NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

Subject Code & Title: NRSG374 Written Critique Palliative Care
Word Count: 1800 words
Assignment Type : Case Study
Students are to provide an 1800 word critique of the provided case study using only ONE CPG.  
To complete this task you will need to discuss and critique relevant elements of the CPG and case study whilst upholding the National Palliative Care Standards at least one of: • NSQHS
• NMBA standards and/or FAQ’s
NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

NRSG374 Written Critique Palliative Care Case Study - Nursing And Midwifery Board Ahpra Australia.

Do we need to use all of these standards to do well?
As the rubric states if you provide “Outstanding knowledge of themes and principles associated with palliative care” this will demonstrate an outstanding application of your knowledge to practice therefore using standards from more than one of the above and relating them together to uphold your critique of the patient care and support the clinical practice guideline selected will demonstrate excellent knowledge and understanding.  Using one standard from one of the above will not provide strong application of knowledge. However, a comparison of multiple standards that as registered nurses we are required to uphold will absolutely demonstrate very strong knowledge and understanding, if you link them together well with evidence based practice (EBP)

Where do I find all of these standards?
You should be aware of all of the standards above as they have been discussed in many units throughout your degree, so now it is time to demonstrate your knowledge and bring them together.  to assist you We have provided links below to each of the standards we would like you to utilise in your critique.

Eight National safety and Quality Health Service Standards to provide a nationally consistent level of care that can be expected by all consumers from all health organisations

Seven Standards that all Registered nurses must uphold to ensure that they
maintain their registration and provide person centred and evidence based
preventative, curative, supportive, formative and palliative elements to their practice

National Palliative Care Standards
Nine National palliative Care standards that you know well as they have formed the framework of NRSG374 and were fundamental for assessment task 1

How do I relate these standards to the case study?
This is where your critical thinking and application of theory to practice is required, we cannot tell you how to do this, as a final year nursing unit it is essential that you are aware of how all of these standards, uphold and maintain, patient centred care, dignity, patient assessment and safety to name a few.  Spend some time reviewing these and map out the ones that you believe are important for your critique.

Students are required to demonstrate an understanding of how theory translates into practical nursing care and how evidence underpins best practice. Each student will review and critique the care given in the Case Study provided according to their choice of ONLY ONE of the provided Clinical Practice Guidelines (CPG’s) best suited to the highlighted discussion.

Where will I find the CPG’s that you want me to use?
You are provided with CPG’s for this task, in this booklet

You need to choose one of these only to demonstrate the area of care that you are providing a critique of.  You are not expected to look for other CPG’s to support your work, however evidence based practice of peer reviewed journal publications are expected to further reinforce the critique.

Learning outcomes assessed: LO1, LO5, LO7

How to submit: Electronic Submission via Turnitin

Return of assignment: The assessment feedback and grade will be returned via Turnitin.

Assessment criteria: The assessment will be marked using the criteria-based rubric. Please note that in-text citations are included in the word count whilst the reference list is not included in the word count. Words that are more than 10% over the word count will not be considered

Rubric – can be found in the unit outline in Appendix B

Aetiology of Motor Neurone Disease
Motor neuron disease (MND) is a progressive neurological disorder characterised by loss of motor neurons (Brown, Edwards, Buckley & Aitken, 2017). There are 4 main types of MND, depending of the level of motor neurone involvement and where symptoms begin. These include:
·  Amyotrophic lateral sclerosis (ALS)
·  Progressive bulbar palsy (PBP)
·  Progressive muscular atrophy (PMA)
·  Primary lateral sclerosis (PLS)

MND usually leads to death 20-48 months after symptoms begin, however 5%- 10% of patients may survive for more than 10 years (MND New Zealand, 2018). The onset of MND is usually between 40 and 70 years of age and is more common in men than women by a ratio of 2:1 (MND Australia, 2018). The prevalence is approximately 8.7 in 100 000 in Australia (MND Australia, 2018).

Motor neurons in the brain stem and the spinal cord gradually degenerate. Dead motor neurons cannot produce or transport signals to muscles. Consequently, electrical and chemical messages originating in the brain do not reach the muscles to activate them. The typical symptoms for diagnosis of MND are limb weakness, dysarthria and dysphagia (Brown et al., 2017). Muscle wasting and fasciculations results from the denervation of the muscles and lack of stimulation and use. Other symptoms include pain, sleep disorders, spasticity, drooling, emotional liability, depression, constipation and oesophageal reflux (Brown et al., 2017). Death usually
results from respiratory tract infection secondary to comprised respiratory function.

Throughout the illness trajectory for MND, the patient remains cognitively intact while physically declining. The patient should be encouraged to partake in moderate intensity, endurance type exercise for the truck and limbs as this may help reduce MND spasticity.

Nursing interventions include but are not limited to (Brown et al., 2017):
· Facilitating communication
· Reducing risk of aspiration
· Facilitating early identification of respiratory insufficiency
· Decreasing pain secondary to muscle weakness
· Decreasing risk of injury related to falls 
·  Providing diversional activities such as reading and companionship

The Patient:
Tyler Morton is a 40-year-old man who spent is childhood and teenage years in Brisbane. Tyler, whilst growing up excelled in all sports and represented QLD in the state Cricket Team. Upon completing high school, Tyler graduated from the University of Queensland with a Bachelor of Business Management before joining the Royal Australian Airforce as a Pilot in 2004. Whilst training to become a Pilot, Tyler met is future wife Catherine in Newcastle and this is where the couple settled to commence their family. Tyler and Catherine have 3 Children. Catherine is a stay
at home Mum to:
·Andrea (8 Years)
·Jessica (5 years)
·Erin (2 Years)

Being from Newcastle, Catherine’s Family is very close to Tyler and Catherine and spend a lot of time together. Tyler’s Family is in Brisbane and has only minimal contact with Tyler and his young Family. Unfortunately, Catherine and Tyler’s mother Joyce do not get along and this causes a lot of conflict in the marriage.

18 months ago
Tyler experienced some weakness in his left hand. His grip strength was not a strong as his right hand and he found he would be dropping anything that he picked up. Tyler also noted he was getting short of breath without exertion. Considering his general fitness is quite good, this was highly abnormal. Tyler made an appointment with the GP on the Air force base to discuss this concern.

After multiple MRI’s and blood tests and lumbar punctures (over a 3-month period),Tyler was diagnosed with Amyotrophic lateral sclerosis (ALS). At the time of diagnosis, Tyler’s weakness in his left hand had progressed to his right hand and he had developed a foot drop in his left ankle.

Upon diagnosis, Catherine was adamant that the children were not going to be told the reason that Dad is no longer working. Tyler’s diagnosis also caused more stress and tension with the relationship between Catherine and Joyce. Joyce wanted to visit and be there with her son, however Catherine was not supportive of Joyce and Tyler’s brothers visiting.

12 months ago
Around 6 months after initial symptoms and 3 months after diagnosis, Tyler’s condition had deteriorated. Tyler now required a walking frame to mobilise. His dyspnoea has increased, he was suffering from headaches and was generally fatigued. Tyler was being assessed by a respiratory specialist for the requirement of Non-invasive ventilation (NIV) especially at night. Tyler now suffers from dysphagia and was being assessed in consultation with the respiratory specialist and dietician for the need for a gastrostomy.

6 months ago:
Tyler’s condition has continued to deteriorate. Due to insufficient nutritional intake secondary to dysphagia, Tyler had a gastrostomy inserted. Since insertion, he has had numerous infections at the insertion site. Tyler also requires assistance of NIV mainly at night, however the demand has increased significantly over the last couple of weeks. Tyler’s mobility is limited. He walks intermittently with the use of an aid and
one person. His mobility is limited due to progressive foot drop and increased dyspnoea. With his condition worsening, Tyler initiated the difficult conversation with Catherine about his mortality. Catherine is still not accepting of Tyler’s condition nor is she wanting the Children to know the extent of Tyler’s condition. Tyler completed an Advanced Health Care Directive and he ensured both Catherine and his mother Joyce had a copy. Tyler is currently visited weekly by the Community Palliative Care
Team and he has daily support from Community nurse to assist with his activities of daily living.

Despite Tyler’s progressive physical deterioration and the ongoing tensions with Catherine’s inability to accept his condition, Tyler values the time he gets to spend with his 3 girls. Watching them play together and their interactions are invaluable to Tyler. Tyler has insisted that his mother and brothers are able to visit monthly. When his family visit, Catherine generally takes the girls and leaves Tyler at home.Although this an ideal situation, Tyler has come to accept the conflict between Catherine and Joyce. Tyler is also still in contact with his colleagues from the Air force who visit him frequently.

Past Medical Hx
 # R) Wrist as a child
 Asthma

Current History
 Weakness in left and right hands
 Increase in dysponea on exertion and at rest
 Restlessness/ sleeplessness nocte
 Headaches
 Dysphagia
 Low mood
 Constipation
 Foot drop left foot
 Increase demand for NIV
 02 Therapy
 Peg Feeds
 Intermittent infections Peg site

Gathering new Information

Thursday 19th March

Tyler’s vital signs when visited by the Palliative Care Nurse:
0900 hrs : RR: 24,HR: 60,BP: 120/70, S a O 2: 92% on 2 L min NP,GCS: 14/15,Temp: 38.2 degrees

1300 hrs : RR: 24,HR: 70,BP: 120/70,SaO2: 92% on 2 L min NP,GCS: 14/15 Temp: 38.6 degrees

1900 hrs : RR: 26,HR: 88,BP: 120/70, SaO2: 92% on 2Lmin NP,GCS: 14/15
Temp: 39.2 degrees

Patient Notes from Community Nurses over 24-hour Period:
“Patient’s mobility has decreased. He is now spending more time in bed secondary to weakness in arms and legs. Increased requirement of care from 1 person to 2 people to transfer patient. Patient appears more SOB. O 2 therapy and NIV continues. Peg feeds continuing as per regimen. Patient’s mood appears low. Friends in attendance during visit. Patient communicating in short bursts.”

“Patient RIB during visit. Patient’s position altered. Patient sleeping for most of nursing visit. Patient appears more fatigued. Extra analgesia administered as per patients request. Peg feeds continue as per regimen. Wife and youngest child in attendance during visit. Patient appears warm to touch. Fan applied to assist with climate control.”

“Patient appears very drowsy throughout visit. Patient appears flushed in the face and remains warm to touch. Peg feed disconnected as per regimen. Peg site appears red and inflamed. Swab taken from Peg site for pathology. Patient appears in discomfort. Paracetamol 1 gram given via peg. Oramorph 5 mg given via PEG. NIV connected. Patient repositioned in bed. Patient’s wife was attending to children during nursing visit. Wife reports spending more time sleeping throughout the day.Voice message left for doctor review mane.”

Processing Information

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

20th March
The medical officer (MO) reviewed Tyler after concerns raised by Registered Nurse. Tyler had developed another peg site infection. It was discussed with Tyler the need for IV antibiotics. The MO suggested admission to hospital for treatment, however Tyler was not keen on this suggestion. After discussing hospital admission with both Tyler and Catherine together, it was decided that this was not an option. The Community Palliative Care Team would provide further care to Tyler with provision of IVAB’s in the home. It was arranged for Tyler to have a day visit to the local hospital for insertion of a PICC line due to expected
long duration of antibiotics.

Post review of Medical Officer from Palliative Care Community Services:

Notes made by MO following review of Tyler:
“Overall decline in patient’s condition on observation. Physically dependent for all activities of daily living.”

“Patient appears to be orientated to person, place and time. Some confusion at times, most likely due to infection present.”

“Patient’s wife appears to be supportive of patient and his decisions. It is my observations that the patient’s wife is expecting a full recovery from current infection. It is uncertain of her understanding of the patients condition.”

Palliative Care Phase – Unstable

Many of these are continuously being assessed and monitored:
 Falls Risk Assessment 
 Braden Pressure Risk Assessment
 Pain Assessment 
 NOK contact details
 Advanced Health Care Directive
 Modified Karnofsky Score of 30-40
 RUG- ADL 17
 SAS Tool Completed

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

What might be some things I need to consider as an RN caring for Tyler and
his family ?
 National Palliative Care Standards ?
 NSQHS Standards?
 NMBA Standards?
 What do I know about the illness trajectory of motor neurone disease?
 How will I recall information previously learnt and understood about this illness?
 Where are some of the best locations to access EBP and current standards of care?
 What is my role in supporting the patient and their family?
 What is a SAS Tool?
 What is the Problems Severity Score/ (PSS)
 What is a Modified karnofsky Score?
 What is a RUG-ADL Score?
 How do I determine the Palliative Care Phase that the patient is in?
 Do I need to start having some difficult conversations and ask the patient and their supports what they understand about his prognosis?
 What are some of the complications that the patient and family may face?
 Are there any specific symptoms that I should be looking for when developing a care plan?
 What is the pathophysiological response when someone dies from the specific illness of this patient?
 What should I expect?
 Am I ready to deal with this?
 Where do I get support as an RN if I feel overwhelmed?
 Have I thought enough about my own well being and resilience for this professional specialty?
 How do I care for a deceased person?
 How will I know what to say?

Establishing Goals and Taking Action

Wednesday 24th March (Afternoon)
Tyler’s peg site appears to be less inflamed and redness has subsided a little. Tyler remains warm to touch. RN administered PRN or amorph to assist with Tyler distress and discomfort. Tyler has developed a wheeze. Repositioned to the semi- recumbent position to assist with breathing. Tyler appeared slightly confused, although was orientated place, person, and time. Tyler’s mood appears low. He puts a brave face on when his daughters are around, however Catherine is noticing a significant difference in his demeanour.

Thursday 25th March (Morning)
Tyler is visited by the Palliative Care Registered Nurse. Catherine is out dropping the children at school. Tyler appears to be extremely short of breath and struggling to breathe. O2 2L via NP was insitu. The RN applied NIV to assist Tyler with his breathing

Thursday 25th March (Afternoon)
When attending to Tyler’s personal cares, Tyler made some requests to the RN. He asked for the CPAP machine to be removed, more analgesia for his increased pain and discomfort, he requested for arrangements to be made for a bed in the hospice and requested for his mother and brothers to be contacted. The RN spoke with Catherine regarding contacting Tyler’s extended family. Time was spent with Catherine talking about Tyler’s condition at present. Tyler was orientated to person, place and time.

Catherine did not want to share this time with Joyce and Tyler’s brothers and therefore she did not contact them.

Evaluating and Identifying new problems

Friday 26th March (Morning) – Sunday 28th March (Morning)
Tyler was visited 3 times per day by the palliative care team. At different times nurses and social workers visited.

Symptom management included:
 Break through intermittent pain relief
 Pressure area care
 Dyspnoea relief – intermittent use of CPAP combined with 02 therapy
 Mouth cares
 Peg feeds continued
 Support and counselling given to Catherine

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

Sunday 28th March (Afternoon)
When the palliative care nurse visited Tyler, she found him to be restless and agitated. Tyler stated he was in pain, and he just wanted it all to be over. Tyler asked again after his mother and brothers and the chance of being transferred to the hospice. After a thorough assessment, talking to Tyler and Catherine extensively, the nurse implemented the following:

 Subcutaneous butterfly (waiting for the order for continuous analgesia infusion)
 Called the hospice and arranged a bed for the following morning
 Peg feeds discontinued
 Called Joyce to inform her of Tyler’s condition

A syringe driver containing morphine, haloperidol and ondansetron was commenced after an order was received from the MO.

A hospice bed was arranged for transfer Monday afternoon.

Joyce and Tyler’s brothers were making flight arrangements to be there asap.

Modified Karnofsky Score – 30

RUG-ADL – 17

Tyler is now in the Terminal Palliative Care Phase

Monday 29th March (Morning)
Upon arrival of the palliative care nurse, Tyler appeared still and comfortable. His breathing was short, shallow and laboured with a respiration rate of 5. Catherine was sitting by Tyler’s bedside. Tyler’s girls were visiting neighbours. Joyce and Tyler’s brothers were due to arrive at 1 pm.

At 1025 hrs, Tyler’s respiration rate decreased further. Upon inspection, Tyler’s peripheral extremities were cyanosed. Tyler’s pupils were fixed and dilated, and he took is last breath with Catherine by his side in the family home.

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

Quality of Life Considerations:
Consider some of the following as you select one of the clinical practice guidelines supplied in the assessments folder to assist you with working through the diagnosis, and journey to the palliative care setting:

 Rapid diagnosis and disease progression leaves little time to consolidate and prepare for death – spiritual, social and cultural needs must be considered 
 Was an adequate pain scale used?
 How can the family be provided with support and continuing bereavement follow-up?
 Consider the adequate and detailed use of the SAS tool. 
 What can nursing staff provide families and the deceased patient to aid them in their grief, loss and need to say goodbye?
 Are the National palliative Care standards considered in the CPG?
 Were the NMBA and NQHS standards considered in the CPG?
 Can the CPG be improved in any way to assist its affiliation with care planning,assessment tools and care provided in the palliative setting?
 What is your responsibility as an RN to understand the disease trajectory of your patient’s, plan their care and the care of their loved one’s through the knowledge of nursing standards?
 Was the Advanced Health Care Plan followed in the care that was provided?

Consider these points and the many others that you may have also thought of as you reflected on the case study.

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

Clinical Practice Guidelines
What are they?

Why are they important?
How do they help us to maintain high levels of care?
Do we improve our care by reflection and updating CPG’s through evidence Based research?

Case Study:
As described in the Unit Outline you are now required to select an appropriate CPG out of the CPG’s that have been provided:

 The CPG’s to select from are:
o Care of the Dying patient 
o End of Life Care
 Review and critique the care given to the patient against the CPG you have selected and provide evidence to support your critique through additional research that you will undertake
 Highlight the importance of the National Palliative Care Standards and at least one of the NSQHSS and/or the NMBA Standards and how they influence our practice 
 Demonstrate knowledge on the illness trajectory of Motor Neurone Disease (MND) in line with Palliative Care Principles
 Provide links between the case study and your chosen CPG to identify highlights or limitations in care 
 Ensure that your sources are all contemporary (within the last five years) and from evidence based sources)
 Read all instructions and the rubric very carefully 

NRSG374 Written Critique Palliative Care Case Study – Nursing And Midwifery Board Ahpra Australia.

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