NURS3005 Assignment 2- CCC Report Guidelines
Weighting: 40% (2500 words)
Details: This academic paper requires students to write up the patient presented at their Clinical Case Conference (CCC) to their Nurs3005 PEP facilitator and present it as a detailed report. There must be analysis of the patients medical condition(s) demonstrating the ability to apply theoretical concepts including (but not limited too) pharmacology; pathophysiology; anatomy and physiology. There must be presentation and evaluation of nursing and medical management of the patient.
Sound clinical rationales must be provided that support the care afforded the patient. Appropriate evidence sources must be used and Harvard referencing used throughout. Students are encouraged to write up this report prior to undertaking their CCC presentations. For specific details please refer to the marking rubric. The CCC Report must be submitted via FLO.
Please use the format below.
Introduction: (150 words)
Introduction of an assignment requires mapping out the essay, outlining your reader the main argument points in the essay. The following should be included:
? Introduction of the assignment content.
? Introduction of the case including biographical data, current and past medical history of the patient.
? Patient confidentiality needs to be maintained all times.
Case Management: (1250 words)
This section should address the current nursing management and the interdisciplinary management that is provided for the patient. This includes;
? patients medical condition(s), including relevant pathophysiology
? clinical assessment using (IS)BAR, or a system based approach, explanation of how nursing management relates to medical management with clear clinical rationales
provided, role of interdisciplinary team involvement explained and primary health care strategies described.
? Medical management and treatments described including all relevant pharmacological, non-pharmacological treatments, pain management explained and clear clinical rationales provided.
? Relevant Laboratory results /Diagnostic tests included and discussed.
? Psychosocial / Environmental / Economic aspects discussed
? Ethical and legal aspects included
? Education needs of patient /family addressed
? Discharge Planning addressed
Establishing the evidence supporting the current practice (1000 words)
? Description of how research findings/recent evidence selected is relevant to the case management.
? Comparison and critique of the management / nursing care of the case against best practice literature included.
? Suggestions of alternative management / nursing care
? All the articles selected needs to be primary or secondary research articles (peer reviewed).
Summary and Conclusion (100 words)
This section should provide a summary of the of the crucial aspects of the case that is presented and overall conclusion. No new information or references are required in this section.
Referencing
Academic writing involves using sound evidence to support and strengthen your own arguments. This assignment needs researching broadly, and skilfully from correctly (Harvard) cited credible sources which were mainly published between 2006-2016.
Peer reviewed research articles, scholarly articles, reference textbooks can be used.
Articles from these publications are usually NOT academic:
newspapers
magazines and trade journals
newsletters
articles without a bibliographyshould be set to 1.5 or 2.0
Left and right margins must be at least 2 cm wide
Assignment text must be in Verdana 10pt or Calibri 12pt
All pages must be numbered
The assignment must be ordered as follows:
title of the assignment at the top of the first page
assignment body text
reference list
appendices
The assignment word count should include any words in the body of the assignment, including headings, in-text references and quotations, but not the reference list or appendices.
Pay particular attention to the specified length (word count) of your assignment. Keep your word count to within plus or minus 10% of the specified length or penalties may be applied.
Introduction
(10 points) Advanced introduction and justification of the
purpose and intention of
the essay and introduction of the case
9-10 points
Case Management (40 points) Exceptional discussion expressed with
insightful and original
thought using exemplary written communication. demonstrating depth of understanding of the case.
Succinct, correct clinical rationales provided
35-40 points
Establishing the evidence
supporting
the discussion
(30 points) Research selected is highly relevant to the
argument, is presented
accurately and completely.
The link between the literature findings and the presented case is consistently and
persuasively made. The management and
nursing care of the patient is compared and
critiqued in detail with the best and most recent
available evidence.
Feasible / thoughtful suggestions of alternative management and nursing care are made, based on
the best available evidence.
26-30 points
Conclusion
(5 points) A succinct yet complete summary of the crucial
aspects of the case is
presented. The short
and long term outcomes are described in depth.
Insightful comments are
made about whether the case and its referenced as per
Harvard Referencing
Guidelines. Reference list is correctly presented and is complete.
9-10 points
Adheres to academic
writing &
presentation guidelines
(5 points) Adheres to all guidelines. Excellent:
*Correct spelling,
punctuation,
*Sentence structure and paragraph
*Use of inclusive
language.
This is the case that you have to write the essay and the way that has to be written.
NURS3005 CCC Report
Introduction
This report will present the case study of Miss X, a 50-year-old Indigenous lady height 164cm, weight 67kgs, who lives in accommodation supported by Disability SA with 24-hour support. Originally from Alice Spring she has nil family support and while she has never married, she does have a Public Guardian. Due to her history of polysubstance abuse and antisocial personality traits with differential diagnosis of drug-induced psychosis, she is under Guardianship in relation to the Administration Act 1993, Section 32 decision and instruction. Therefore, she cannot move to alternate accommodation without the direct permission of her Guardian and as a result is under 24/7 supervision of one Registered Nurse (RN). Ms. X has had a number of admissions to mental health facilities and has been referred to mental services. The patient stated that she felt controlled by the dead people, however denied suicide ideation or thoughts of self-harm. She is under The Mental Health Act. At the age of 10, Ms. X stole cigarettes from her tutor and commenced smoking. She has since advanced to be an intravenous drug user (IVDU), stating that she uses drugs such as heroin, twice a week. During her hospital admission she continues to be an active smoker, consuming 6-7 cigarettes every day. Her carers are responsible for taking her out for cigarettes during designated times. The patient denied providing any more information.
She presented to Royal Adelaide Hospital (RAH) at the Emergency Department (ED) due to chest pain, dyspnoea and hot flushes on a background of IVDU. While she was a difficult historian, she did describe a few weeks of feeling off with ankle, back and head pain. On investigation, her observations were temperature 38.6 C, heart rate 122, blood pressure 115/75, Spo2 96% on room air and respirations were 16. An ECG showed sinus tachycardia. On admission to ED, a transoesophogeal echocardiogram (TEE) was performed which showed two vegetations approximately one centimetre on the aortic valve with moderate. As such, diagnosis confirmed for an infective endocarditis (IE). Post diagnosis from the medical team decided to keep her in hospital for the iinfective endocarditis (IE) for a surgical treatment with the consent of guardianship. The day of the surgery the patient dint want to take place and surgery it was cancelled. After this the medical team decided to put the patient on prophylactic antimicrobial (Ceftriaxone IV 2mg and Antidulafungin) for at least two – six weeks, based on the negative blood culture and resolution of symptoms as per the Infectious diseases protocols (McNeece 2015).
Miss. X has a past medical history of hep C positive-genotype 3A never treated, Type II Diabetes-insulin dependent, Chronic Schizophrenia, Hidradenitis Suppurativa, L) hand Cellulitis, Smoker, IVDU and methicillin resistant staphylococcus aureus (MRSA) in 2009, but has no allergies. Despite multiple hospital admissions, her most recent admissions were E years ago where she presented to RAH due to Dyspnoea, and again on a year and half ago with cellulitis of her L) hand. This was followed by two more admissions this year to the RAH with flank pain and later hyperthermia and tachycardia respectively.
This paper will discuss the current medical condition of the patient and relates to the condition with infection prevention and control. According to literature, intravenous drug users are more likely to contract infectious diseases. This could be due to a range of factors including homelessness, malnutrition, engaging in sexual intercourse for financial gain, immunodeficiency and needle sharing. This is a major cause of morbidity and mortality among IVDU (Mertz et al. 2008, p. 2).
Infective endocarditis is a life threatening infection of the endothelial surface of the heart, the endocardium. The endocardium lines the heart and covers the heart valves (Porth 2011, p. 466). The heart has four valves, which consist of the tricuspid, pulmonary, mitral and aortic valves. Infection can present in any part of the endocardium, however mostly affects the heart valves (Porth 2011, p.466).
IE is caused by an invasion of the heart valves and endocardium by an infectious agent. Pathogens can enter the blood stream through poor oral hygiene; needle sharing and can also result from the use of a catheter or injury to the skin (Lajiness 2007, p. 329). Moreover IVDU are at a higher risk due to sharing and reusing needles without aseptic techniques (National Heart, Lung and Blood institute 2010). The combination of poor oral hygiene, IVD use and a history of MRSA in relation to this patient could very well be the leading cause of IE.
When tissue becomes colonised then fibrin and platelets surrounds the microorganisms and produce coating on the valves. This coating can cause the infected tissue to form vegetation on the valves, which destroys underlying cardiac tissues; enlarging and allowing pathogens to enter into blood stream, causing persistent bacteraemia (Hayes 2015, p. 23 & Lajiness 2007, p.329). Ultimately, the vegetations on the valves can cause holes, scars and obstructions in forward blood flow or closing incompletely (Hales 2011, p. 1057). Moreover, these vegetations can break off and loose organisation possibly forming emboli. It can travel in any body organ or tissue and may cause infection to other body organs, initiating stroke, brain abscesses, pulmonary embolism, heart failure and acute renal failure (Porth 2011, p.466).
Infecting organisms such as viridans staphylococci, streptococcus aureus or enterococci are most responsible for IE, especially in IVDU. However rarely, gram-negative bacteria and fungi are also involved (Cosgrove & Karchmer 2005, p. 66). Signs and symptoms of IE include hyperthermia, chest pain, dyspnoea, heart murmur, tachycardia, fatigue, malaise, edema and paleness. The treatment consists of prophylactic antibiotics and good medical and nursing management to eliminate the causative organism (Porth 2011, p.467). Miss X was diagnosed with IE caused by viridans streptococci bacteria and candida. While the patient had positive blood cultures for viridans streptococci and candida, the source of the infection was unclear.
To provide effective care to this patient, daily health assessments are necessary to monitor her health status. Hence, this part will present the nursing assessment on admission day 20.
Central nervous system: The patient was stable, alert and orientated but seemed agitated at times. Despite the patients complaints of left leg pain, no ultrasound evidence of deep vein thrombosis of the left leg was identified. The patient is taking Diazepam (central nervous system depressant), olanzipine (atypical antipsychotic), Mitazapine (tetra cyclic antidepressant), Zuclopenthixo (typical antipsychotic) l, buprenorphine/ naloxone (opioid partial agonist-antagonists) for mental illness, anxiety and to treat opioid dependence due to the patients history of IVDU. Moreover, the patient is also taking oxycodone (opioid) and fentanyl (opioid). This however did not stop the patients demands for more fentanyl. These medications can cause constipation, headache, dizziness, and difficulty in breathing (Lehne 2013). Besides, this patient is at risk of stroke and seizure. Due to the combination of these factors, nursing interventions include strict monitoring of neurological observations, and the noting and reporting of neurological deficit. In addition, the patients sleep pattern assessment was made and documented on the sleep behaviour chart as per hospital protocol. Documentation is evidence of nursing care and also works as a communication tool between health professionals (Anastasi & Anderson 2012, p.77).
Cardiovascular System: The patients blood pressure was 135/95 and heart rate 86 per minute. Vital signs provides key information about a patients condition as normal vital signs reflect on a patients physiological wellbeing, whereas abnormal vital signs may be an indication of clinical deterioration (Sydney South West Area Health Service 2010). As the patient is at a risk of congestive heart failure due to IE, nursing interventions include strict monitoring of blood pressure and heart rate. As well as motivating the client for bed rest and watching the patient for signs and symptoms of heart murmur, dyspnea, tachycardia, edema, and weight gain. Should the patient present any of these symptoms then the nurse must make a referral to the cardiologist and infectious diseases specialists team for reviewal of the patient immediately (Bellchambers 2012, p. 603).
Respiration: The patients respiration rate was between 17- 19 on auscultation- equal air entry, oxygen saturation levels were 95-97% on room air. Too often nurses estimate a patients respiratory rate, but it is essential to accurately assess the respiration rate for a full minute. It is the first and most important sign of patient deterioration as it is closely related to oxygen flow and saturation (Bellchambers 2012, p. 603). Moreover, the patient is at risk of respiratory depression due to use of oxycodone and fentanyl (Lehne 2013). To provide holistic care to Ms. X timely and accurately, monitoring is vital for this patient (Bellchambers 2012, p. 604).
Gastrointestinal system: The patient is on a normal ward diet, yet refuses breakfast and has a preference for junk food. Her bowels opened after four days and were documented on the bowel chart. Movicol was administered as per order, with the patient encouraged to consume more fluids and fibre intake. In addition, her use of opioids should be lessened with the suggestion to take paracetamol instead of oxycodone for pain (Searl, Carville & Hewerdine 2012, pp. 1482-84). The dietician was informed to review Miss X and to provide suggestions for a high fibre diet as constipation can cause further GI problems.
Renal system: The patient has nil history or sign of renal problems voiding well with potassium levels at 4.2, sodium levels at 137 and urea 5.6 within normal range. Due to IE, the patient is at risk of kidney failure. Hence, the nursing interventions include care full monitoring of input and output of urine, skin colour, dry mucous membrane, tissues turgur, and oedema as oliguria can result from renal embolisation (Reid-Searl et al. 2012, pp. 1442-1444).
Metabolic: Temperature 36.5 (a febrile) temperature has been closely monitored and recorded. Blood glucose levels 6.5, LV normal, whereas white cells count 13.8, neutrophils 9.81, C-reactive protein 93 are elevated due to infection. Blood culture is negative. The antimicrobial medications IV Ceftriaxone and Anidulafungin were administered as per the order and hospital protocols to treat bacterial infection (Wallace 2015). The patient is at risk of chest pain and fever due to the side effects of this medication (Cosgrove & Karchmer 2005, pp. 67-68 & Lehne 2013). Hence, it is important to perform vital signs three times daily. The oral antidiabetic Metformin and gliclazide were administered as per order. The patient is also at risk of hypoglycaemia due to the side effects of the above oral antidiabetic. Therefore as a nursing intervention blood glucose levels are checked prior to administration of these medications (Lehne 2013).
Due to PMHx of Type II diabetes, patient education about healthy diet is essential to reduce further health complications. A Diabetic Nurse Educator may be consulted to review and give patient education about management for type II diabetes (Hill & Clark 2009, p. 56). High blood glucose can harden the arteries, which can further cause hypertension, arthrosclerosis and heart problems. (Australian Institute of health and Welfare 2015). Aboriginal health workers can be involved in education regarding Miss Xs healthy diet plan, particularly because Miss X has a strong therapeutic relationship with her health worker (Smykowsky & Williams 2015, p. 28).
Integument: The patient has an IV cannula on her left hand. As such, she was educated about hand hygiene and recommended not to touch the IV cannula site to prevent further risk of infection as bacteria can effectively enter via the cracked and broken skin (The Queen Elizabeth Hospital 2010). Nursing intervention includes assisting the client with hand washing, oral hygiene and teaching the patient the importance of selfcare as much as possible (Laws & Hillman 2012, pp. 757-761). Due to PMHx of MRSA, cellulites and hidradenitis suppurativa, the patient is at risk of skin infections. Aseptic techniques are always practised during the administration of IV medications with personal protective equipment to prevent infection, with the site assessed for inflammation and pain (Laws & Hillman 2012, pp. 757-761). Consent was taken prior to administration, with confidentiality and privacy maintained as per nursing standards (Australian Nursing and Midwifery Council et al. 2006).
Hygiene: The patient showered independently but refused to attend to her oral hygiene. Infection control is a critical aspect of her nursing care because of her above-mentioned history of skin infections. Regardless of the patients mental condition, the patient was educated and encouraged to perform daily oral care to prevent infection. Referral to the Infection control nurse was made to educate the patient about oral and hand hygiene (Laws & Hillman 2012, pp. 757-761).
Safety and psychosocial: The patient is safe to mobilise independently under the supervision of health care staff. However, no drink bottles can be left in the room as the patient uses them as ashtrays. In addition, all IV lines must be disposed of outside the room after they are used. While the patient had adequate communication skills with the nursing staff, the Aboriginal liaison officer and Aboriginal Health worker were also involved when needed, to further improve communication between health care staff and the patient (Smykowsky & Williams 2015, p. 28).
Ethical, economical and legal
The provided care has been documented in the nursing charts with the correct time and date. The patient was taken for smoking during designated times with respect and empathy, however the patient has been motivated to quit smoking. Nurses were mindful towards the patients culture and religion. A search of her room was never taken in her absence (School of Nursing and Midwifery 2013). Permission was sought from the patient to search her room should there be suspicion of her harbouring tobacco/lighter or any illicit equipment. The patient was always treated with respect, empathy and without stereotyping. The patient, positive attitude adopted reinforces professionalism and further develops trust in the therapeutic relationship. Effective nursing management is planned to provide patient-centred care without discrimination to get the best possible outcome for the patient (School of Nursing and Midwifery 2013 & Moxham, Robson & pegg 2012, p.1233). While the patient receives a disability pension, a referral was made to the welfare support worker to assist the patient during admission and post discharge, in particular with financial support and necessary shopping.
Social and discharge planning
Poor discharge planning can negatively influence a patients recovery. Furthermore, it can be stressful for the patient (Lees, 2013). According to literature, the main objective of discharge planning is to ensure that post discharge requirements of the patient are fulfilled to maintain their wellbeing after discharge (Lin et al. 2012, p. 237). Patients are given education on how to recognise the symptoms of endocarditis and recommended to seek immediate medical advice if they notice any symptoms. Referrals are made to the counsellor to discuss alternate ways of coping with drug withdrawal programs. Moreover, community support agencies are also contacted to educate clients on how to use drugs safely should the patient not be willing to withdraw from drugs. The patient will be given written and verbal education about medication and their importance (Baldwin & Bentley 2012, pp. 165-167). Moreover, essential phone numbers and vital information will be provided to the patients accommodation manager. The Infection Control Nurse will also offer education about MRSA with a fact sheet for future references for the patient. Close long-term follow up appointments have been organised with infectious disease specialists and the cardiologist to monitor the patients physiological wellbeing (Thunky et al. 2012, p. 971).
Article discussion (few already discussed above)
Due to mental illness, Miss X need may not fully comprehend treatment. For this reason the nurse must be mindful to provide emotional support to the patient in addition to effective discussion of their treatment, aspect of care and services to maintain culture of safety (Ofori-Atta 2015, p. 2). Moreover, as Miss X belongs to an Indigenous culture, she might have different belief and values; therefore effective communication is a key part of her nursing care. In addition, supportive listening, staff and group meetings with the mental health nurse to educate staff to understand the patients behaviour will prove effective in nursing care (Smykowsky & William 2015, p. 28). New Guidelines suggest that prophylactic antibiotic can cause more adverse effects in the long term and can promote resistant microorganisms. As bacteria is much more likely to occur with IE, some protection is possible with daily oral and hand hygiene. Therefore the nurse should encourage and teach Miss X to stop her use of IVD, maintain daily oral and hand hygiene as well as establish regular dental care to protect against IE (Hayes 2015, p. 23). Nurses should practice with an evidence -based environment to provide effective and safe care to Miss X. Hence there is need to ensure appropriate antimicrobial use to reduce overdose and misuse to get better result for patient with minimum harm (McGregor et al. 2015, p. 16). In addition, the patients cardiologist should be consulted along with hospital protocols for the final determination to clear any doubts instead of administering a wrong or overdose (Lajiness 2007, p.330).
Summary
Based on the information presented above, this report relates to the clinical case study of Miss X. an Indigenous lady and IVDU who presented to ED with chest pain, dyspnea, hyperthermia and hot flushes. Following further investigation, she was diagnosed with infective endocarditis. Current and past medical history of Miss X were clearly stated and assists in better management of nursing care whilst the patient is in hospital. Pharmacological treatment has been linked with patients past and present medical history. The system-based assessment was analysed with rationales given for any particular actions. The nursing interventions and risk involved in the treatment were also discussed. Patient educational, ethical, environmental, and psychosocial have also been addressed with an importance of aseptic technique to prevent the patient from further infection. Relevant recommendations especially on infection prevention and control have been made and necessary inter-professional teams involved during patient care. Patient discharge planning with long-term follows up with inter-professional team has been covered. Besides that, IE can cause short term and long-term health outcomes for the patient. Delayed and inappropriate treatment can be fatal for the patient. The short-term outcome includes neurological complications, brain abscesses, kidney failure and stroke. While long term complications can include recurrence of infection, cardiac surgery if the treatment is ineffective, heart valve damage, heart failure and even death. The combination of these short and long term complications would need to be addressed sooner rather than later. Finally, nurses must utilise their skills and knowledge to inform patients regarding self- care measures to protect future complications of IE.
References:
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5 points
management was representative.
Excellent alignment between introduction and conclusion 5 points
Referencing
(10 points) Multiple sources utilised and all correctly
