Clearly state the problem: Consider the problem within its context and attempt to distinguish between ethical problems and other medical, social and legal problems

Ethical and Legal Case Studies

Ethical and Legal Case Studies

Order Description

Case study: Mr Wang is 62 years old. He is an alcoholic gentleman who has been diagnosed with cirrhosis of the liver some 3 years ago.
Mr Wang attends the clinic regularly for check -ups however recently his condition has worsened and he has presented with nausea, ascites, and slothfulness. Mr Wang

was informed that the disease process was advancing. Mr Wang’s family were informed that he was now terminal and that care would be largely palliative from this point

on. The family asked that the terminal nature of the disease be retained from their father and the consultant agreed.

The clinic proposed that he be admitted to hospital for drainage of the ascites and the insertion of a urinary catheter. Mr Wang agrees to go to the hospital for the

interim care and tells his family he will be home soon and ready to spend the Christmas holidays with them all.

Mr Wang dies in hospital prior to the holiday seasons arrival.

-Use the ethical decision making framework to determine your analysis of the care provided to Mr Wang

-Consider the legal and ethical implications surrounding the withholding of the truth from Mr Wang as his disease status becomes terminal.

-Can it be justified to withhold information?

-Consider professional and regulatory responsibilities as well for the Nurses involved together with other members of the multidisciplinary team.

Model for Ethical Decision-Making.

• Please use these headings when writing your case study

1. Clearly state the problem:
Consider the problem within its context and attempt to distinguish between ethical problems and other medical, social and legal problems

2. Get the facts:
Find out as much as you can about the problem through history, examination and relevant investigations.
Are there necessary facts that you do not have? If not search for them.

3. Consider the four ethical principles:
• Autonomy: what are the patient’s preferences?
• Beneficence: What benefits can be obtained for the patient?
• Non-maleficence: what are the risks and how can they be avoided?
• Justice: how are the interests of different parties to be balanced?

4. Identify ethical conflicts:
Explain why the conflicts occur and how they may be resolved.

5. Consider the Law:
Identify relevant legal concepts and laws and how they might guide management,
Examine relationships between the clinical-ethical decision and the law.

6. Making the ethical decision: Clearly state the clinical ethical decision and justify it eg:
Specify how guiding principles were balanced and why( i.e. justify the decision)
Take responsibility for the decision & provide alternative management;
Evaluate the decision;
Document the decision
Use the Model for Ethical Decision Making provided below to determine your recommendations for the ongoing care of your chosen client.

You MUST include in your referencing two (2) or more of the following: (please see useful resources link at the top of your Assessments tab in Blackboard for links to

documents required).

Health Practitioner Regulation National Law Act 2010 (WA)
ANMC Code of Conduct for the Registered Nurse
Singapore Code of Ethics and Professional Conduct
ANMC National Competency Standards for the Registered Nurse 2012
Singapore Nursing Board Standards of Practice
ANMC Code of Ethics for Registered Nurses 2008 or Singapore Code of Ethics
ANMC National Framework for the Development of Decision Making Framework:
2007 Scope of Nursing Practice
ANMC Professional Boundaries 2010

Guideline:

There should be attention to spelling grammar and punctuation. Citations within text and reference list should conform to APA 6th ed format. There should be evidence

of critical thinking.

Introduction:
To include a rationale as to why they are using a Model for Ethical Decision Making and to correctly. Reference the particular model in the text and the reference list

the introduction should include the ethical problem statement, the medical problem statement, the legal problem statement and the social problem statement. This should

look like:
Ethical: Is it ethical that Mr Wang does not know his condition? Has Mr Wang’s Family been fair in withholding information?
Medical There should be referenced material about cirrhosis. Some reference should be made to terminal and palliative. Consideration should be made around the possible

psychological effects of being having this condition and not knowing about it and the impact of being given the information about his condition.
Describe social issues such as family support.
Legal Describe legal issues such as potential for harm to be caused to Mr Wang because he has not had information about his disease or treatment.

Get the Facts
What further questions would you ask from the history, what further investigations are needed?Are there any other necessary facts that you don’t have and would want to

know?

Consider the Four Ethical Principles
Referenced definition of each principle
Statement of how each principle applies to the case.

Autonomy
Mr Wang’s right to have information about his condition and treatment and to actively participate in decision making.
Beneficence
Is it in Mr Wang’s best interest that his family had stopped him from knowing about his condition and treatment? Does the doctor have a role in changing this

situation?

Non Maleficence
Is the fact that Mr Wang doesn’t have knowledge about his treatment causing him harm? Does the doctor have a role in changing this situation?

Justice
Is it fair that Mr Wang is being treated differently to other patients because of his family asking that he not be told about the nature of his condition?

Ethical Conflicts
Discuss conflicts that may occur between autonomy and justice or beneficence and nonmaleficence.

Consider The Law
Explain with regard to Mr Wang Consent, relevant ANMC codes and standards. Potential for harm to Mr Wang not understanding treatment.

Ethical Decision
As per marking guide
Decision is clearly stated
Referenced justification for decision
Considers how decision would be evaluated
Evidence of clear understanding of the documentation process required
Uses appropriate in text citations

Marking Criteria:
Consideration of practice standards, law and legislation. (15 marks)

Identification and application of ethical principles
Identification of potential ethical conflicts (15 marks)

Resolution to problem reached and conclusion(10 marks)

Conventions:
• grammar
• spelling
• punctuation
• APA style
• in-text referencing
end-text referencing (10 marks)

 

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Critically discuss four (4) components of the PACU discharge criteria outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in your case study.

Case Study 3: John Wong (Transurethral Resection of the Prostate).

Case Study 3: John Wong (Transurethral Resection of the Prostate).

John Wong is an 80 year old male of Chinese origin. John’s medical history includes
hypothyroidism and osteoporosis and he smokes 10 cigarettes per day. His gait has
recently been increasingly unstable and he has difficulty with simple tasks, such as
getting up his house stairs and getting up from chairs.
In the last 4 weeks, he has noticed that he has been having difficulty passing urine and
some abdominal discomfort. His GP referred him to a urologist and a prostate biopsy
was taken. This showed BPH (benign prostate hyperplasia) and it was recommended
that he undergo a Transurethral Resection of the Prostate (TURP).
While conducting John’s pre-admission assessment it is noted that John is slightly
hypertensive and is fidgeting and moving around the waiting room. After some education
John states that he is pleased to have the surgery as he hopes it will relieve some of the
discomfort he has been experiencing. John tells the nurse that he currently lives alone.
John’s surgery is uneventful during the intra-operative stage. On arrival to PACU John is
placed in a supine position. He is drowsy and restless and oxygenated through a
facemask on 02 at 5l/min. A wheeze and non-productive cough is noted. John has an
IDC insitu with continuous bladder irrigation with output noted to be a reddish pink. A
number of blankets are placed on top of him as he is shivering. His observations are T
36.5c, HR 90, RR 30, BP 150/90 and SpO2 91%.
John is transferred to the surgical ward after a 65 minute stay in PACU. John remains
drowsy but easily rousable. He is oxygenated via intra-nasal cannulae at 2l/min and he
states his pain is 3/10. He has 0.9% sodium chloride infusion running at 125ml/hr. Postoperative
orders include IVF, analgesia (PRN Endone, 5mg 6hrly and Paracetamol, 1g
4-6hourly), strict FBC and continuous bladder irrigation for 24 hours, with an aim of rose
urine output.
Four hours after John’s return to the ward he is observed to be in pain and distressed.
He is diaphoretic and restless and states that his bladder feels full and he feels the urge
to urinate. At this time, vital signs are noted to be: T 36.9c, HR 91, RR 28, BP 146/91 &
SPO2 98%. On review of his documentation it is found that his fluid status has a positive
500ml balance and his urine is of red colour. There are blood clots in his urine.
QUESTIONS
Please refer to the rubric on page 14 on the Unit Outline for full marking criteria
1. In relation to your chosen patient, discuss the pathophysiology of their
condition and using evidence based practice explore current treatment options
for your patient’s condition, include any pharmacological and nonpharmacological
considerations.
2. Critically discuss four (4) components of the PACU discharge criteria
outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in
your case study.
3. Develop a discharge plan to support your patient on discharge. Include
any education you deem relevant, any referrals to allied health professional/s
required, and discuss your rationale.

NRSG258 Acute Care Nursing 1, Semester 1 2015 Page 12 of 19;

Assessment Task 1: Case Study
Description: Students are to choose one (1) of the case studies available (see
LEO) and answer the associated questions. The assignment is to
be presented in a question/answer format, and not as an essay
(i.e. no introduction or conclusion). Each answer has a word limit;
each answer must be supported with citations. Students should
follow the recommended formatting for academic papers
http://students.acu.edu.au/308971 Students must provide in-text
referencing and a reference list must be provided at the end of
the assignment.
Due date: Friday 27th March: Midnight (Week 5)
Weighting: 40%
Length and/or format: 1500 words
Purpose: Facilitate the development of critical thinking in relation to nursing
management along the perioperative continuum including
effective care, safety and evaluation.
Learning outcomes assessed: 1, 2, 3, 5 & 6
How to submit: Students are to submit the following via Turnitin Case Study
submission folder as one document:
?? Assignment
?? Reference List (adhering to APA style)
Return of assignment: Case Study submissions will be returned to students online via
LEO.
Assessment criteria: This assessment task will be graded against a standardised
criterion referenced rubric. Please follow these criteria closely
during the planning and development of your assignment.
For more comprehensive information on this assessment task, including the available case studies and
the Aldrete resource required for this assignment, please refer to the Case Study Folder in LEO under
‘My Assessments’.

 

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Compare four or five models of reflection but must include (Gibbs model of reflection 1988) Explain why this is commonly used in nursing practice and it’s simplicity for student nurses.

Cycles of reflection

Cycles of reflection

Order Description

• 1100 words

• written to a masters level

• Harvard Referenced

• Cycle of reflection

• Compare four or five models of reflection but must include (Gibbs model of reflection 1988) Explain why this is commonly used in nursing practice and it’s simplicity for student nurses.

• Also Johns model 1994, Kolb”s model 1980 and Goodman”s model 1984 need to be compared and why some of these would be better used by the more experienced nurse.

• Describe which model would be best used in nursing practice , that is more detailed and will accumulate more learning and information for the nurse using this model.

• Frameworks for reflection can be used to encourage and support reflection and therefore the choice of framework depends on the students skills and experience Why is this important to their learning and development.

• Critically analysis all of the models arguing with what is good and bad about them

• Talk about reflective practice and is use to medical education.

• The importance of students developing a habit of assessing their own learning needs.

• When referencing please use journals as well as books

 

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Mentoring Student Nurses as a guide into practice. Mentoring Student Nurses as a guide into practice. Order Description • Mentoring Student Nurses • Written at Maters level.

Mentoring Student Nurses as a guide into practice.

Mentoring Student Nurses as a guide into practice.

Order Description

• Mentoring Student Nurses

• Written at Maters level.

• Harvard Referencing. And to incorporate journals and books and to remain in the UK as much as possible.

• Mentoring strategies to prepare students for clinical practice.

• Establishing work relationships.

• How to plan out learning, so the student would achieve their learning outcomes.

• Assessment of accountability, NMC

• How to evaluate learning

• Teaching skills.

• Why use a SWOT analysis and argue why this is good or bad and compare.

• Base this on the NMC (nursing and midwifery council) “Standards To Support Learning and Assessment In Practice”

• Also use the “Frances Report to refer to and use the Six C’s (Care, Compassion, Competence, Communication, Courage, Commitment,)

• Use Learning styles and facilitation of learning.

• Learning styles with student. In detail.

• Analysis mentors teaching skills and techniques

• Also analysis mentors barriers such as “failing to fail” Duffy 2003 and Failure to fail “art and science “ Nursing Standard 2007 The Toxic Mentor who makes it difficult for the student to achieve their learning outcomes.

• Use “Scot I and Spouse J 2010 Practice Based Learning in Health and Social Care.

• Use Principles of Practice assessment.

• Facilitation of learning. For example use knowledge of the students stage of learning to select appropriate learning opportunities to meet individual needs and feedback.

• Facilitation and selection of appropriate learning strategies to integrate learning from practice and academic experiences.

• Assessment and accountability and how to provide feedback

• Must use and compare to NMC Standards of Support learning and assessment in practice.

• Mentor’s accountability in nursing practice and use NMC Code.

• How a mentor should perform as teacher. (learning and assessing. )

• Critically analysis in depth and map this out.

• Barriers that can occur and why.

• Some books that also must be used are as follows. “Being an Effective Mentor” Kathleen Feeney Jonson
2008, Nurse as Educator, Susan B Bastable 2014, Mentoring Preceptor ship and Clinical Supervision. 2000, Mastering Mentorship, Julie Baily- McHale and Donna Hart, 2011, The Code: Standards of Conduct, Performance and ethics for nurses and midwives . 2008.

 

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1)Introduction 2) Analyzes factors that impact professional socialization of nursing students, and provides accurate, quality details and references.

Professional Socialization

Professional Socialization

Order Description

As a nurse educator, you are responsible for facilitating students’ socialization into the professional nursing role. You may also be in a position to help new nursing faculty with their transition to the academic environment.

For this assignment, create an activity—such as a role play, group project, or other activity—that facilitates this professional socialization. Successful completion of this assignment will demonstrate your knowledge of the factors that impact professional socialization of nursing students and the nursing faculty, which will allow you to evaluate the instructor’s role in facilitating professional socialization, and create a learning environment focused on socialization. Include the following in your paper:

Introduction or description: Describe the professional socialization activity you created. Who will be involved? Where and when will it take place? What resources are needed?
Rationale: Describe factors that impact professional socialization. How does this activity relate to these factors? Why will this activity be successful?
Role of the faculty: Aside from designing this activity, what will be your role? Will you act as an advisor or mentor? Will you participate in the activity? Secure resources? Provide feedback?
Intended outcomes: What are the specific outcomes you expect about the professional socialization of nursing students who participate in this activity?
Evaluation: Which assessment or evaluation strategies will you use to determine achievement of outcome.
Grading criteria:
1)Introduction

2) Analyzes factors that impact professional socialization of nursing students, and provides accurate, quality details and references.

3)Evaluates the instructor’s role in facilitating students’ socialization into the professional nursing role, and provides accurate, quality details and references.

4)Creates learning environments or activities that are solely focused on socialization into the role of the nurse, and provides accurate, quality details on the learning environment.

5)Identifies and evaluates intended outcomes of learning environments or activities that are focused on socialization into the role of the nurse. The intended outcomes are attainable through the activities.

6)Consistently communicates through scholarly writing that is concise, balanced, and organized, flows with smooth transitions between ideas, and demonstrates critical analysis of the literature.

7)Consistently communicates through scholarly writing that demonstrates mastery of sixth edition style and formatting, is free of errors, and follows all assignment instructions.

 

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Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?

1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?

Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory)
Normal

High-normal

Stage 1

Stage 2

2)    What lifestyle measures would you advise Mr KK to help lower his blood pressure? Why are lifestyle measures important?

3)    About 1 week later Mr KK comes back into your pharmacy, he has now had 24 hour BP monitoring and his diagnosis of hypertension has been confirmed.

a.    How should an initial antihypertensive treatment be chosen for Mr KK?

b.    What antihypertensive therapy would you choose to start Mr KK on? What target blood pressure would you recommend for Mr KK and how often would you monitor his

blood pressure?

Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Hypertension

PART B: CARDIOVASCULAR RISK

4)    Mr KK has a cholesterol of 6.5mmol/L and his total cholesterol:HDL ratio is 6.5. Calculate his overall cardiovascular risk using the tables in the BNF.

Complete the table below with his modifiable and non-modifiable risk factors for CVD

Modifiable    Non-modifiable

5)    Mr KK’s doctor now wants to start other medicines for primary prevention. What do you understand by primary prevention? Suggest a drug and dosage regime if

appropriate. What counselling would you give Mr KK about any new medicines you recommend?

Fill this in on your care plan.

Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Cardiovascular Risk

PART C: OTHER CO-MORBIDITIES

Although you should refer to the NICE guidance for hypertension when choosing antihypertensive therapy consideration should also be given to co-morbid conditions

6)    In four groups, discuss, giving reasons, which antihypertensive(s)
would be a good choice or poor choice. What target BP would you aim for in these patients?

•    White male accountant, 34 years old, asthma and weighs 82kg

•    White male, 70 years old, diabetes and CKD (Creatinine 250micromol/L). He weighs 70kg and is 5 feet 9 inches tall.

•    28 year old African woman with CKD (Creatinine 290micrmol/L)

•    72 year old African American woman with chronic cardiac failure NYHA Stage 3.

PART D: ISCHAEMIC HEART DISEASE

7)    About 6 months later, Mr KK visits your pharmacy again. He tells you
his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?

8)    What changes would you recommend to Mr KK’s prescription and why? What counselling and monitoring would he need?

9)    Mr KK comes back to your pharmacy 3 months later with a prescription for a GTN spray. You notice this will be his 4th repeat prescription for this in the last

3 months. What questions do you want to ask him before you dispense this and what changes could you suggest to his therapy?

Question        Response

10)    Mr KK collects a new prescription for his GTN spray and asks you when he should expect to need a new one. Each GTN spray contains 200sprays; Mr KK is now using

2 puffs 4 times a week. The spray you have dispensed for him expires in May 2015.

WORKSHOP THREE

MAJOR THEMES:
CHRONIC HEART FAILURE

LEARNING OBJECTIVES

Following the lecture, workshop, directed and background reading, students should be able to:

1)     Describe the aetiology and presentation of heart failure
2)     List the desired outcomes in care of patients with heart failure and how
pharmacists can help achieve these
3)     Discuss the pharmaceutical management of heart failure
4)     Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy
5)    List the counselling required by patients commencing therapy on ACEIs and beta blockers for heart failure

DIRECTED READING

Karagkounis D. Heart Failure – clinical features and diagnosis. Clinical Pharmacist. 2014; 6: 119-122 2010

Williams H. Heart Failure – management. Clinical Pharmacist. 2014; 6:123-1282010

BNF sections 2.5.5

NICE Bites – Chronic Heart Failure (NW MI) September 2010

NICE Clinical Guideline No: 108 August 2010: Management of Chronic Heart Failure in adults in Primary and Secondary Care. NICE guideline Pages 15-20 Pharmacological

Treatment of Heart Failure and Appendix D – Practical Notes

BACKGROUND READING

Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007

Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook
PRE- WORKSHOP LEARNING – A HEART FAILURE FORMULARY

For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.

Beta-blockers (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin Converting Enzyme Inhibitors
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin II Receptor Antagonist (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Aldosterone Antagonists
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Loop diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Thiazide diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

WORKSHOP THREE: ANSWER ALL THESE QUESTIONS USING THE READING LIST IN THE PREVIOUS PAGE TO HELP YOU ANSWER THESE QUESTIONS PLEASE ANSWER THEM IN DETAIL

Mrs LL a 70 year old lady attended her GP practice as she had noticed that she had become increasingly tired and short of breath on carrying out her usual activities.

PC     Increased tiredness, SOB and swollen ankles

HPC   She noticed she needed to stop for breath when walking up the stairs.
Feeling tired and lethargic as not sleeping well at night for the last 2/52. Legs are feeling heavy and her shoes feel tight.

PMH    IHD, OA, MI 4 yrs ago
SHx    Lives alone in a house, usually independent, doesn’t drink any alcohol, ex-smoker, quit after her MI
RS    Basal creps in both lower bases, cough for past week producing watery sputum
CVS    BP 150/95mmHg    Pulse 90bpm reg
CNS     Grossly intact

O/E    Pitting oedema on both feet

Weight today = 67kg
Last recorded weight (4 months ago) in practice records = 60kg

Working diagnosis:    Heart failure/COPD/General deterioration

Current Rx:    Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Atenolol 50mg Mane
Ramipril 1.25mg Mane
GTN spray 400mcg 1-2 sprays when required for chest pain

1.    What do you understand by the term heart failure?

2. What medical conditions can lead to the development of heart failure?

3. What signs and symptoms does Mrs LL have that may be suggestive of
heart failure? How do these arise?

4. How would the diagnosis of heart failure in Mrs LL be confirmed?

5. What treatment option would you add to Mrs LL whilst she is awaiting her ECHO and specialist review? Include a suggested dose, preferred route of administration,

any monitoring required, and counselling you should offer Mrs LL.

Mrs LL is seen by a Cardiologist and her ECHO confirms that she has Left Ventricular Systolic Dysfunction (LVSD) with an Ejection Fraction of 30%. The aetiology of her

heart failure is due to ischaemia. The Cardiologist felt no further interventions or stents would be beneficial and optimisation of medical management was the plan.

Mrs LL was referred to the local Community heart failure nurses for optimisation.

On her first appointment the recommendation is to titrate ramipril to 2.5mg daily and switch atenolol to bisoprolol 2.5mg once daily.

6.   Why are angiotensin converting enzyme (ACE) inhibitors and beta-blockers recommended first line in the management of heart failure?

7.    a) How should ACE therapy be titrated and what monitoring is required?

b) What are the main side effects of ACE inhibitors? How should they be managed?

8.    a) How should beta-blockers be initiated in heart failure and what monitoring is required?

b) Why was Mrs LL switched from atenolol to bisoprolol?

c) In which situations are beta –blockers contra-indicated?

d) What are the main side effects of beta –blockers and how can they be managed?

9.    Mrs LL wants to know how many pints of water she can drink in a day? Calculate and advise Mrs LL. (1 pint = 568ml)

Mrs LL attends for a follow up appointment at the heart failure clinic she has noticed an increase in breathlessness since her last appointment and simple things like

brushing her teeth and getting dressed can make her extremely tired. Her osteoarthritis pain has worsened and her GP has given her a new prescription for her pain.

Current Treatment:
Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Bisoprolol 10mg Mane
Ramipril 10 mg Mane
Furosemide 40mg Mane
GTN spray 400mcg PRN
Naproxen 500mg TDS

Bloods: Creatinine 120micromol/L (60-120), urea 9mmol/L (2.5-7.5), potassium 4.5mmol/L (3.5-5)

BP 130/80mmHg, HR 65bpm. mild ankle swelling and lungs clear.

10.    Using the New York Heart Association (NYHA) functional classification,
how would you grade the severity of Mrs LL’s heart failure? Give reasons for your answer.

11.    Could any of Mrs LL’s drug treatments exacerbate her heart failure? If so,
how? Can you suggest alternative treatments that would not exacerbate her heart failure? Fill this in on your care plan.

12. Which other classes of drugs can precipitate or exacerbate heart failure?

13.    If Mrs LL’s heart failure were not controlled on her first-line agents, what second-line agents are available to add in?

14.    Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is
likely to have caused this and what would you recommend?

Pharmaceutical care plan for Mrs LL (on review clinic at question 11)

Problem    Desired Outcome     Assessment    Actions
Options    Follow up / monitoring    Counselling

Worsening Heart Failure symptoms following titration of ACEi and BB.

Osteoarthritis

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 According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?

8)    According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?

9)    A nursing student comes to you and tells you Miss HH’s “BMs are 2.3” (Random peripheral blood glucose is 2.3 mmol/L). What are the symptoms of a hypoglycaemic

attack and how would you would treat it? Why do some patients not exhibit any symptoms?

10)    Three months later, Miss HH is taking gliclazide 160mg BD but her blood sugar remains at least 11.5mmol/L most of the day. Three possible options exist other

than starting insulin. Which of the three possibilities below might or might not be suitable for Miss HH? Which would you support? Refer to the NICE algorithm.

a) Exenatide

b) sitagliptin

c) pioglitazone

11)    After a further 6 months on pioglitazone 30mg daily and gliclazide 160mg BD, Miss HH’s HbA1c remains stubbornly high at 78mmol/mol in the diabetic clinic. The

doctor decides to stop her pioglitazone and start subcutaneous insulin therapy whilst continuing gliclazide. Describe 3 different kinds of insulin regime – suggest

preparations and doses. Which one would you recommend for Miss HH? Which regime best mimics the body’s natural insulin release?

12)    Should Miss HH be started on aspirin or a statin? (Refer to the NICE Guidance 2009).

At home, complete the care plan for Miss HH at the point of hospital admission in Q7.
Pharmaceutical care plan for Miss HH  DOB 1/6/1968 (on admission)
Problem    Desired outcome     Assessment    Actions
Options    Follow up/monitoring    Counselling
DM2

HBA1c to 6.5%
No hypos (see below)
HBA1c and glucose uncontrolled on metformin 1g BD
? Compliance
Cr= 250 micromol/L
BMs/HbA1c in longer term
Push dietary advice
How to manage hypos
Risk of hypoglycaemic attacks

Want none     None yet but risk if starts non-metformin based therapy

Cardiovascular risk

Reduce risk of CVD (CHD+stroke) plus PVD,CKD, retinopathy and nephropathy    DM2 (Uncontrolled)        BP, CBG (BM), lipids, HbA1c regularly
CKD    Stop further deterioration, avoid ESRF>> Check chronic/acute    Already lost 2/3 of GFR by age 65- bodes ill Needs tight BP (esp c ACE); tight sugar control

BP, Cr, urinary protein regularly,

VTE prophylaxis whilst in hospital

WORKSHOP TWO

MAJOR THEMES
HYPERTENSION
PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE
ISCHAEMIC HEART DISEASE

LEARNING OBJECTIVES

Following the workshop, directed and background reading, students should be able to describe/understand:
1)    Basic principles and problems in the management of hypertension
2)    The importance of considering concomitant illness in the selection of antihypertensive therapy
3)    The concept of cardiovascular risk including primary and secondary prevention of cardiovascular disease.
4)    Management of stable ischaemic heart disease

DIRECTED READING

BNF sections 2.5 Introductory pages
Stable angina. NICE Clinical Guideline CG126 2011- Quick reference guide

Management of hypertension in adults in primary care. NICE Clinical Guideline CG127 2011

MHRA and CHM. Aspirin: not licensed for primary prevention of thrombotic vascular disease. Drug Safety Update 2009;3(3):10-11.

NICE Bites – Hypertension, UKMI September 2011

NICE Bites – Management of stable angina, UKMI, September 2011

BACKGROUND READING

Stable angina – Clinical features and diagnosis. Clinical Pharmacist, January 2012

Stable angina – Management. Clinical Pharmacist, January 2012

WORKSHOP EXERCISE

Fill in the empty boxes in the diagram of the renin-angiotensin system below.

ANSWER ALL THESE QUESTIONS USE THE READING LIST IN PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS IN DETAIL

Mr KK, a 61 year old Caucasian secondary school teacher, has recently been diagnosed with hypertension. His recent blood pressure reading was 165/100mmHg.

He feels generally well but has been under a great deal of stress at work recently. He has no past medical history. His older brother has hypertension and type II

diabetes and his father died aged 52 following a myocardial infarction. He has no other medical problems. He smokes 15 cigarettes a day and weighs about 100kg.

He doesn’t think that he has hypertension as he has had only 2 high readings but he is to have 24 hour blood pressure (BP) monitoring next week. He has also had blood

tests to check his blood sugar, cholesterol, renal function and liver function. He has read about white coat hypertension in the newspaper but was not sure what this

means.

 

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Following the workshop, directed and background reading, students should be able to: 1)    Outline the dietary recommendations given to patients with diabetes 2)    Discuss the place in therapy of the different oral hypoglycaemic agents 3)    Describe the different insulins available 4)    List the factors influencing choice of insulins and insulin delivery devices in diabetic patients.

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

LEARNING OBJECTIVES

Following the workshop, directed and background reading, students should be able to:
1)    Outline the dietary recommendations given to patients with diabetes
2)    Discuss the place in therapy of the different oral hypoglycaemic agents
3)    Describe the different insulins available
4)    List the factors influencing choice of insulins and insulin delivery devices in diabetic patients.

DIRECTED READING

BNF Section 6.1.1-6.1.4 Drugs used in diabetes (Introduction and section headings)

National Institute for Health and Clinical Excellence. Clinical Guideline 87 Management of type 2 diabetes. May 2009.

Jacques N. New NICE guidelines for type 2 diabetes treatment. Br J Clin Pharmacy 2009;1:167-8.

Questions:

What devices/forms are insulins commonly available in?

What are the major types of insulin by onset/duration of action?

BACKGROUND READING
National Institute for Health and Clinical Excellence. Clinical Guideline 15. The diagnosis and management of type 1 diabetes in adults. July 2004. (Look at pages 5-

10)

Hackett E, Jacques N, Gallagher A. Type 1 Diabetes: Pathophysiology and diagnosis. Clinical Pharmacist 2013;5:69-72.

Hackett E, Jacques N. Type 1 Diabetes: Insulin management. Clinical Pharmacist 2013;5:69-72.

WORKSHOP EXERCISE
Example of medicine    Typical starting and maximum dose    Class    How it works to lower blood glucose    Any other notes (place in therapy, common adverse

events, contra-indications etc.)
Insulin

Metformin

500mg od-max 2g OD

.
Gliclazide

40mg OD-max 320mg in divided doses

.
Pioglitazone

15mg OD- max 45mg OD

Nateglinide

60mg TDS to max 180mg TDS

Exenatide

5mcg BD top max 10mcg BD

Sitagliptin

100mg OD

Dapagliflozin     10mg OD

ANSWER ALL THESE QUESTIONS IN DETAIL AND USE THE READING LIST ON THE PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS

Miss HH is a 65 yr old lady weighing 83kg who presents to a community pharmacy, where you regularly do a locum, asking for “something stronger for thrush which keeps

coming back”. On further questioning she is feeling increasingly lethargic recently and is complaining of going to the toilet more often. You suspect she may have

diabetes mellitus and refer her to a G.P.

She has mild osteoarthritis and is only on ibuprofen and co-codamol.

1)    What signs and symptoms of diabetes mellitus does Miss HH have? What other initial symptoms may also be present?

2)    Miss HH has heard that in one type of diabetes she will need injections. She asks you how the G.P. will determine she has diabetes and which type she has?

What are the two types and is there a precise diagnosis for diabetes?

3)    What complications can arise in someone with diabetes mellitus?

4)    What are the aims of treating diabetes?

5) The G.P. diagnoses Miss HH with type 2 diabetes and gives her dietary advice. What type of diet is recommended in diabetic patients, and why?

6)    The GP also starts Miss HH on metformin 500mg TDS. In general, is this a reasonable initial therapy? What would make it not so?

7)    A year later Miss HH is seen in clinic and it is clear her diabetes is uncontrolled. She is admitted for review of her therapy. She is on metformin 1g bd for

her diabetes and usual painkillers. Blood tests came back as:
U&Es    FBCs
Glucose    22.3 mmol/L (3.6-8)    Hb     12.1 g/dl (11.5-16.5)
HbA1c     105mmol/mol
(<48mmol/mol/6.5%)     WBC 10.2×109/l (4-11)
Na            136 mmol/L (135-145)    Plts    293×109/l (150-450)
K               4.8 mmol/L (3.5-5.0)
Urea         11.7 mmol/L (2.5-7.5)
Creatinine 250micromol/l (60-120)

Wgt  80kg    Temp. 37.1 degrees
Hgt   5’6’’    BP 147/85mmHg

a)    Comment on Miss HH’s glucose and HbA1c in relation to NICE guidance.
You can use the 2112 rule to convert old HbA1c to new units and vice versa:
old to new:  -2 x 11 -2;
new to old: +2 divided by 11 +2.

b)    Work out Miss HH’s B.M.I. and ideal body weight. Are these relevant?
BMI = wt (kg)                IBW= 50kg (men)/45.5kg (women)
Ht2(m2).                 + 2.3kg for each inch > 5 feet.

c)    Comment on Miss HH’s creatinine and urea: use Cockcroft and Gault’s method to estimate her renal function.

 

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In relation to your chosen patient, discuss the pathophysiology of their condition and using evidence based practice explore current treatment options for your patient’s condition, include any pharmacological and nonpharmacological considerations.

Case Study 3: John Wong (Transurethral Resection of the Prostate).

Case Study 3: John Wong (Transurethral Resection of the Prostate).

John Wong is an 80 year old male of Chinese origin. John’s medical history includes
hypothyroidism and osteoporosis and he smokes 10 cigarettes per day. His gait has
recently been increasingly unstable and he has difficulty with simple tasks, such as
getting up his house stairs and getting up from chairs.
In the last 4 weeks, he has noticed that he has been having difficulty passing urine and
some abdominal discomfort. His GP referred him to a urologist and a prostate biopsy
was taken. This showed BPH (benign prostate hyperplasia) and it was recommended
that he undergo a Transurethral Resection of the Prostate (TURP).
While conducting John’s pre-admission assessment it is noted that John is slightly
hypertensive and is fidgeting and moving around the waiting room. After some education
John states that he is pleased to have the surgery as he hopes it will relieve some of the
discomfort he has been experiencing. John tells the nurse that he currently lives alone.
John’s surgery is uneventful during the intra-operative stage. On arrival to PACU John is
placed in a supine position. He is drowsy and restless and oxygenated through a
facemask on 02 at 5l/min. A wheeze and non-productive cough is noted. John has an
IDC insitu with continuous bladder irrigation with output noted to be a reddish pink. A
number of blankets are placed on top of him as he is shivering. His observations are T
36.5c, HR 90, RR 30, BP 150/90 and SpO2 91%.
John is transferred to the surgical ward after a 65 minute stay in PACU. John remains
drowsy but easily rousable. He is oxygenated via intra-nasal cannulae at 2l/min and he
states his pain is 3/10. He has 0.9% sodium chloride infusion running at 125ml/hr. Postoperative
orders include IVF, analgesia (PRN Endone, 5mg 6hrly and Paracetamol, 1g
4-6hourly), strict FBC and continuous bladder irrigation for 24 hours, with an aim of rose
urine output.
Four hours after John’s return to the ward he is observed to be in pain and distressed.
He is diaphoretic and restless and states that his bladder feels full and he feels the urge
to urinate. At this time, vital signs are noted to be: T 36.9c, HR 91, RR 28, BP 146/91 &
SPO2 98%. On review of his documentation it is found that his fluid status has a positive
500ml balance and his urine is of red colour. There are blood clots in his urine.
QUESTIONS
Please refer to the rubric on page 14 on the Unit Outline for full marking criteria
1. In relation to your chosen patient, discuss the pathophysiology of their
condition and using evidence based practice explore current treatment options
for your patient’s condition, include any pharmacological and nonpharmacological
considerations.
2. Critically discuss four (4) components of the PACU discharge criteria
outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in
your case study.
3. Develop a discharge plan to support your patient on discharge. Include
any education you deem relevant, any referrals to allied health professional/s
required, and discuss your rationale.

NRSG258 Acute Care Nursing 1, Semester 1 2015 Page 12 of 19;

Assessment Task 1: Case Study
Description: Students are to choose one (1) of the case studies available (see
LEO) and answer the associated questions. The assignment is to
be presented in a question/answer format, and not as an essay
(i.e. no introduction or conclusion). Each answer has a word limit;
each answer must be supported with citations. Students should
follow the recommended formatting for academic papers
http://students.acu.edu.au/308971 Students must provide in-text
referencing and a reference list must be provided at the end of
the assignment.
Due date: Friday 27th March: Midnight (Week 5)
Weighting: 40%
Length and/or format: 1500 words
Purpose: Facilitate the development of critical thinking in relation to nursing
management along the perioperative continuum including
effective care, safety and evaluation.
Learning outcomes assessed: 1, 2, 3, 5 & 6
How to submit: Students are to submit the following via Turnitin Case Study
submission folder as one document:
?? Assignment
?? Reference List (adhering to APA style)
Return of assignment: Case Study submissions will be returned to students online via
LEO.
Assessment criteria: This assessment task will be graded against a standardised
criterion referenced rubric. Please follow these criteria closely
during the planning and development of your assignment.
For more comprehensive information on this assessment task, including the available case studies and
the Aldrete resource required for this assignment, please refer to the Case Study Folder in LEO under
‘My Assessments’.

 

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