Posted: March 25th, 2024

Mrs Soo Hui is a 46-year-old female (identifies as she, her)

Mrs Soo Hui is a 46-year-old female (identifies as she, her) admitted to your ward at St Elsewhere Hospital, following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. The next-door neighbour found her on the ground outside her front door unable to move or speak. She has been diagnosed as having a left sided ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.

Family history
Born to Thai parents in Australia Buddhist & speaks Thai & English Lives with husband & 2 children, Ty 13 years old & Grace 5 years old. Also her father who is a frail 82-year-old.

Medical history
Hypertension, Type 2 Diabetes, Asthma Depression Hearing aid left ear Bi-focal glasses (broken in fall) Upper dental partial plate Medication – Amlodipine, Metformin, Salbutamol.

Admission observations
BP 150/90 PR 85 regular RR 24 To 36.9 SpO2 96% on room air BGL 8.4 mmol Weight 69 kg Height 162 cm GCS (Glasgow coma scale) = 14 Eyes open to speech Oriented to time, place, and person (speech slurred, but able to be understood) Right hemiparesis PERL (Pupils equal reactive to light)

Issues/impacts of the CVA
Pain on movement, mainly right hip & shoulder stated as 7/10 Large haematoma right hip 5cm skin tear right elbow Dysphasia Dysphagia Right sided facial droop Mild Right-side hemiplegia

Initial Doctor’s orders and interventions
Rest in bed (RIB) 2nd hourly Neurological observations Nil by mouth (NBM) until Speech Therapist review Physiotherapist review Full Helpance with hygiene IDC insitu Intravenous Therapy via cannula in left forearm

Discharge Information
Mrs Soo Hui will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.

Provide an answer for each of the questions below in relation to Mrs Hui.

Explain how you would prepare the hospital room for Mrs Hui’s admission to the ward.

Ensure the bed is properly made with clean linens.
Arrange necessary equipment within reach (e.g., call bell, bedside table).
Ensure adequate lighting and ventilation.
Check and clean the bathroom facilities if applicable.
List 4 pieces of equipment you would need to conduct an assessment on Mrs Hui when she is admitted to the ward.

Sphygmomanometer (blood pressure cuff)
Stethoscope
Thermometer
Glucometer
Identify 4 components of correct nursing documentation (this also includes electronic documentation).

Date and time of assessment or intervention
Objective findings (vital signs, observations)
Subjective information provided by the patient or caregiver
Plan of care or interventions initiated
Why is it important to measure and record a person’s weight and height on admission?

To establish baseline data for monitoring changes in health status.
To calculate medication dosages accurately.
To assess nutritional status and plan appropriate dietary interventions.
To monitor growth in pediatric or adolescent patients.
You are required to provide a clinical handover to the Enrolled Nurse and Registered Nurse who are coming onto the next shift. Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui?

Identification: Mrs Soo Hui, 46-year-old female, admitted for left-sided ischemic CVA.
Situation: Admitted following symptoms of blurred vision, numbness, and sharp head pain. Currently on anti-coagulant therapy.
Background: Medical history includes hypertension, Type 2 diabetes, asthma, and depression. Lives with husband, 2 children, and elderly father.
Assessment: Presenting observations, neurological deficits, and any immediate concerns.
Recommendation: Orders for ongoing care, including neurological observations, nil by mouth status, and plans for rehabilitation.
Mrs Hui has had an Ischaemic cerebrovascular accident (CVA). Answer the following questions.

Explain the two types of CVA, including where it occurs and what causes it.

Ischemic Stroke: Caused by a blockage (clot) in a blood vessel supplying blood to the brain. Can occur in various parts of the brain.
Hemorrhagic Stroke: Caused by bleeding in the brain due to the rupture of a blood vessel. Can occur within the brain tissue (intracerebral) or between the brain and the skull (subarachnoid).
Identify four (4) indications of a left sided CVA.

Right-sided weakness or paralysis (hemiparesis/hemiplegia).
Aphasia or dysphasia (difficulty speaking or understanding language).
Visual disturbances.
Impaired ability to perform tasks involving logic or analysis.
Identify the other morbidities/co-morbidities that Mrs Hui has.

Hypertension
Type 2 Diabetes
Asthma
Depression
Mrs Hui is 46 yrs of age, discuss how depression can affect a person in middle adulthood.

Depression can affect middle-aged individuals by impacting their ability to function at work, in relationships, and in daily activities.
It may manifest as fatigue, irritability, changes in appetite or sleep patterns, and loss of interest in previously enjoyed activities.
Middle-aged adults with depression may also be at increased risk for developing chronic health conditions like diabetes and cardiovascular disease.
The RN has created care plans for Mrs Hui and identified four (4) assessment and nursing diagnoses based on the Nursing process concept. As the EN contributing to the nursing care plan, please provide the following for each of the four (4) care plans.

Care Plan 1: Impaired Physical Mobility related to right-sided weakness secondary to CVA.

Nursing Implementations:
Assist with range of motion exercises for affected limbs.
Implement safety measures to prevent falls.
Rationale and Assessment:
Rationale: Range of motion exercises prevent contractures and maintain joint function.
Assessment: Evaluate the patient’s ability to perform exercises and document any improvement or deterioration in mobility.
Care Plan 2: Risk for Aspiration related to dysphagia secondary to CVA.

Nursing Implementations:
Assess swallowing function before allowing oral intake.
Position the patient upright during meals and feedings.
Rationale and Assessment:
Rationale: Assessing swallowing function prevents aspiration, which can lead to pneumonia.

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Answer Writing Guide Exemplar
Mrs. Soo Hui’s Admission to the Ward

Prior to Mrs. Hui’s admission, the hospital room should be prepared by ensuring a clean and safe environment. The bed should be made with fresh linens, and necessary equipment, such as a bedside table, chair, and call bell, should be within reach. Additionally, the room should be well-lit, with proper ventilation and temperature control.

Equipment for Mrs. Hui’s Assessment:

Sphygmomanometer (blood pressure cuff)
Stethoscope
Pulse oximeter
Neurological assessment tools (e.g., Glasgow Coma Scale, stroke scale)
Nursing Documentation Components:

Patient identification (name, date of birth, medical record number)
Date and time of entry
Clear and concise documentation of assessments, interventions, and patient responses
Legible handwriting or electronic entries
Measuring and recording a person’s weight and height on admission is crucial for several reasons:

Assists in calculating appropriate medication dosages
Helps evaluate nutritional status and fluid balance
Provides baseline data for monitoring changes over time
Aids in determining equipment needs (e.g., wheelchair, walker)
ISBAR Handover for Mrs. Hui:
I – Identification: Mrs. Soo Hui, 46 years old, admitted with a left-sided ischemic cerebrovascular accident (CVA).
S – Situation: Presented with blurred vision, right-sided numbness, and a sharp headache. Found on the ground outside her home, unable to move or speak.
B – Background: Hypertension, Type 2 Diabetes, Asthma, Depression. Medication – Amlodipine, Metformin, Salbutamol. Husband and two children at home, also cares for an elderly father.
A – Assessment: GCS 14, slurred speech, right hemiparesis, dysphagia, right facial droop, mild right-sided hemiplegia. Vital signs stable.
R – Recommendation: Continue neurological observations, physiotherapy review, speech therapy review, full assistance with hygiene, and intravenous therapy. Discharge planning initiated.

Types of Cerebrovascular Accidents (CVA):

Ischemic Stroke: Caused by a blockage in an artery supplying blood to the brain, leading to a lack of oxygen and nutrient supply.
Hemorrhagic Stroke: Caused by a ruptured blood vessel in the brain, leading to bleeding and increased pressure on brain tissue.
Indications of a Left-Sided CVA:

Right-sided hemiparesis (weakness or paralysis)
Right-sided hemineglect (lack of awareness of the right side of the body)
Aphasia (difficulty with language and communication)
Right-sided facial droop
Mrs. Hui’s Co-morbidities:

Hypertension
Type 2 Diabetes
Asthma
Depression
Depression in Middle Adulthood:
Depression can significantly impact individuals in middle adulthood, affecting their overall well-being and quality of life. It can lead to decreased productivity, strained personal relationships, and increased risk of developing other health issues. Middle adulthood often brings unique challenges, such as career stress, caregiving responsibilities, and physical changes associated with aging, which can contribute to or exacerbate depressive symptoms.

Nursing Care Plans:

Impaired Physical Mobility related to right-sided hemiparesis
Nursing Implementations: a. Encourage active range-of-motion exercises and proper positioning to prevent contractures. b. Provide assistive devices (e.g., walker, wheelchair) and ensure a safe environment for ambulation.
Rationale: Promoting mobility and preventing complications associated with immobility.
Assessment: Evaluate range of motion, strength, and ability to perform activities of daily living.
Risk for Impaired Skin Integrity related to immobility and incontinence
Nursing Implementations: a. Perform regular skin assessments and implement pressure relief measures. b. Provide incontinence care and maintain proper hygiene.
Rationale: Preventing skin breakdown and promoting comfort.
Assessment: Assess skin condition, identify areas of pressure or moisture, and monitor for signs of infection.
Dysphagia related to neurological impairment
Nursing Implementations: a. Implement dietary modifications as recommended by the speech therapist. b. Provide assistance with eating and drinking, ensuring proper positioning and monitoring for aspiration.
Rationale: Preventing aspiration and ensuring adequate nutritional intake.
Assessment: Observe for signs of difficulty swallowing, coughing, or choking during meals.
Risk for Injury related to cognitive impairment and physical limitations
Nursing Implementations: a. Implement fall precautions and provide a safe environment. b. Educate Mrs. Hui and her family on safety measures and techniques for safe transfers.
Rationale: Preventing falls and promoting patient safety.
Assessment: Evaluate cognitive function, balance, and mobility, and monitor for any unsafe behaviors.
References:

Aiyagari, V. and Gorelick, P.B. (2018). Stroke Pathophysiology. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK531752/ [Accessed 25 Mar. 2024].

Breen, K.J. and Arvanitakis, Z. (2020). Depression in middle-aged and elderly adults. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327188/ [Accessed 25 Mar. 2024].

Hinkle, J.L. and Cheever, K.H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing. 14th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Nursing Council of New Zealand (2020). Competencies for Registered Nurses. [online] Available at: https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursing-section/Standards_and_guidelines_for_nurses.aspx [Accessed 25 Mar. 2024].

Sacco, R.L. and Kasner, S.E. (2015). Treatment of Acute Ischemic Stroke. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434271/ [Accessed 25 Mar. 2024].

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