Mr. Smith shows that he was an abusive husband who battered his own wife and children on countless occasions. Moreover, he has a past history of alcohol addiction that could have contributed to his aggressive and brutal personality. This social vices would make a physician or caregiver to develop a negative attitude towards Mr. Smith. This is because he showed no respect or concern for his wife or children and did not play the part of a responsible father or husband. His alcohol and cigarette addiction has also largely contributed to his deteriorating state of health, something that he does not show any concern for whatsoever. When caring for Mr. Smith, I would be prejudiced to show low quality care compared to other patients due to his unhealthy habits of smoking and drinking for a person of his age.
The medical records show that Mr. Smith lived on baked beans and beer, yet he knew that it is not advisable to drink before having a healthy diet. The palliative unit care also recorded that Mr. Smith was stubborn and he refused to eat, making his body become emaciated and highly dehydrated. As a caregiver, I would be prejudiced to take care of such a patient because it would seem that they are not doing their best to get better despite being given helpful advice and care by the physicians. What’s more, Mr. Smith does not like taking any fluids which would help in rehydrating the body. A caregiver can only do as much to a patient to help them recover, but if the patient does not want to co-operate, then the caregiver would be faced with a hard time and would tend to develop a bias towards such a patient.
- Review the following professional Australian nursing standards:
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx
- Code of Ethics for Nurses
This code documents the value that nurses have towards providing quality care for all classes of people. In addition, this code affirms that nurses value kindness and respect for themselves and for others. It is the duty of nurses to value quality based health care to all people under their care. What’s more, nurses value making informed decisions that will help in preserving the value of a culture safely while still maintaining good health care. This ethical code for nurses states that nurses highly value an environment that is sustainable both socially and economically since it is capable of promoting health and well being of patients.
- Code of Professional Conduct for Nurses
This code states that nurses should offer their services to patients in a safe and competent manner in accordance to the standards set by their professional body. Moreover, nurses are expected to respect the culture, ethnicity and dignity of the patients under their care. This includes treating any personal information with a lot of privacy and confidentiality. Nurses are also expected to preserve and promote the trust that exists between patients and health care givers. In overall, it should always be the duty of a nurse to practice nursing in an ethical and professional manner.
- EN Competency Standards
These standards apply to all enrolled nurses and they aim at demonstrating a high level of knowledge in the law that relates to the nursing practice. Secondly, these standards require nurses to show that they have knowledge in organizational procedures and policies that closely relate to nursing. Thirdly, an enrolled nurse should fulfill their duty of providing health care during their practice. Moreover, these standards ensure that there is a safe outcome for all groups and individuals by identifying a situation that is likely to cause harm to others. In addition, these standards are set in such a way that they liaise with others so that the rights of all individuals are maintained properly.
- Outline the standards / codes that relate to non-judgmental nursing care in this situation.
In this situation, Mr. Smith is a patient who has a past history of domestic violence towards his family. In addition, he is also an alcoholic and a heavy cigarette smoker who does not observe a proper diet. His medical records indicate that he is stubborn and he hardly eats meals and neither does he take fluids regularly. These factors would make a caregiver or nurse to become judgmental about his current health status, leading to prejudiced health care. The standard codes that relate to non-judgmental nursing care affirm that it is the duty of a nurse to provide quality care to all people. This is regardless of their social behaviors or ethnical background. Therefore, the nurse attending to Mr. Smith is expected to show no bias despite of his difficult and stubborn nature of refusing to eat or drink fluids.
3)Compile a list of questions you would ask Mr Smith as part of a holistic health assessment These questions should be framed to enable collection of information on
- Physical health status including pain assessment:
- Has the level of pain reduced since you were transferred to palliative care?
- Has the regular analgesia been working positively to relieve you of your pain?
- Do you think that if we put you on a regular diet you would try and improve your eating habits?
- Mental and emotional status:
- Do you sometimes think that your past habits are to blame for the kind of pain you are experiencing today?
- Do you think your hostile and aggressive nature is the reason why your children and wife do not come to visit you?
- Do you sometimes think that if you had someone to talk to regularly your pain and illness would go away at a faster rate?
- Social and cultural issues:
- What is the reason why you indulged in a lot of alcohol consumption and chain smoking?
- Does your cultural background have any connection with the various types of illness you have and does it conflict with the therapy that we propose to provide?
- What is the explanation for having physically abused and battered your own wife and children?
4) Mr Smith asks you about planning for his future. He states that he does not want to be resuscitated. Provide Mr Smith with a brief description (with APA referencing) of the following and apply it to this scenario:
- a) Advanced Health Directive
This refers to a formal way of giving instructions and advice for the future healthcare and it is only applicable if a patient is unable to make their own decisions. This directive allows a person to decide what medical treatment they would prefer should they be in a position where they cannot make their won decisions. In this scenario, Mr. Smith has already decided that he does not want to be resuscitated should he go into a cardiac arrest. The Advanced Health Directive favors Mr. Smith’s decision and nurses have no choice but to abide by his choice of treatment.
- b) Enduring Power of Attorney
This is a legal agreement that enables a person to appoint an attorney who can make legal decisions on their behalf. It is an agreement that is made by choice and can be executed by any person who is above 18 years of age. In Mr. Smith’s case, the attorney he appoints has the power to oversee that no resuscitation is conducted should he go into a cardiac arrest or any other serious condition.
- Organ Donation
This is the practice where some terminally ill patients state that they wish to give out their organs for research or to an anonymous person who is in desperate need of a major organ. Since Mr. Smith only stated that he does not wish to be resuscitated, the nurse in charge can decide whether to preserve his body after he succumbs or donate his organs for a worthy cause.
5) Suggest alternative strategies (complimentary therapies) other than pharmaceutical pain management that could help Mr. Smith’s pain
Mr. Smith’s pain is caused by a combination of various physical conditions such as bone pain, ascites, dyspnoea and pruritus. In addition to the use of drug therapy, there are other complementary therapies that are used to help patients relieve pain caused by physical illnesses. Ascites is a medical condition where the body has a build up of fluids which can occur due to cancer or other such like conditions. The complimentary therapy that can be used to relieve this pain would involve draining the fluid from the abdomen in order to relieve the swelling. This method does not involve the use of conventional drugs and can be quite effective if done professionally. For the bone pain, Mr. Smith can consider chiropractic which is a manipulation of the functioning of the spinal cord and body joints. Chiropractors work by aligning the bones and joints in order to relieve any form of pain. This is an established form of complimentary therapy that supports the use of chiropractic and spinal manipulation to treat bone, neck and back pain.
6) List appropriate referrals for Mr Smith to other members of the multi-disciplinary team. Provide a rationale and a description of the service for each referral
Mr. Smith is a patient who suffers from many forms of illnesses that can better be addressed by other members of the multi-disciplinary (MDT) healthcare team. To begin with, I would refer Mr. Smith to a medical oncologist to check whether he has any malignant or benign tumors. This is because ascites is mainly caused by cancer, which would be possible for Mr. Smith given his long history of tobacco smoking. Secondly, I would refer Mr. Smith to an orthopaedic surgeon who is better placed to explain the genesis of bone pain in Mr. Smith’s body. Thirdly, I would also refer Mr. Smith to a nutritionist who would help in devising the appropriate diet for Mr.Smith to enable him gain full health in the shortest time. Finally, I would also refer Mr. Smith to a psychologist to help in assessing the mental problems that cause Mr. Smith to have such wanting social behaviors.
7)What support / referral could be offered to Mr Smith’s family?
The best support that would be offered to Mr. Smith would be psychological counseling that would help them heal the scars caused by domestic violence and physical abuse of Mr. Smith. This would be the first step towards obtaining healing for all the wrongs that Mr. Smith did to this family. On the part of Mr. Smith, reconciling with his family would be beneficial to his health since he would be able to recover at a much faster rate.
8)Outline the pathophysiology of the following conditions ensuring you relate back to Mr Smith and his clinical presentation. Include within your answer the possible management strategies and rationale for these symptoms
- a) Anorexia
The pathophysiology of this condition begins with the person having a devastating fear of adding weight. Consequently, the person does not observe a healthy eating routine and the body then begins to develop symptoms that indicate it is being deprived of necessary nutrients. For Mr. Smith, he was severely anorexic and this was manifested by symptoms such as drying of the skin, swelling of submandibular glands that caused pain to develop in his mouth and peripheral oedema that also contributed to accumulation of fluids in his body. The management strategy for anorexia is eating healthy foods so that the body is able to function properly and have the strength to fight diseases.
- b) Ascites
This is a medical condition where the body accumulates a lot of fluids in the peritoneal cavity and is mainly caused by certain forms of cancer. The pathophysiology of ascites is such that the rate of accumulation of body fluids is faster than the rate at which fluids are removed from the body. Mr. Smith could have developed ascites possibly due to lung cancer that would have resulted due to cigarette smoking. The possible management of this condition is drainage of the accumulated fluid so that the abdominal cavity can go back to its original size.
c)Dyspnoea
This is a medical condition where the patient suffers from an acute shortness of breath that becomes pathological if it occurs in unexpected circumstances. The pathophysiology of dyspnoea is such that the body receptors are not able to relay information appropriately. For instance, the lung muscles would be strained such that they do not stretch or relax as they should. Mr. Smith suffers from dyspnoea possibly because he is a chain smoker and the state of his lungs have been compromised. Consequently, his lungs are not well ventilated and this largely impairs the exchange of gases. The possible management strategy for this condition would be the use of opioids that will enhance the functioning of receptors in order to reduce the occurrence of shortness of breath.
- Hiccups
This is an involuntary action that the body uses to alert an individual that the body is dehydrated. Hiccups act as warning signs to signal the person that the body is in urgent need of water. The medical records showed that Mr. Smith suffered from regular hiccups that would last for up to 20 minutes. Hiccups are actually quite serious and can cause death if a person does not rehydrate the body by drinking water immediately. The hiccups suffered by Mr. Smith show that he was severely dehydrated and he requires to drink lots of fluids in order to ensure that his body is hydrated to the appropriate level.
9)Consider Mr Smith’s deterioration. What data provided about Mr Smith’s condition on 06/02/2013 would assist in determining if Mr Smith is at end of life?
The records on this date indicate that Mr smith is actually bedridden and all the care is given to him at his bedside. He cannot be able to shower himself and he is sponge bathed by the caregivers. Moreover, his dyspnoea has worsened and he is having 4/24 Ventolin nebs to assist with his breathing. His condition is even worsened by the fact that he takes ginger beer to treat his hiccups instead of taking normal fluids. These conditions are telltale signs that he does not have much time to live.