Assessment Task Five - Clinical Scenario 4

Running head: ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 1

Diploma of Nursing

Name: Mahnaz Mobedi

Student ID:

Analyse Health & respond to client information

HLT54115

Due Date: 08/06/2018

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 2

TASK A

1. Define gastroenteritis.

Gastroenteritis is stomach inflammation caused by either viral infections or toxins from bacteria

2. What is Gastritis?

Gastritis is any group of conditions which lead to inflammation of the stomach lining.

3. Explain Mr Bate’s poor skin turgor in relation to his gastroenteritis.

Mr. Bate’s poor skin turgor is caused by dehydration or decreased intake of fluids.

4. How does his blood pressure reflect his illness? Why is it low?

A high blood pressure is a reflection of the illness but the severe dehydration is the cause of

Bate’s low blood pressure.

5. Provide two (2) signs /symptoms of gastroenteritis

Other Gastroenteritis signs are diarrhea and painful cramps in the tummy.

6. Describe the pathophysiology of multiple sclerosis

Multiple sclerosis is activated when immune cells attack the CNS

7. Provide two (2) signs/symptoms of Multiple Sclerosis.

Its symptoms are tissue damage and inflammation (Moorhead et al., 2014).

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 3

8. Define Rhabdomyolysis.

Rhabdomyololysis is a condition that leads to muscle tissue injury/breakdown thereby releasing

into the blood a damaging protein.

9. Name one group of medications that is prescribed to lower cholesterol and has this

as a side effect. What education should you give to your patient when commencing

this medication

Statins are recommended to lower cholesterol but may cause this condition. .Once the patient

notices this effect he/she should consult the doctor for a change of medication rather than

stopping taking the pills.

10. What is the medical term for black stools and what could it mean?

Melena is the medical term for black stool which means an oxidation of iron in hemoglobin.

11. What does ‘emesis’ mean? What does hematemesis mean?

Emesis is the action of vomiting while hematemesis is vomiting blood.

12. Explain the pathophysiology as to what would be happening to an individual that

was admitted to your ward with hematemesis and melena?

Hematemesis and melena occur due to the internal bleeding resulting from stomach tumors,

ulcers, radiation exposure etc.

13. What is the term used to describe skin colour and the sclera of the eyes becoming

yellow? What organ of the body is usually involved?

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 4

Yellowing of the skin color or sclera of the eyes is called jaundice and occurs due to liver

problems or blocked bile duct.

14. Give an example of a disease process that might cause this and explain why.

This may be caused by pancreatic cancer which blocks the bile duct causing bile retention in the

body (Brown et al., 2017).

15. Pruritus often accompanies this discolouration, what is pruritus?

Pruritus is severe skin itching associated with several disorders.

16. Explain what a Hiatus Hernia is and list two common symptoms the individual may

report.

Hiatus Hernia is a condition whereby stomach part pushes through the muscle of the diaphragm

indicated by heart burn, abdominal discomfort and chest pain (Roman & Kahrilas, 2014)

17. What does the acronym GORD stand for?

Acronym GORD stands for Gastro-esophageal reflux disease.

18. Complete three nursing care plans for Michael. Each plan must identify one patient

problem/issue, one goal and two courses of action you would take.

Nursing

Diagnosis

Goals

Intervention: rationale

Implementation

Evaluation

Diarrhea

Reducing the

 Advice Bate to

Yes

Bate

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 5

rate of

dehydration

through and

ensuring he

has enough

water in the

body

drink a lot of water

to reduce

dehydration and

proposing a diet

rich in fiber and

Iron like vegetables

and grains.

 Checking Bate’s

medical history of

consuming

contaminated food

or water.

demonstrate

that he

understands

the importance

of taking a lot

of fluids.

Additionally

ensuring Bate

drink six

glasses of

water daily.

Nursing

Diagnosis

Goals

Intervention:

Rationale

Implementation

Evaluation

Feeling pain

in the joints

and potential

fall.

Bate will not

feel any pain

during the

stay and in

future will

have flexible

joints

 Assessing the

condition of Bate’s

joint and tissue then

provide appropriate

medication that will

reduce pain like

aspirin and

ibuprofen.

Yes

The goal is

met by

following the

action plan of

providing

medication

for reducing

pain and

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 6

 Encourage Bate to

engage in physical

activities to keep the

joints active.

allowing to

have enough

rest.

Supervising

Bate while

doing some

exercise

without

experiencing

pain or fall.

Nursing

Diagnosis

Goals

Intervention:

Rationale

implementation

Evaluation

Activity

intolerance

related to

inflammation

due to

colored stool.

Bate will not

produce any

colored stool

after the stay the

stool will be

normal.

 The first activity

will involve

measuring Bates’

weight and

educate on how

to chew food

thoroughly and

eat in an orderly

manner.

 Induce

Yes

Demonstrate

to Bate’s on

taking a

balance diet to

help in

digestion and

measure the

body weight.

Take the stool

for testing in

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 7

medication like

the nonsteroidal

anti-

inflammatory

drugs such as

naproxen and

antibiotics.

the laboratory

and see if it

has changed

color.

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 8

Task B.

1. What factors would have contributed to her developing osteoarthritis?

Factors that would have contributed to Carol’s osteoarthritis condition are; the bleeding condition

after the fall, her old age and her family history (Johnson & Hunter, 2014).

2. What education would you provide to an individual diagnosed with Osteoarthritis?

The education would include her engaging in regular physical activities and also instructing her

to reduce food intake to maintain a healthy weight.

3. Explain the pathophysiology of Parkinson’s disease and how it can contribute to

falls.

Parkinson disease results from the gradual loss of brain cells in substantia nigra leading to a

decrease in dopamine hence loss of balance leading to possible falls.

4. What other symptoms might Carol have in relation to Parkinson’s disease?

Other symptoms include; tremor, stiff muscles and dystonia.

5. Besides monitoring the above vital signs what other observations should be

conducted? Explain why.

Other observations include taking the patient’s medical history to help know the progression of

the disease, observations of her speech and her memory level. This is because most of the

Parkinson’s disease patients experience a substantial reduction in olfactory and cognitive

functions before the motor challenges emerge (Shin & Habermann, 2017).

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 9

6. Carol starts to complain of a headache and is feeling nauseated. What do you think

could be happening?

Carol’s headache and nausea are due to the hyper-activation of the central dopaminergic

pathways.

7. Complete three nursing care plans for Carol. Each plan must identify one patient

problem/issue, one goal and two courses of action you would take.

Nursing

Diagnosis

Goal

Intervention:

Rationale

Implementation

Evaluation

Potential

failure of not

being able to

move within

physical

environment

like mobility,

transfers and

ambulation.

Carol avoiding

the dangers of

immobility,

preventing

dependent

disabilities and

maintaining

mobility.

 Carol to use

safety measures

to aid her in

movement to

prevent potential

injury from fall.

Additionally

Carol performs

physical activity

without

assistance within

the limits of her

disease.

Yes

Carol is can

walk regular

paces without

stopping.

Likewise she

indicates a

sign of not

walking

without using

safety

measures and

as result no

injury occurs.

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 10

Nursing

Diagnosis

Goal

Intervention:

Rationale

Implementation

Evaluation

Activity

intolerance

related to

ineffectiveness

coping,

hopelessness

and fatigue

which causes

stress and

anxiety

Looking at the

level of

impairment and

assess how

carol copes

with abilities

and skill while

dealing with the

current

situations to

reduce

depression

 It would be of

importance to

educate Carol

about

depression

through feelings

expression.

 Provide

medication like

anti-depressant

drugs and

review their

adverse effects.

Yes

Carol can

verbally state

that she is

aware and able

to cope with

her feelings.

she is also able

to identify

effective

coping

behaviors and

their outcomes.

Nursing

Diagnosis

Goal

Intervention:

Rationale

Implementation

Evaluation

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 11

Bleeding

after fall

Reducing the

level of bleeding

after fall by

Carol due to as a

result of her old

age.

 Check Carol's

medical history

and to find out

whether the

disease is

hereditary and

provide

medication.

 Educate her on the

eating meals rich

in carbohydrates to

help her gain

energy.

Yes

Check her

body weight

and evaluate

the meals she

is taking

from

breakfast,

lunch to

dinner.

Verbally and

practically

affirmation

by warning

her in case

she is going

to fall.

8. Name an Allied Health Worker that you could include in this individuals care in

regard to her allergy and poor appetite. Explain their role.

I would include a dietician to help Carol deal with poor appetite and allergy. The dietician will

help her on how to manage diets to have significant weight change and guide her on appropriate

food preparation practices.

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 12

PART C

1. Briefly explain the pathophysiology of decompression sickness.

Decompression sickness is caused by the formation of inert gas i.e. nitrogen gas bubbles within

arterial gas embolism as well as within the body tissues (McCance & Huether, 2015).

2. What symptoms would you be looking for in an individual admitted to your ward

who had been deep sea diving?

An individual admitted in award after having been in deep sea diving may exhibit chest and

abdominal pains, fatigue as well as weak upper extremities (McCance & Huether, 2015).

3. List two forms of treatment.

The treatment of the DCI includes placing the patient on an oxygen mask to deliver high flow of

oxygen and IV fluids as well as recompressing the patient in a hyperbaric chamber (McCance &

Huether, 2015).

4. What is the recommended time between a dive and an individual flying?

The recommended time between a dive and an individual flying is 12-24 hours.

5. Can an individual prepare for flying into high altitudes? List two risk factors.

Flying into high altitude after diving is not recommended as it leads to DCI. The risk factors are

the cold water, long or the deep dives, hard exercise while at that great depth and rapid ascents

during the dive (McCance & Huether, 2015).

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 13

6. What symptoms would you educate Melony to look out for and what advice would

you give her when she arrives to the high altitude?

Melony should look for formation of bubbles near the joints which later leads to joint pains. Also

she should look for bubbles formation on her body tissues. While at high altitude Melony should

wear a pressure suit or be in a pressure cabin. In addition, she can wear an oxygen mask

(McCance & Huether, 2015).

7. Explain the difference in the signs and symptoms for Heat exhaustion and for Heat

Stroke

The symptoms of heat exhaustion are milder than those of heat stroke. For example, while heat

exhaustion is accompanied by a fever that does not exceed 104 degrees Fahrenheit the heat stroke

temperatures go over 105 degrees Fahrenheit. In heat exhaustion, the patient profusely sweats but

in heat stroke no sweating due to a high level of dehydration in the patient (McCance & Huether,

2015).

8. Define Hypothermia. List two signs and symptoms Melony might show if she became

very cold in Machu Pichu

Hypothermia is a condition of having abnormally very low body temperature due to the body

losing more heat than it can produce. Its signs and symptoms include; shivering, weak pulse,

memory loss and bright red cold skin (Pasquier, 2014).

9. Why should you never remove a penetrating object? What action should the guide

with her take?

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 14

The penetrating stick in Melony’s skin should not be removed as this will lead to a further

damage in her nerves and blood vessels. Rather, the guide should fasten the stick into the foot

with a bandage to prevent its further movements as she seeks medical intervention (Pasquier,

2014).

10. List the most common signs of a Benzodiazopine (sleeping tablet) overdose.

As a first responder what contact number in Australia should you ring for advise if

you suspect an overdose or poisoning?

The most common signs of benzodiazepine overdose are impaired balance, slurred speech, CNS

depression and ataxia. In case of suspect of poisoning or overdose in Australia, I should call

131126 or 000

11. After watching the video on Concussion, list four (4) of the common symptoms you

would need to look out for if Melony was to fall and sustain a head injury

If Melony was to fall and sustain head injury after taking the concussion, I would look out for

loss of consciousness, her repetition of phrases in her speech, dizziness and also nausea or

vomiting (www.youtube.com).

12. Define Blunt trauma.

Blunt trauma is a serious body injury which is caused by a collision with a blunt surface or being

hit by a blunt object.

ASSESSMENT TASK FIVE - CLINICAL SCENARIO 4 15

References

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2017). Lewis's Medical-Surgical Nursing:

Assessment and Management of Clinical Problems. Elsevier Health Sciences.

https://www.youtube.com/watch?v=xvjK-4NXRsM

Johnson, V. L., & Hunter, D. J. (2014). The epidemiology of osteoarthritis. Best practice &

research Clinical rheumatology, 28(1), 5-15.

McCance, K. L., & Huether, S. E. (2015). Pathophysiology-E-Book: The Biologic Basis for

Disease in Adults and Children. Elsevier Health Sciences.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes

Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health

Sciences.

Pasquier, M., Zurron, N., Weith, B., Turini, P., Dami, F., Carron, P. N., & Paal, P. (2014). Deep

accidental hypothermia with core temperature below 24 C presenting with vital

signs. High altitude medicine & biology, 15(1), 58-63.

Shin, J. Y., &Habermann, B. (2017). Nursing Research in Parkinson’s Disease From 2006 to

2015: A systematic review. Clinical nursing research, 26(2), 142-156.

Assessment task five - clinical scenario 4

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