NURS90131 Written Examination Assessment – Australia.

Subject Code & Title : NURS90131 Written Examination
Word Limit : 2000 words (+/- 10%)
Weighting : 30%
Assessment Activity :
There are THREE case studies to be completed for this written exam assessment:
1.Postoperative care of the client following laparoscopy
2.Managing the diabetic patient
3.Managing the client with chronic obstructive pulmonary disease (COPD)
NURS90131 Written Examination Assessment – Australia.

Case 1: Postoperative care of the client following laparoscopy

Past and present medical/surgical history

Jenna Campbell is a 28-year old architect. She has suffered from chronic abdominal pain since she was thirteen years old, and dysmenorrhea since menstruation commenced at aged 15. Since the age of 20, menorrhagia has persisted, requiring two previous iron transfusions 18 and 9 months ago respectively. Hemoglobin level two months ago was 106 g/L, when Jenna was prescribed oral iron tablets. Last year she developed dyspareunia, and her GP referred her to University Hospital for further investigation, with a working diagnosis of endometriosis.Abdominal symptoms related to endometriosis were otherwise managed at home with analgesia. However, Jenna has re-presented to University Hospital emergency department (ED) after 8/10 abdominal pain not relieved by analgesia and vaginal bleeding. After assessment by the on-call physician, confirmation of endometriosis and a laparoscopy was required, with
possible treatment provided during laparoscopy. She was subsequently admitted to your ward.

Medications- current and on going
Ibuprofen 200mg TDS/PRN
Paracetamol 1000mg QID/PRN
Ferrous Sulfate 325mg daily
Oxycodone 5mg PRN
Morphine sulphate 5mg IV on admission to ED.
Cefazolin IV 1 g

Signs and symptoms :
It is now three days post laparoscopic procedure, Jenna was treated for removal of endometriosis tissue and two ovarian cysts through diathermy in the pelvic region. During theatre there was minimal blood loss, however Jenna has remained in the ward due to abdominal pain, nausea and haemoglobin monitoring. You are looking after Jenna post- operative day three at 1400 hours, and your assessment findings are:

CNS: Jenna appears to be in pain, her face shows grimacing, and she keeps trying to catch her breath as the waves of pain occur. On further assessment the type of pain has felt different today than previous days and occurring where her laparoscopic wound is located. It feels sharp, hot and is significantly worse on movement.

CVS: Manual BP 93/49 mmHg supine, 107 sinus tachycardia. The doctor has prescribed a 1 litre bag of normal saline to run over 6 hours to improve blood pressure.

Respiratory: RR 24 Bpm and SpO2 95% on RA.

GIT: Jenna reports being thirsty but extremely nauseous, which has been continuing since the surgery but has worsened this morning. Her oral intake was 400 mls yesterday in total and her fluid balance so far since midnight is negative 250 mls.

Integumentary: Jenna’s Jackson Pratt drain was removed yesterday as there was no drainage.
The dressings covering her five laparoscopic wounds are intact, however one 3 cm x 3 cm dressing is soaked, and another distal wound dressing has had slow persistent blood ooze since yesterday, needing two dressing changes overnight.

1. Outline a systematic assessment of the patient at the start of your shift, and provide a rationale for the observations undertaken, data collected, and assessment methods used. Identify any missing assessment information in the case study and outline how you intend to obtain this detail.

2.Using established clinical practice guidelines, design a comprehensive nursing care plan for the patient for the rest of your shift. Consider the following elements in your plan of care.

a. monitoring and surveillance (include physiological parameters)
b. safety and comfort
c. positioning and mobility
d. nutrition and hydration
e. communication and information needs
f. psychosocial supports
g. documentation of care

3.Jenna’s IV fluids commenced at 09.00 hrs, and at 14.30 hrs you evaluate the intravenous fluid bag and note approximately 825 mls of normal saline is left in the bag. Discuss two actions that you would take when noting this amount and rationalise in relation to two potential patient complications.

4.Jenna is also due soon for the afternoon TDS dose of Cefazolin 1 g. She has pressed the call bell three times in the last 20 minutes complaining of pain 8/10, and increasing nausea, when you see her call bell light again. Your other patient in bed 6 is currently on a commode alone and has a history of falls. Your buddy nurse is calling you from another room to bring her a linen-skip and PPE. Discuss what nursing tasks you would prioritise in this situation, including communication strategies and rationale for the
order of your priorities.

NURS90131 Written Examination Assessment – Australia.

Case 2: Managing the diabetic patient

Past and present medical/surgical history
Kenny Ng aged 63, a financial analyst, is admitted to the emergency department at 1500 hrs via ambulance with nausea, vomiting and abdominal pain. His wife reports that he has been drinking excessive amounts of water during the past several weeks, and has been urinating frequently, more so at night. Kenny has a 10-year history of hypertension, 15-year history of Type 2 diabetes, obesity (145 kg) and abnormal cholesterol and triglyceride levels. He was also diagnosed with hypothyroidism 12 years ago. Kenny’s eyesight has declined significantly in the last five years, where he has complained of ‘floaters’ and shapes moving within his vision field, and nyctalopia. There is an old, peeling dressing (comprised of 4 Band-Aids overlapping) on the sole of Kenny’s right foot, and when removed there is a 2 cm long x 2 mm deep laceration that is across the fat pad over the calcaneus, that has a small amount of purulent exudate on the Band-Aid. Kenny’s wife Ann explains he was gardening last week, when he cut his foot on a spade. Kenny is non-compliant with his diabetic medications. His wife states he only takes them
when he “feels like his sugar is up”. Kenny monitors his blood glucose levels via gluco meter only
a few times per week.

Signs and symptoms :
On admission to the hospital, Kenny appears confused and disoriented, is lethargic, his skin warm, dry and flushed, pulse rapid at 98 beats per minute. Kenny appears dyspneic with a respiratory rate of 24 respirations per minute. He has an acetone smelling breath and polydipsia. Blood pressure is 166/95. Temperature 37.3 C. Kenny’s initial plasma glucose level is 39 mmol/L, his arterial blood pH is 7.30 (normal 7.35-7.45) and serum bicarbonate is 16 mmol/L (normal 22-26 mmol/L). ECG has recorded:

Medications- current and on going :
Metformin 1000 mg daily, Gliclazide 80mg daily, Captopril 25 mg B D, Amlodipine 2.5 mg daily, Simvastatin 20 mg daily, Thyroxine 100 mcg daily.

Hospital treatment:
• Insulin (Actrapid) intravenous infusion (0.1 unit/kg IV bolus followed by a 0.1 unit/kg/hr infusion after the first litre of saline has been infused.)
• 0.9% normal saline, 15 to 20 mL/kg/hr

One hour following the commencement of the intravenous insulin infusion treatment, Kenny’s blood glucose reduces to 30 mmol/L and other laboratory blood test results are:

1.Critically analyse the case study and identify the two most important actual nursing problems for the patient at the commencement of the shift and state these as nursing diagnoses. A two- or three-part NANDA statement is utilised as appropriate.

NURS90131 Written Examination Assessment – Australia.

2.Analyse the case study and rationalise in no more than 150 words the pathophysiological basis for TWO signs/symptoms observed in the chosen case study

3.Explain with rationale, three nursing interventions associated with the safe administration of three of Kenny’s admission medications

4.Discuss how you would assess Kenny’s right foot wound and justify how would this inform your decision to identify one actual and two potential problems. Then, choose one problem (out of the three identified) to discuss one independent nursing intervention aimed at addressing that problem.

5.From the table above, what blood test result(s) would be the most significant to monitor, in relation to insulin infusions, and why?

6.You have just been notified by the doctor that the insulin infusion will be ceased and a Act rapid insulin sliding scale will be charted. When you inform Kenny, he becomes extremely agitated and refuses to have the insulin infusion removed. Explain how you would manage this situation.

Case 3: Managing the client with chronic obstructive pulmonary disease (COPD)

Past and present medical/surgical history
Mrs XXX, a 61-year-old woman has been brought in by ambulance to the ED, with exacerbation of COPD. Six years ago, she was diagnosed with emphysema. For many years before this, Mrs XXX was thought to have a milder broncho-restrictive disorder treated with puffers, however over time this became less effective to deal with symptoms of shortness of breath. She was then screened for genetic causes of the respiratory conditions and at age 38,blood tests illustrated alpha-1 antitrypsin (AAT) deficiency.

She has a history of rheumatoid arthritis, early stage cirrhosis of the liver secondary to AAT, and gastroes ophageal reflux. She was a social smoker and heavy drinker in her 20’s, but non-smoker since. After her AAT diagnosis, she has quit alcohol.

Medications- current and ongoing
hydroxychloroquine 400 mg mane, methotrexate 15 mg weekly, esomeprazole 20 mg mane,thiamine 100 mg mane; salbutamol 100 mcg/dose MDI, ipratropium 20mcg/dose MDI, initiated when she is dyspneic.

Signs and symptoms
Mrs XXX lives alone and works in a café on a casual basis. Her husband tragically passed away two years ago from a work-place accident. She has two children that both live interstate.Her exercise tolerance (no aid needed) has been decreasing over the last few months, normally 300 m before moderate shortness of breath ensues. However, she is determined to continue with her exercise. Over the last 10 days, she had complained of increasing fatigue, shortness of breath in the mornings, lack of appetite and oral intake, intermittent cough. Exercise tolerance with moderate shortness of breath is approximately 80 meters.

She called the ambulance this morning after feeling faint, feeling palpitations and sudden wheeze.

You receive the ambulance handover in ED, with the following information:

GCS 14-15/15; E3-4 M6 V5, PEARL 3mm, upper and lower limb strength normal. Denies cardiac or respiratory pain. Mild tenderness left lower calf.

BP 156/90, Pulse regular 102bpm, sinus tachycardia on telemetry, temperature 37.3 C. Peripheral cannula 18G inserted right cubital fossa (capped). JVP 2cm elevated.

NURS90131 Written Examination Assessment – Australia.

Cool and clammy peripherally, capillary refill 3 seconds, cyanotic tinge to fingertips.

RR 30, oxygen saturation SpO2 84% RA at home and 93% on 6 L Hudson mask. Unable to speak in full sentences. Sternocleidomastoid muscle use, pursed lip breathing. Sub costal retraction, audible expiratory wheeze, decreased breaths sounds bilateral lobes, fine crackles left lower lobe. Non-productive cough.

Denies nausea or abdominal pain, nil ascites on inspection. Liver palpation non tender. Denies dysuria, voided during the night, patient stated urine was a dark amber colour.

After admission, a respiratory function test is performed illustrating a FVC (Forced Vital Capacity) of 1.8L, which is 52% the predicated value for her age, illustrating moderate-severe pulmonary obstructive disease. Mrs XXX’s chest X ray illustrates dynamic hyperinflation, flattened hemi diaphragm that is suggestive of emphysema, and bilateral lower lobe and left middle lobe atelectasis.

NURS90131 Written Examination Assessment – Australia.

1.Using the ABCDE approach, discuss the immediate nursing care priorities and the rationale in the management of this patient, for what you would implement in the first hour of care in the ED.

2.Discuss how you would assess Mrs XXX’s respiratory status and justify how would this inform your decision to identify two actual and one potential problem. Then, choose one problem (out of the three identified) to discuss one independent nursing intervention aimed at addressing that problem.

3.Given the clinical assessment, data collection and nursing care priorities since arrival into emergency department, using the ISOBAR framework, outline how you would report Mrs XXX to the respiratory physician on-call.