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Assessment 3 – Written assessment
The final written assessment measures application of knowledge relating to the content areas of the unit and then applied to the action of graduate applications. The finalized assignment is formatted to provide the basis of a job application portfolio to which students are encouraged to add additional questions and answers
This 2000 word assignment will function as a blue print of the student’s preparation for interview and will have 4 sections:
Section 1. Clinical question.
Your patient is 2 days post laparotomy and has started taking fluids. They are now complaining of abdominal discomfort and nausea. What will your actions be?
Explain your answer in detail including your assessment, hypotheses and rationales for actions. 500 words
After morning handover of your 4 patients you have reviewed the charts and have entered the room to greet your patients. It is 0730 and breakfast is usually delivered at 0740. Before you can introduce yourself, the following demands on your time occur concurrently:
Patient 1 Mrs Peterson is asking for help to the ensuite to use her bowels. You know Mrs Peterson had a stroke 2 weeks ago and has a moderate left hemiplegia and needs assistance to move. She is classified as a high falls risk.
Registered Nurse An Nguyen in the adjacent bed unit enters the room and asks you to check some Endone for her patient.
Patient 2 Mrs Walters requires a blood glucose assessment. You noted it was not done at 0600 when you reviewed the chart. She may require sliding scale insulin prior to eating.
Patient 3 Mr Young is nil by mouth and has IV therapy running at 167mls per hour. The infusion pump alarm is sounding and the IV flask appears to be close to empty.
Patient 4 Mr Stavropoulous has been admitted for acute asthma. He is due to have Ventolin
and Seretide at 0800 but as you look at him you note he appears short of breath and he is sitting upright with increased work of breathing.
In what order would you address these requests? Describe your rationale for each decision.
Section 3. Professional
Your patient Mr Stanley is having an ascitic tap on the ward today. You have reviewed the requirements of the procedure and understand that you need to assist by caring for the patient, managing analgesia and monitoring vital signs during the procedure. It is lunchtime in your busy ward. Your colleagues including the ANUM in charge, are off the ward having lunch. The ANUM handed over to you that Mr Stanley is having the ascitic tap after 1.30 when sufficient staff are available and that she has negotiated this with the resident medical officer (RMO). You are monitoring another patient with hypoglycaemia when you see the RMO with the procedure trolley going into Mr Stanley’s room. The procedure requires a nurse be in attendance. You have no available staff and you need to monitor your hypoglycaemic patient. How will you manage this RMO?
Describe in detail your response to your chosen scenario drawing upon your knowledge and research of professional regulations and requirements, professional behaviour, conflict resolution techniques, education and provision of feedback.
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Section 1.Clinical question ( This section is under the word limit should be 500 words )
According to Agabiti et al., (2012), the first step would be to gather all the information about the patient’s pre-operative health status, details of the operation and the consequent progress since the procedure was done. This information could be available from case notes about the patient’s medical history, general fitness, examination findings, and medications administered. From the medical history, attention is drawn to any information that gives evidence of chronic abdominal problems and the various investigations that have been undertaken and may give clues to the current problem. In the case of any problems that may be associated with the operation such as the procedure itself or anaesthesia, these should again be noted (Campos et al., 2013). Case records and nursing observations made since the time of the procedure will also be useful in the determination of the cause of the problem, as well as any investigations that may have been performed since the procedure.
Nursing assessment should comprise inspection which consists of visual exam of the Nursing assessment should comprise inspection which consists of visual exam of the patients abdomen with interest in the shape of the abdomen, skin abnormalities, movement of the abdominal wall with respiration which provide clues to the intra-abdominal pathology (Campos et al., 2013). This can be followed with auscultation of the abdomen that would be useful in detecting bowel sounds, vascular bruits or rubs since normal peristalsis creates a particular sound pattern that would be altered in case of surgical complications. Finally, palpation could also be done gently to assess the presence of tenderness or abdominal masses.
After examination of history, if the state of the patient allows, present history should be taken, against an observation of the patient’s present state, with a particular interest in evidence of obstruction of the bowel functioning and/ or loss of intestinal movement (Khandra et al., 2015). Testing some of these hypotheses may require several investigations such as blood culture, abdominal ultrasound etc. In the event that sepsis is likely, broad spectrum antibiotics would be recommended. Khandra et al., (2015) identifies infections as the main cause of sepsis and may occur after surgery, either at the point of incision or as an infection that occurs following the surgery and therefore IV antibiotics would be recommended.
Bowel blockages and/or lack of intestinal movements may be diagnosed through clinical assessments such as inspection, auscultation and palpation or abdominal ultrasound scans and may be indicative of post-surgical adhesions (Khandra et al., 2015. Sometimes, a diagnosis may not be possible without surgical procedures such as laparoscopy, endoscopy, and colonoscopy, laparotomy, as well as blood tests, CT scans and X-rays to determine the extent of the problem. Treatment will vary, depending on the nature and severity of the problem. In some cases, this problem may improve without surgery and therefore, unless it’s an emergency, doctors may opt to treat the symptoms rather than carry out a surgical procedure. Esomeprazole and Domperidone would be helpful to alleviate the abdominal pain and nausea.
Often times, nurses tend to focus on problems rather than the whole picture, which affects their ability to set priorities. By necessity, however, some care needs may be delayed due to the preference for the most pressing needs of other patients. Priorities, therefore, will be influenced by the acuity of the condition of a patient, or that of all patients that are assigned to a nurse. According to Davies (2014), the first priority should be given to first level patient problems, which are direct threats to a patient’s survival and often demand the immediate attention of the nurse. They include the airway, circulation and breathing problems. Second level problems follow, and these include changes in mental status, acute pain, and untreated medical conditions requiring immediate attention. The third and last level of priority is those that do not fit into any of the above-mentioned categories such as medication monitoring for side effects, problems with living activities among others. In cases where there is no life -threatening problems, nurses often use both professional judgments and patients to set these priorities and determine the best plan of action.
Immediate attention should be directed to the patient with a first level problem, in this case, patient 4, who has an acute asthma problem. While his next dose is due at 8 am, it’s evident that he is short of breath and is struggling to breathe. According to The National Clinical Guideline (2015), asthma attacks are characterized by shortness of breath, difficulties in breathing, wheezing and coughing among others and therefore the observed symptoms could be signs of an impending asthma attack, which if not quickly attended to, could be fatal. Giving the Ventolin and Seretide are helpful in clearing the airways, which helps normalize the breathing system.
The second priority is Mrs Walters who needs a blood glucose assessment. According to Diabetes care (2013), fasting blood sugar test is an essential test that is used for, determination of the success of treatment options and hypoglycaemia, which helps healthcare professionals to monitor patients with these conditions. Since this test was not done at the right time, it becomes a priority since there is little time left for breakfast, yet it is a fasting glucose test.
Mrs Peterson, who requires using the bathroom, is also a high-falls risk patient, due to her stroke and the left hemiplegia, requiring her to use assistance to walk. KÜLCÜ (2015) identifies falling as one of the most common complications of stroke patients, thus occasioning the need to determine the falling risk of a patient as well as taking the necessary precautions to prevent falls. Reportedly, 14-65% of patients fall during hospitalization while 37%-73% fall within 6 months after discharge. This is corroborated by Cho,Yu, & Rhee, (2016) who noted that the mortality rates of falls rises dramatically with age with more than 90% of hip fractures occurring as a result of falls
Patient 3, Mrs Young should be next on the line. Seeing that the IV therapy is almost finished, it’s important to get it refilled. According to the Royal College of nursing (2016), IV therapy management need not to be a life threatening activity, if it’s well-managed, in terms of infection control and prevention, site and devise selection and placement etc. When the IV therapy gets finished, the nurse needs to follow the set guidelines on refilling so as not to put the patient at risk of infection or IV complications.
After attending to these patients, it’s only then that the Endone for my colleague’s patient can be checked. Endone is a moderate -to-severe painkiller, and therefore, may not precede the attendance to more critical patients, as such pain is obviously not life threatening. Davies (2014) identifies moderate to severe pain as a third level patient problem which may only be attended to after more life threatening issues have been addressed. In fact, in the first instance, I should ask the nurse to wait to check the Endone or find someone to do it since I have to attend my first three patients very urgently.
The role of medical professionals is to ensure the welfare of the patient is safeguarded. To safeguard this welfare, medical professionals are bound by a code of professional ethics that guides their conduct in relation to their patients, colleagues, and associates (Medical board of Australia, March 2014. Non-adherence to these laid down standards may jeopardize the health and safety of the patient, resulting in personal liability as well as institutional vicarious liability.
The code of conduct for medical officers demands that medical professionals must maintain a very high level of medical competence and professional conduct so as to guarantee good medical practice (Medical board of Australia, March 2014). This involves recognizing and working within their limits of competence and scope of practice and also ensuring that they practice in a safe and conducive environment for the benefit of their patients (Code of conduct for doctors in Australia, 2014). They should also maintain good relationships with colleagues, nursing, and other healthcare professionals so as to enhance their patient care. Besides, they should work in an environment that fosters mutual respect and clear communication between and among healthcare professionals by acknowledging and respecting the contribution and input of other healthcare professionals that are involved in the care of the patient (Code of conduct for doctors in Australia, March 2014).
In this case study, it’s clear that professional requirements and conduct that have been ignored. First, this procedure requires a nurse to care for the patient, manage analgesia and monitor the vital signs during the ascitic tap procedure, yet the resident medical officer intends to carry out the procedure without the help of a nurse, yet it is a requirement for the procedure (Kieft et al., 2014). This being a patient assigned to me, there is the general feeling of responsibility for their wellbeing and therefore these calls for action on the best way forward. Since the only nurse in the ward is busy attending to and hypoglycaemic patient, it’s not possible to assist with the procedure. I would do the following regarding this RMO.
The most immediate step is to inform the RMO that the procedure should not be undertaken in the absence of a nurse, and that given the momentary staffing challenge, the procedure should be adjourned, at least until there is a nurse who can assist with the above-mentioned activities, as I am currently unable to assist, given my current engagement with another patient. If the RMO insists on continuing with the procedure, I am bound by professional reporting obligations. According to the medical association section 140 (d), mandatory notification should be done when the public ‘is at risk of harm because the practice constitutes a departure from accepted professional standards’ (Medical board of Australia, 2014. Conducting the ascitic tap, without the help of a nurse who would be charged with the responsibility of such vital activities such as monitoring vital signs, analgesics and patient care risks the safety of the patient and therefore is a deviation from the accepted professional standards and there a reporting obligation regarding this incident. Professional standards, in this case, relate to those standards that are generally accepted by a ‘reasonable’ proportion of practitioners, are associates the departure risks to the patient’s welfare (Nursing and Midwifery Board of Australia, 2013).
The above actions may result in a conflict with the RMO, which must be addressed for a harmonious work environment. According to Registered Nurses’ Association of Ontario (2012), conflict resolution is a time-consuming but necessary activity. Organizations manage conflict by developing a professional code of conduct, policies, and staff-bylaws. Having proper ground rules makes it easier to discipline individuals as personalities are removed from the equation. A disciplinary structure that is well developed with patterns of referral to a higher authority, as well as knowledge on the disciplinary pathway, is a key in resolving conflicts among healthcare professional. The management must institute workable conflict resolution mechanisms that are geared at ensuring that we are able to work together and that each and every one of us understands their obligations and expectations of their professional conduct in the workplace. The most effective conflict resolution mechanism in this circumstance would be collaboration, which is a dispute resolution technique that encourages a deeper understanding of the cause of conflict and tries to satisfy the concerns of the affected parties (Louisiana State University, 2014).
Agabiti, N., Stafoggia, M., Davoli,M., Fusco,D., Barone, A.P. &, Perucci,C.,A.(2012). Thirty-day complications after laparoscopic or open cholecystectomy: a population-based cohort study in Italy. BMJ Open. doi:10.1136/bmjopen- 001943
Campos, L.S., Limberger,L.F., Stein,A.T., & Kalil,A.N. (2013).Postoperative pain and perioperative outcomes after laparoscopic radical hysterectomy and abdominal radical hysterectomy in patients with early cervical cancer: a randomized controlled trial. Biomed central.
Davies, N (2014).The benefits of prioritization. Electronic. Retrieved fromhttp://journals.rcni.com/doi/full/10.7748/ns.29.11.65.s53
Khandra,H.P., Vyas,P.H.,Patel,N.J & Mathew,J,G. (2015).Factors affecting postoperative wound complications. International archives of integrated medicine. Retrieved from http://iaimjournal.com/
Kieft A. R., Brouwer,B.J., Frankle,A.L & Deljoij, D.M (2014).How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. Retrieved from https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-249
Louisiana State University (2014). Effective Conflict Resolution Strategies. Retrieved from: http://www.civilservice.louisiana.gov/files/divisions/Training/Manuals/Effective%20Conflict%20Resolution%20Strategies.pdf
Medical board of Australia (2014, March).Codes, guidelines, and policies, retrieved from http://www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx
Nursing and Midwifery Board of Australia (2013, June). Professional codes and guidelines: retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements.aspx
The National Clinical Guideline (2015). Management of an Acute Asthma Attack in Adults (aged 16 years and older) retrieved from www.health.gov.ie/patient-safety/ncec and www.hse.ie/asthma
Külcü,D.G (2015). Fall Risk Evaluation in Stroke. Turkish Journal of Physical and Medical Rehabilitation; 61:296-7.retrieved from http://www.ftrdergisi.com/uploads/sayilar/296/buyuk/296-297y.pdf
Cho, K., Yu, J., & Rhee H. (2016). Risk factors related to falling in stroke patients: a cross-sectional study. Journal of Physical Therapy Science 2015;27:1751-3.
Royal College of Nursing. (2016). Standards for infusion therapy, 4th edition. Retrieved from https://www.rcn.org.uk/professional-development/publications/pub-005704