nurs2105sp_ver1_int_2008

FLINDERS UNIVERSITYADELAIDE AUSTRALIA

Faculty of Health Sciences

Nursing&Midwifery

NURS2105 Nursing 4

Study planSemester 2 2008

Schoolof

Ver1

The information in this Study plan was correct at time of printing. Please refer to https://flo.flinders.edu.au for up-to-date information. School of Nursing & Midwifery, Flinders University 2007 2

ContentsWeek 2: Part 2 - Nursing Management of Musculoskeletal Disorders.............................10 Week 5: Part 1 - Nursing Management of Endocrine Disorders Type 1 Diabetes Mellitus ...............27 Week 6: Part 2 - Nursing Management of Endocrine Disorders Type 2 Diabetes Mellitus................35 Week 7: Nursing Management of Renal Disorders End Stage Renal Failure................41 Week 8: Part 2 - Nursing Management of Urological Disorders UTI & SPC.................46 Week 9: Nursing Management of Gastrointestinal Disorders Large Bowel Obstruction51 Week 10: Nursing management of Hepatobilary Disorders.............................................60 Week 11: Nursing Management of Haematological Disorders ............................... .........65 Week 12: Part 1 - Nursing management of Reproductive Disorders Female Focus.....71 Week 13: Part 2 - Nursing management of Reproductive Disorders Male Focus..........76

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NURS2105: Study plan

Week 1: Part 1 - Nursing Management of Musculoskeletal DisordersThis week focuses on two problems related to the musculoskeletal system. The tutorial will focus on osteoarthritis, resulting total knee replacement and nursing management options. The workshop will involve a number of activities including management of the postoperative patient following total joint replacement Total hip replacement.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the musculoskeletal system describe the aetiology, pathophysiology, clinical manifestations and management of metabolic bone disorders describe the types of reconstructive surgery associated with osteoarthritis and rheumatoid arthritis identify the preoperative and postoperative teaching and collaborative care of the patient having reconstructive joint surgery associated with osteoarthritis and rheumatoid arthritis describe the pathophysiology, collaborative care and nursing management of the person with a total knee replacement and total hip replacement

What you need to do to meet your learning outcomes1. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 60 Nursing assessment: musculoskeletal system 61 Nursing management: musculoskeletal trauma and orthopaedic surgery 63 Nursing management: arthritis and connective tissue disease (this will be especially useful for this weeks practical session). Consult a pharmacology text regarding:

non-steroidal anti-inflammatory (NSAID), antipyretic and analgesic drugs

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2. If you wish to read more widely you may wish to revise these chapters.Crisp, J & Taylor, C (eds) 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Chapter: 49 Care of surgical patients 62 Nursing management: musculoskeletal problems Skills: 49-1 Demonstrating postoperative exercises, p. 1556 (also on CD) 39-6 Cardiopulmonary resuscitation, p. 1092 Sample nursing care plan: Peri operative patient, p. 1552 Client teaching boxes 32-20 Vascular assessment, p. 723 42-17 Preparation for patient controlled analgesia, p. 1211

3. Visit these websitesAccess the following websites: Osteoporosis site: http://www.osteoporosis.org.au/html/index.php Arthritis Foundation: http://www.arthritisfoundation.com.au/html/index.php Orthopaedic sites: http://www.worldortho.com/database/etext/ and http://www.ozarkortho.com/patiented/totaljr.htm#What

4. Attend the tutorial and workshop for this weekThe scenario questions will be discussed in the tutorial. Remember the workshops are compulsory.

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Consider this scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial.Mr Harold Heinrich is an 80 year old and has lived in the Barossa Valley town of Tanunda all of his life. Before retiring at 65 he worked for Penfolds Winery, managing their back blocks where the very old shiraz grapes are grown. At age 20 Harold was thrown from his horse and sustained a fracture to his left tibial plateau. This was treated at the Nuriootpa hospital where he was immobilised in traction in bed for four weeks and then on crutches for another four weeks. As a consequence of this injury Harold has gone on to develop osteoarthritis in his left knee joint. His orthopaedic specialist, who he visits in the city every six months, has managed him conservatively with medications including NSAIDs and COX inhibitors and physical aids for three years. Harold has undergone two arthroscopies and joint lavages to his left knee and now reluctantly uses a walking stick. As a public patient Mr Heinrich has been waiting to be called up for a total knee replacement ( TKR - total joint arthroplasty). Finally the letter has arrived which has asked him to attend the pre-admission clinic and donate a unit of his blood and repeat this in two weeks timethis will be used as an autologous blood transfusion postoperatively. At the pre-admission clinic he meets the RN, Greg, from the wards where he will be nursed postoperatively. Greg goes through all the standard teaching and lets Mr Heinrich borrow a video which explains important patient information regarding the pre and postoperative care he will require during his stay in hospital and several weeks after. Surgery was uneventful and Mr Heinrich is recovering well after the procedure was carried out under a spinal anaesthetic. To block out the noise in the theatre, Mr Heinrich was able to wear headphones and listen to music throughout the procedure. Postoperatively his care is outlined as follows:

routine post op vital signs rest in bed wound checks wound drain checks morphine Patient Controlled Analgesia (PCA) with purges keep L) leg in Zimmer knee splint anti-emetics ordered autologous blood up with orders for second unit to go up leg exercises C&B exercises.

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5. Consider these questions relating to the scenarioPlease come to the tutorial prepared to discuss the following questions: Prioritise the nursing care for Mr Heinrich in preparation for his return to the ward and then when he arrives on the ward postoperatively and give reasons for your priority.

Define a PCA and explain why it is not used on all patients.

Define osteoarthritis and its pathophysiology. Outline its relation to the resulting total knee replacement.

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Formulate a nursing care plan for Mr Heinrich for the first 24 hours post op. Include the following: statement of patient need or nursing diagnosis outcome statement that is patient-focused nursing interventions including rationale changes that may need to occur to the nursing care plan during the 24-hr post op period.

Discuss the complications that may occur in patients who have total joint replacements.

Outline the discharge planning which is required for Mr Heinrich.

Primary health care issues relating to the musculoskeletal system are vital for healthy ageing. List some public health strategies that are currently in place.

Focus on Mr Heinrichs elderly Primary Health Care issues.

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Week 2: Part 2 - Nursing Management of Musculoskeletal DisordersThis week focuses on acute infection problems related to the musculoskeletal system. The tutorial will focus on osteomyelitis and appropriate nursing management options. The workshop will involve a number of activities including management of the patient with osteomyelitis and rehabilitation options.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the musculoskeletal system describe the aetiology, pathophysiology, clinical manifestations and management of metabolic bone infections identify the preoperative and postoperative teaching and collaborative care of the patient having reconstructive surgery associated with acute musculoskeletal injury and subsequent metabolic infection describe the pathophysiology, collaborative care and nursing management of the person with osteomyelitis

What you need to do to meet your learning outcomes6. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapter: 62 Nursing management: musculoskeletal problems. Consult a pharmacology text regarding:

non-steroidal anti-inflammatory (NSAID), antipyretic, and analgesic medications. IV antibiotics. Analgesic medications.

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7. If you wish to read more widely you may wish to revise these chapters.Brown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 60 Nursing assessment: musculoskeletal system 61 Nursing management: musculoskeletal trauma and orthopaedic surgery 63 Nursing management: arthritis and connective tissue disease (this will be especially useful for this weeks practical session). Crisp, J & Taylor, C (eds) 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Chapter: 50 Care of surgical patients Skills: 49-1 Demonstrating postoperative exercises, p. 1556 (also on CD) 39-6 Cardiopulmonary resuscitation, p. 1092 Sample nursing care plan: Peri operative patient, p. 1552 Client teaching boxes 32-20 Vascular assessment, p. 723 42-17 Preparation for patient controlled analgesia, p. 1211

8. Visit these websitesAccess the following websites: Osteomyelitis site: www.kidshealth.org/teen/diseases_conditions/bones/osteomyelitis.html Osteomyelitis site: www.nlm.nih.gov/medlineplus/ency/article/000437.htm Osteoporosis site: http://www.osteoporosis.org.au/html/index.php Arthritis Foundation: http://www.arthritisfoundation.com.au/html/index.php Orthopaedic sites: http://www.worldortho.com/database/etext/ and http://www.ozarkortho.com/patiented/totaljr.htm#What

9. Attend the tutorial and workshop for this weekThe scenario questions will be discussed in the tutorial. Remember the workshops are compulsory.

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Consider this scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. The workshop activity involves the same scenario where the learning acquired in the tutorial can be implemented and consolidated in the nursing interventions undertaken in the workshop.Mr Stephen Cartwright is 56 years old living in Adelaide within the eastern suburbs. He is married with three adolescent children and works in an executive banking position in the city. He enjoys weekend home maintenance and landscaping as relaxation activities. He is a committed Jehovah Witness and attends twice weekly services at the local Jehovahs Witness Kingdom Hall. His general health is sound for his age. His wife is committed to a healthy eating and physical lifestyle. They play tennis weekly and walk several kilometres throughout the week. They entertain at their home frequently and consume large amounts of alcoholic beverages mainly wine and spirits. A month ago Stephen was on the roof of his house performing maintenance following discovery of a cracked roof tile. On descending the ladder whilst carrying the replaced tile he slipped and fell to the ground, landing on the rough rocky garden edges. His injuries included a severe compound fracture (open fracture) of his right tibia. Numerous cuts and scratches of his face and right and left arms were also evident. Surgery involving debridement of the damaged tissue and reduction of the fracture was performed. A right leg cast was applied equipped with cast-windows to enable the surgical sight to be visualised. His facial and body scratches and bruising were treated and some dressed with gauze and hyperfix. He made sound progress on the orthopaedic ward and was discharged after two weeks. After one week being home he began feeling unwell accompanied with fever, some night sweats, restlessness and generally increasing malaise. His surgical sight had become more painful and had increased swelling and erythema. He is currently admitted with the development of osteomyelitis of his right lower leg. The organism Staphylococcus aureus has been identified as the infective agent. Bone ischemia has not yet developed and so vigorous and prolonged IV AB therapy is anticipated, including after discharge from hospital. PICC line to be inserted into right upper arm prior to discharge for long term IV AB therapy. His care is outlined as follows:

4/24 vital signs rest in bed (RIB) 4/24 wound checks morphine PCA with purges R) leg cast insitu pending possible further surgical intervention anti-emetics ordered Maxalon 10mg 6/24 prn IV ABs 1g Penicillin 8/24. C&B exercises. Ward diet and fluids. Bowel monitoring and coloxyl and senna when necessary.

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10. Consider these questions relating to the scenario Prioritise the nursing assessment for Mr Cartwright on admission to the orthopaedic ward. Give reasons for your priority.

Formulate a nursing care plan for Mr Cartwright for the first 24 hours on the ward. Include the following: statement of patient need or nursing diagnosis outcome statement that is patient-focused nursing interventions including rationale changes that may need to occur to the nursing care plan during the first 24-hrs period.

Detail the possible clinical symptoms Mr Cartwright would have increasingly experienced at home and presented to the admitting hospitals Emergency Department.

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Detail the range of diagnostic studies undertaking to confirm the presence of osteomyelitis. Include the likely values and possible causative agents involved.

What medications would be most likely commenced immediately upon hospital admission? List these under the appropriate drug class e.g. antiemetics and analgesia. Provide a rationale for their administration.

Discuss the complications that may occur in patients who have osteomyelitis.

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Outline the discharge planning which is required for Mr Cartwright. Include actions he can implement at home for infection control. How will IV AB therapy be performed at home?

Primary health care issues relating to the musculoskeletal system are vital for healthy ageing. List some public health strategies that are currently in place.

Focus these Primary health issues on Mr Cartwrights circumstances.


Week 3: Part 1 Nursing management of Cognitive and Perceptual DisordersThis week the tutorial will focus on the nursing management required during the acute and rehabilitative phases for the person who has had a stroke. The workshop will focus on the nursing care required for the semi-comatose/concussed patient and the patient with seizures.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: describe the incidence and risk factors for stroke in Australia

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describe the acute and rehabilitative nursing management for the stroke patient describe the common diagnostic study abnormalities found in patients with a cerebrovascular (CVA) accident describe age-related changes to the nervous system and differences in assessment findings describe first aid management of the person who is having a seizure and the nursing responsibilities

What you need to do to meet your learning outcomes11. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 2 Culturally competent care 54 Nursing assessment: nervous system 56 Nursing management: patient with a stroke

12. If you wish to read more widely you may wish to revise these chapters.Crisp, J & Taylor, C (eds) 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Client teaching box: 32-34 Neurological assessment, p. 759 Sample nursing care plan: Sensory/perceptual alterations, p. 1544 Skill: 37-2 Seizure precautions, p. 962 McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults and children, 4th edn, Mosby, St Louis, Missouri. Chapter: 16 Alterations in neurologic dysfunction. Consult a pharmacology text regarding thrombolyticsstreptokinase, heparin and warfarin antihypertensive medicationsenalapril (Renitec), amiloride (Moduretic) anti-seizure medicationsDexamethasone, Diazepam and Mannitol

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13. Visit the following websitesThese three sites have been developed specifically for registered nurses as continuing education sites. The diagnostic test section is particularly interesting. The first site will take you to all the neurological studies on the site. http://www.nurseceu.com/nur.htm http://www.nursingceu.com/NCEU/courses/strokeac/index.htm http://nsweb.nursingspectrum.com/ce/ce98.htm Please see the following sites that are linked from the above site: http://ww1.heartandstroke.ca/Page.asp?PageID=1017&CategoryID=2&Src=stroke http://www.strokefoundation.com.au/ http://www.strokeresearch.com.au/ This site is interactive with photos, x-rays and video clips: http://www.umassmed.edu/strokestop/index.html Epilepsy Australia has an award-winning site. It is worth a visit, especially see the teen section. http://www.epilepsy.org.au/ The Centre for Neuro Skills has a good article on brain function: http://www.neuroskills.com/index.shtml?main=/tbi/brain.html

14. Attend the lecture, tutorial and workshop for this week

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Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial.Angelo is a very proud 70-year-old retired market gardener who now lives with his son and continues to help in the family business of tomato and onion farming. Today while out tending the tomato vines, Angelo suddenly realised he was dragging his left leg and his left arm would not hold the rake. He stumbled to the ground and was found by his son, who called the ambulance because he could not understand what his father was saying and his father could not get up from the ground. In emergency the nurses obtain a health history from the son who is quite distressed to see his father this way. His health history reveals:

cigarette smoker for 50 years, about 10 a day hypertension managed with enalapril (Renitec) amiloride (Moduretic)

having some difficulty passing urine with poor stream and urgency particularly at night otherwise healthy no history of recent head trauma no FFFFTs (no fits, faints, falls, funny turns) vital signs pulse 70 resps 20 BP 160/95 temp 37C

ECG shows sinus rhythm assessed by emergency medical officer who orders a CT scan CT confirms Angelo has had a CVA with possible embolism in the right hemispheres of the brain evidenced by swelling on the CT neurological examination found the following clinical features: weakness and parathaesia of left limbs R sided hemianopia expressive dysphasia mild dysphagia confusionspeaking in Italian with apparent no understanding of English

The decision is made to give him streptokinase, followed by a heparin infusion.

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A MO sees Angelo and orders:

O2 therapy 2L/min through nasal cannulae Activated Partial Thrombin test IVT 2L in 24 hours4% dextrose and 1/5 normal saline continue with antihypertensive therapy IV heparin therapy1000u every hour electrolyte blood levels CBP Speech therapy consult

Physiotherapy consult

Nil orally until seen by the speech therapist.

Please come to the tutorial prepared to discuss the following questions: Outline any further information that you need to know about Angelo

List the risk factors that Angelo has for developing a CVA

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Discuss the different types of CVAs.

TIAs are often seen as a precursor to CVAs. Discuss the pathophysiology associated with TIAs.

Explain the rationale for the MOs orders, including the streptokinase administered in the ER.

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Prioritise the problems, both physical and psychological, Angelo has.

Formulate a nursing care plan for Angelo.

Determine the aims of rehabilitation for Angelo.


Week 4: Part 2 Nursing management of Cognitive and Perceptual DisordersThis week the tutorial will focus on the nursing management required during the acute and rehabilitative phases for the person with raised intracranial pressure (ICP). The workshop will focus on the nursing care required for raised intracranial pressure and other trauma following a motor vehicle accident (MVA).

Learning outcomes for this weekUpon the successful completion of this section you should be able to:

describe the incidence and risk factors for raised intracranial pressure

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describe the acute and rehabilitative nursing management for the raised intracranial pressure patient describe the common diagnostic study abnormalities found in patients with raised intracranial pressure. describe age-related changes to the nervous system and differences in assessment findings describe first aid management of the person who is having a seizure and the nursing responsibilities

What you need to do to meet your learning outcomes15. Before attending your tutorial read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 55 Nursing management: intracranial problems 57 Nursing management: chronic neurological problems

16. If you wish to read more widely you may wish to revise these chapters.Crisp, J & Taylor, C (eds) 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Client teaching box: 32-34 Neurological assessment, p. 759 Sample nursing care plan: Sensory/perceptual alterations, p. 1544 Skill: 37-2 Seizure precautions, p. 962 McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults and children, 4th edn, Mosby, St Louis, Missouri. Chapter: 17 Alterations in neurologic dysfunction. Consult a pharmacology text regarding thrombolyticsstreptokinase, heparin and warfarin antihypertensive medicationsenalapril (Renitec), amiloride (Moduretic) anti-seizure medicationsDexamethasone, Diazepam and Mannitol

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17. Visit the following websitesThese three sites have been developed specifically for registered nurses as continuing education sites. The diagnostic test section is particularly interesting. The first site will take you to all the neurological studies on the site. http://www.nurseceu.com/nur.htm http://www.nursingceu.com/NCEU/courses/strokeac/index.htm http://nsweb.nursingspectrum.com/ce/ce98.htm Please see the following intracranial web sites:www.nda.ox.ac.uk/wfsa/html/u08/u08_013.htm www.med.monash.edu.au/paediatrics/resources/icp.html www.braininjury.com/intracranialpressure.html

Please see the following sites that are linked from the above site: http://ww1.heartandstroke.ca/Page.asp?PageID=1017&CategoryID=2&Src=stroke http://www.strokefoundation.com.au/ http://www.strokeresearch.com.au/ This site is interactive with photos, x-rays and video clips: http://www.umassmed.edu/strokestop/index.html Epilepsy Australia has an award-winning site. It is worth a visit, especially see the teen section. http://www.epilepsy.org.au/ The Centre for Neuro Skills has a good article on brain function: http://www.neuroskills.com/index.shtml?main=/tbi/brain.html


Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial.Martin is a 28-year-old physical education instructor working in various high schools. His physical fitness is very sound as he undertakes numerous physical activities and he incorporates a considered dietary routine. He is single and spends significant time associating with friends and sporting group clubs. His general outlook on life is life should always be lived to the fullest.

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Martin is devoted to his motorcycle and spends weekends riding through the Adelaide Hills and sometimes races at local meetings. Today he was riding through a difficult piece of road in the rain and collided with an oncoming motor vehicle. He incurred serious head, thoracic, and leg injuries and subsequently had to be sedated and intubated by ambulance paramedics at the crash scene prior to being transported to the emergency department. Medical investigations confirm a closed head injury with an associated fracture of the frontal skull. His right wrist (with severe soft tissue damage) and left tibia are broken transversely and will be set in plaster. No internal organ damaged is confirmed and he has numerous cuts and deep lacerations about his torso and forehead. In emergency the nurses obtain a health history from his father who is quite distressed to see his son this way. At the scene of the accident he was:

Unresponsive with Glasgow Coma Scale of 3. Hypotensive with systolic varying between 55 and 82 mmHg. Diastolic ranged from 35 and 45 mmHg. Tachycardic 120 to 130 bpm. Respirations rapid and shallow 30 breaths per minute. Pupils 3mm and non-reactive. assessed by emergency medical officer who orders a CT scans

In the emergency department:

CT confirms Martin has a frontal skull fracture with right subdural haematoma, subarachnoid haemorrhage. Pronounced cerebral oedema confirmed. X-Ray show right wrist fracture and left tibial transverse fracture. Increased Cranial Pressure confirmed at 3 mmHg. Bleeding from numerous lacerations to his leg, torso, and forehead.

Please come to the tutorial prepared to discuss the following questions: Outline the pathophysiology of a closed head injury and the medical tests required to confirm it.

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What clinical manifestations of Martins head injury are presented?

Outline the pathophysiology of Intracranial Pressure and how increases in it present life threatening situations.

Outline the progression of increased intracranial pressure.

What are the clinical manifestations of intracranial pressure?

What are the clinical instruments used to monitor intracranial pressure?

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Detail the nursing management for Martins increase in intracranial pressure and formulate a nursing care plan.

Describe medications that may be implemented in Martins care.

Determine the aims of rehabilitation and discharge planning care for Martin.


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Week 5: Part 1 - Nursing Management of Endocrine Disorders Type 1 Diabetes MellitusThe endocrine system is under study this week. The case study focuses on a six year old girl who has Type 1 Diabetes mellitus and has had a hypoglycaemic episode. The element to be particularly covered in the tutorial around this case study is primary health care. Relevant clinical nursing skills will be covered in your workshop related to the patient with such diabetes.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: 1 apply critical thinking to the case study presented 2 apply primary health principles to the case study presented 3 apply biophysical and pharmacological knowledge to the case study presented 4 develop your application of nursing research to the case study presented 5 extend your knowledge of lifespan development in childhood and the implications for nursing practice 6 expand on your assessment skills in the area of the endocrine system 7 apply diabetes management principles to type 1 diabetes mellitus 8 develop your knowledge base in the nursing management of a child who has type 1 diabetes mellitus 9 practise and discuss nursing skills relevant to the area under study including: care of skin, feet and eyes in a client with diabetes, mixing of insulin medications, oral hypoglycaemic medications, BGLs, and diabetic diet.

2What you need to do to meet your learning outcomesAttend your lectures, one tutorial and one workshop session as well as the following activities. Read the case study, ask the critical questions and then refer to the relevant pages in the following texts to answer those critical thinking questions. By this stage students should be able to find their own reference material pertaining to the area of study.

1Complete these activitiesPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 46 Nursing assessment: endocrine system 47 Nursing management: diabetes mellitus Crisp, J & Taylor, C 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney.

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Chapter 4 Nutrition

19. Extra readingsPlease read and refer to the following readings that are available electronically on eReserve in the library or on hard copy.

Reading 5.1 on eReserveMeyers, L 2005, Safe at school: treating diabetes in the classroom, Diabetes Forecast, May, vol. 58, no. 5, pp. 44-49.

Reading 5.2 on eReserveShilling, F 2003, Foot care in patients with diabetes, Nursing Standard, vol. 17, no. 23, pp. 61-68.

Reading 5.3 on eReserveCruciani, M, Lipsky, BA, Mengoli, C & de Lalla, F 2005, Are granulocyte colony-stimulating factors beneficial in treating diabetic foot infections a meta analysis, Diabetes Care, vol. 28, pp. 454-460.

Reading 5.4 on eReserveStorch, EA, Lewin, A, Silverstein, JH, Heidgerken, AD, Strawser, MS, Baumeister A, Geffken, GR 2004, Peer victimization and psychosocial adjustment in children with type 1 diabetes, Clinical Paediatric, June, vol. 43, no. 5, pp. 467-471.

Reading 5.5 on eReserveBarker, JM, Goehrig, SH, Barriga, K, Hoffman, M, Slover, R, Eisenbarth, GS, Norris, JM, Klingensmith, GJ & Rewers, M 2004, Clinical characteristics of children diagnosed with type 1 diabetes through intensive screening and follow-up, Diabetes Care, June, vol. 27, no. 6, pp. 13991404.

20. Further referencesExtra text readings (for pertinent information) McCance, K & Huether, S 2002, Pathophysiology. The biological basis for disease in adults & children, 4th edn, Mosby, St. Louis. Chapter 20 Alterations in hormonal regulation

21. Consult the additional texts listed in the Topic information/Topic details for additional information pertinent to the case studyfurther specific reference will given to these texts during the semesterThere are always more references that can extend your knowledge in any area.

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Suggested websites http://www.realitycheck.org.au/ http://www.diabetes.org/home.jsp http://www.idf.org/home/ http://www.nlm.nih.gov/medlineplus/diabetes.html http://www.adea.com.au/ http://www.emedicinehealth.com/articles/17044-1.asp http://www.idi.org.au/home.htmwww.med.umich.edu/1libr/pa/pa_diabmell_hhg.htm www.ispad.org

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Activity Research the following medications and complete the pharmacology worksheet before coming to class.MEDICATION Trade and Generic Name INSULIN (Include all forms) MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS

GLICLAZIDE

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MEDICATION Trade and Generic Name METFORMIN MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS

ARCABOSE

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Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. Emily is a six year old little girl. She has Type 1 diabetes. She loves to go to school and being a very energetic child, and likes to participate in active sport activities with her friends at lunchtime. Emily is cared for by her conscientious mother and father. Her mother has informed the teacher about Emilys condition and what should be done if she should suffer from a hypo event. To maintain glycaemia management, Emily requires an insulin injection before breakfast, lunch and tea. Her meals consist of a well balanced diabetic diet. The problem: Emily has her usual injection before lunch but does not eat all her food that day because the class finishes late and she wants to join in the usual sports activity. Half way through the sports activity Emily suddenly has a hypo and the sports teacher has no idea how to cope with the situation. Emily rapidly becomes drowsy and then becomes unconscious. She is admitted to your ward after she has been stabilised. Her parents Jane 29 and Graham, 27 are very worried about Emilys situation and diabetic status especially as it was diagnosed at five years of age. They have decided to not have any more children so that they can devote themselves to Emilys welfare and Jane has reduced her full time employment to part-time so that she can be more readily available to Emily. Jane tells you that she had an aunt who had diabetes and she died at 53 from a heart attack, but before her death she had had one leg amputated, was blind and was in renal failure. Please come to the tutorial prepared to discuss the following questions: Outline the purpose and functions of the Endocrine System

What are the predominant glands of the Endocrine System?

Outline the communicating functions of the Endocrine System.

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Outline the assessment of the Endocrine System.

What is Diabetes Mellitus Type 1?

Discuss the aetiology and pathophysiology of Diabetes Mellitus Type 1.

What are the main differences between Type 1 and Type 2 Diabetes Mellitus?

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Discuss the major differences in medications used to regulate blood sugar levels in both, Type 1 & Type 2. Why do they differ?

Outline the meaning of Emilys Hypo event.

Detail the nursing and collaborative care plan management for Emily.

Outline the two types of hypoglycaemic medications. Why can insulin only be administered either subcutaneously or intravenously?

Discuss the discharge educational required to alleviate Emilys parents concerns and knowledge. Does Emily require further education? What about the sports teacher?


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Week 6: Part 2 - Nursing Management of Endocrine Disorders Type 2 Diabetes MellitusThe endocrine system is under study this week. The Tutorial scenario focuses on a 72 year old man who has Type 2 Diabetes mellitus and relating health conditions. Differences with Type 1 Diabetes Mellitus will be made clearer as well as the nursing interventions required. Relevant clinical nursing skills will be covered in your workshop related to the patient with Type 2 Diabetes mellitus.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: 2 apply critical thinking to the case study presented 3 apply primary health principles to the case study presented 4 apply biophysical and pharmacological knowledge to the case study presented 5 develop your application of nursing research to the case study presented 6 extend your knowledge of lifespan development for the elderly and the implications for nursing practice 7 expand on your assessment skills in the area of the endocrine system 8 apply diabetes management principles to Type 2 diabetes mellitus 9 develop your knowledge base in the nursing management of an elderly man who has type 2 diabetes mellitus 10 practise and discuss nursing skills relevant to the area under study including: care of skin, feet and eyes in a client with diabetes, mixing of insulin, oral hypoglycaemic medications, BGLs, and diabetic diet.

3What you need to do to meet your learning outcomesAttend your lectures, one tutorial and one workshop session as well as the following activities. Read the case study, ask the critical questions and then refer to the relevant pages in the following texts to answer those critical thinking questions. By this stage students should be able to find their own reference material pertaining to the area of study.

1Complete these activitiesPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 46 Nursing assessment: endocrine system

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47 Nursing management: diabetes mellitus Crisp, J & Taylor, C 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Chapter 4 Nutrition

22. Extra readingsPlease read and refer to the following readings that are available electronically on eReserve in the library or on hard copy.

Reading 5.1 on eReserveMeyers, L 2005, Safe at school: treating diabetes in the classroom, Diabetes Forecast, May, vol. 58, no. 5, pp. 44-49.

Reading 5.2 on eReserveShilling, F 2003, Foot care in patients with diabetes, Nursing Standard, vol. 17, no. 23, pp. 61-68.

Reading 5.3 on eReserveCruciani, M, Lipsky, BA, Mengoli, C & de Lalla, F 2005, Are granulocyte colonystimulating factors beneficial in treating diabetic foot infections a meta analysis, Diabetes Care, vol. 28, pp. 454-460.

Reading 5.4 on eReserveStorch, EA, Lewin, A, Silverstein, JH, Heidgerken, AD, Strawser, MS, Baumeister A, Geffken, GR 2004, Peer victimization and psychosocial adjustment in children with type 1 diabetes, Clinical Paediatric, June, vol. 43, no. 5, pp. 467-471.

Reading 5.5 on eReserveBarker, JM, Goehrig, SH, Barriga, K, Hoffman, M, Slover, R, Eisenbarth, GS, Norris, JM, Klingensmith, GJ & Rewers, M 2004, Clinical characteristics of children diagnosed with type 1 diabetes through intensive screening and follow-up, Diabetes Care, June, vol. 27, no. 6, pp. 1399-1404.

23. Further referencesExtra text readings (for pertinent information) McCance, K & Huether, S 2002, Pathophysiology. The biological basis for disease in adults & children, 4th edn, Mosby, St. Louis. Chapter 20 Alterations in hormonal regulation

36

24. Consult the additional texts listed in the Topic information/Topic details for additional information pertinent to the case study further specific reference will given to these texts during the semesterThere are always more references that can extend your knowledge in any area.

Available under the extra resources for week 0Suggested websites http://www.realitycheck.org.au/ http://www.diabetes.org/home.jsp http://www.idf.org/home/ http://www.nlm.nih.gov/medlineplus/diabetes.html http://www.adea.com.au/ http://www.emedicinehealth.com/articles/17044-1.asp http://www.idi.org.au/home.htm

Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. Jean Paul is a 75 year old man living on his own in a small apartment in the suburbs. He was a chief for many years and had a French restaurant for 15 years after immigrating to Australia. He never married but has a son living nearby with his family. He was diagnosed with Type 2 Diabetes Mellitus eight years ago after the development of several foot neurotropic ulcerations and various points of dermopathy around his body. He has begun to develop early signs of diabetic neuropathy in his right hand. Changes in his urinary function were also detected and a diagnosis of nephropathy was confirmed. This renal condition is monitored annually. His father died of diseases related to Diabetes Mellitus Type 2 aged 82 years. His physical activity is minimal due to lifestyle choices, foot pain, and not having the willingness to do so. Consequently he is obese and weights 127kgs at 5ft 9. He smokes heavily in his apartment and consumes approximately 1 packet daily. His diet is devoted to his love of homeland French cuisine and he consumes large amounts of it. He does not drink alcohol as he thinks it diminishes the taste of his cooking. Despite medical instructions, he takes his BGL reading infrequently and does not incorporate nutritional modifications to his eating habits. He is determined to remain a smoker. Jean Pauls medications include: Enalapril (ACE inhibitor) for his hypertension and kidney conditions. Metformin, for blood sugar level maintenance, which he often forgets to administer. He takes regular Panadol for foot and other bodily pain.

37

His son Michael came to visit him where he found Jean Paul very somnolent and almost unable to move or coordinate. He was immediately taken to the emergency department. A diagnosis of Hyperosmolar Hyperglycaemic Non-Ketotic Syndrome (HHNS) is made and medical treatment is rapidly instigated to manage this life-threatening syndrome. The findings of the emergency department are: BP: 85/55 Temp: 37.8 Resps: 28 Pulse: 118 SAO2 91% BGL: 48 mmol/L IV Insulin: immediate treatment for high BGL IV N/S 1000mls 250mls hour then titrated according to fluid volume status. IV 5% dextrose administered when BGL is 12-16 mmol/L to prevent hypoglycaemia. Cardiac irregularity detected by ECG Pronounced dehydration and serum osmolarity frequent urination. Ketoacidosis not present. Routine blood and urine tests for electrolyte balances. Oxygen therapy via nasal cannula commenced at 4L. Please come to the tutorial prepared to discuss the following questions: Outline the aetiology and pathophysiology of Type 2 Diabetes Mellitus.

Discuss the meanings of Endogenous and Exogenous insulin.

38

Detail Jean Pauls HHNS diagnosis. What are the main differences with Diabetic Ketoacidosis?

Outline the medical treatment of HHNS. What are the most vital interventions at the beginning of treatment?

What is the reason underlying advanced dehydration? What is its precise pathological cause?

What are the main differences between Type 1 and Type 2 Diabetes Mellitus?

Discuss the major differences in medications used to regulate blood sugar levels in both Type 1 & Type 2. Why do they differ?

39

Draw a flowchart of the progression of untreated or controllable HHNS.

Outline the nutritional education that should be emphasised to Jean Paul when discharged.

Discuss the discharge educational able to be supplied to patients with Type 2 Diabetes Mellitus. Focus on Jean Pauls age and management of his condition.

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Week 7: Nursing Management of Renal Disorders End Stage Renal FailureThis week will focus on urological/renal diseases culminating in urological/renal failure. The tutorial focuses on chronic renal disease (CRD) leading to end stage renal disease (ESRD). The practical workshop will involve a number of activities including fluid and electrolyte management, blood pressure (BP) management, arterio-venous fistula/graft (AVF or AVG) care and central venous dialysis catheter (CVDC) care.


describe the clinical manifestations, complications, collaborative care, and nursing management of a person with CRD leading to ESRD describe the preoperative and postoperative nursing management for a person requiring AVF or AVG formation prior to haemodialysis describe the treatment options of a person with ESRD including haemodialysis, chronic ambulatory peritoneal dialysis (CAPD), intermittent peritoneal dialysis (IPD) and renal (kidney) transplantation describe the nursing and collaborative management of a person undergoing haemodialysis

What you need to do to meet your learning outcomesVisit the following websites

The following websites have useful information for health professionals and patients. Access the sites and note what you found most interesting for the seminar discussion. The Renal Resource Centre website has many useful fact sheets available to download www.kidney.org.au/renalresources Kidney Health Australia is a non-profit organisation with a mission to be the lead organisation promoting kidney and urinary tract health through research, advocacy, education and health service excellence in Australia. www.kidney.org.au/

41

Renal Society of Australasia is an Australasian society of mainly nursing, technical and allied health professionals, aiming for excellence in the dissemination of knowledge in Renal Replacement Therapies www.renalsociety.org/ Hypertension, Dialysis and Clinical Nephrology (HDCN) is a useful website with many links for renal professionals www.hdcn.com Nephron Information Centre is a very informative website that features basic renal anatomy, basic renal disease information and "professional" links (for doctors, nurses, social workers, technicians, dieticians) to jobs and conferences. Dialysis Patient's Health Guide. www.nephron.com The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) collects a wide range of statistics that relate to the outcomes of treatment of those with end stage renal failure www.anzdata.org.au Atlas of Diseases of the Kidney www.kidneyatlas.orgPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 43 Nursing assessment: urinary system 45 Nursing management: acute renal failure and chronic kidney disease Extra text readings (for pertinent information) Lewis, S., Heitkemper, M. & Dirksen, S. 2004, MedicalSurgical NursingAssessment and Management of Clinical Problems, 6th edn, Mosby Inc., Missouri. Chapter 44. NURSING MANAGEMENT: Renal and Urological Problems Chapter 45. NURSING MANAGEMENT: Acute Renal Failure and Chronic Kidney Disease Lehne, R. A. 2001, Pharmacology for Nursing Care, 4th edn, W. B. Saunders Co., Philadelphia. Please read the following research paper: Lindqvist R. Carlsson M. Sjoden PO. 2000 Perceived consequences of being a renal failure patient. Nephrology Nursing Journal: Journal of the American Nephrology Nurses' Association. 27(3):291-7;

Attend the lecture, seminar and practical workshop for this week 42

Elements covered in the lecture will relate to the scenario below. The scenario questions will be discussed in the seminar. Remember the practical workshops are compulsory.

Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. Nguyen is a 35 year old female who lives in Fulham Gardens. She is married with two young children (8 and 6 years old). She has lived in Australia for the past two years and her English is limited. She was admitted 2 weeks ago with symptoms of increasing lethargy, nausea, weakness, depression, and recurring gastritis. Following diagnostic tests including blood tests (urea, creatinine, potassium), renal ultrasound and renal biopsy she was diagnosed with ESRD. Nguyen had not previously been diagnosed with (chronic renal disease) CRD. On day 2 after admission Nguyen had a CVDC (often called a Permcath) inserted into her left subclavian vein and haemodialysis was commenced. After 10 days of intermittent haemodialysis (every alternate day) she had an (arteriovenous fistula) AVF surgically constructed in her left forearm. She returned from theatre 8 hours ago.

Current nursing care includes

post-operative observations (BP not on operated arm) post-operative neurovascular observations observation of bruit/thrill wound observation RIB IVT FBC Her medications include:o o o o o o o

Paracetamol or Panadine Forte 1g QID prn IV AB (Two Doses) Cephalothin 1gm 8/24. Alutab 1 TDS Amlodipine 10mg nocte Caltrate 3 TDS Calcitriol 1 mcg non-dialysis days EPO 6000u s/c twice weekly

43

o o o o

Folic Acid 5mg daily Loperimide 2 nocte Vit C 500mg post dialysis Mega B 1 post dialysis

Consider these questions relating to the scenario Please come to the seminar prepared to discuss the following questions:

Outline how a patient can progress from CRD to ESRD without previous clinical manifestations of CRD.

How have Nguyens cultural background and language difficulties contributed to the above disease state progression?

Do Nguyens presenting clinical manifestations concur with the above disease state progression?

Detail the medical tests and related pathophysiology and possible aetiology involved in Nguyens diagnosis of ESRD.

Detail the nursing management of a patient with CRD focus on Nguyens treatment.

44

Why was Nguyen commenced on haemodialysis and what were her likely main test results indicating such a move?

Discuss the principles of Haemodialysis and Dialysis. List the medical options available.

Describe the AVF operative procedure.

Prioritise Nguyens care post operatively and give a rationale for your answer.

Formulate a nursing care plan for Nguyen including the following:o o o o

need/problem/nursing diagnosis outcome statement nursing interventions including rationale possible changes to the nursing care plan if required List the psychosocial needs Nguyen may have in the near future

o

45

Describe why Nguyen is administered each of her medications:


Week 8: Part 2 - Nursing Management of Urological Disorders UTI & SPCThis week will focus on permanent urological problems of an elderly man. The tutorial focuses on chronic UTI development due to the use of a permanent SPC. The practical workshop will involve the nursing responsibilities for treating a UTI and the assessment and maintenance of an SPC.


describe the clinical manifestations, complications, collaborative care, and nursing management of a person with chronic urological problems chronic UTI development describe the nursing management for a person requiring UTI treatment and SPC monitoring describe the treatment options of a person with urological problems chronic UTI describe the education and public health information able to be give to such patients

What you need to do to meet your learning outcomesThe following websites have useful information for health professionals and patients. Access the sites and note what you found most interesting for the seminar discussion. The Renal Resource Centre website has many useful fact sheets available to download www.kidney.org.au/renalresources

46

Kidney Health Australia is a non-profit organisation with a mission to be the lead organisation promoting kidney and urinary tract health through research, advocacy, education and health service excellence in Australia. www.kidney.org.au Renal Society of Australasia is an Australasian society of mainly nursing, technical and allied health professionals, aiming for excellence in the dissemination of knowledge in Renal Replacement Therapies www.renalsociety.org Hypertension, Dialysis and Clinical Nephrology (HDCN) is a useful website with many links for renal professionals www.hdcn.com Nephron Information Centre is a very informative website that features basic renal anatomy, basic renal disease information and "professional" links (for doctors, nurses, social workers, technicians, dieticians) to jobs and conferences. Dialysis Patient's Health Guide www.nephron.com The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) collects a wide range of statistics that relate to the outcomes of treatment of those with end stage renal failure www.anzdata.org.au Atlas of Diseases of the Kidney www.kidneyatlas.orgPlease refer, refresh, read and/or note the relevant pages and chapters in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 43 Nursing assessment: urinary system 44 Nursing management: renal and urological problems Extra text readings (for pertinent information) Lewis, S., Heitkemper, M. & Dirksen, S. 2004, MedicalSurgical NursingAssessment and Management of Clinical Problems, 6th edn, Mosby Inc., Missouri. Chapter 44. NURSING MANAGEMENT: Renal and Urological Problems Lehne, R. A. 2001, Pharmacology for Nursing Care, 4th edn, W. B. Saunders Co., Philadelphia.

Attend the lecture, seminar and practical workshop for this week

47

Elements covered in the lecture will relate to the scenario below. The scenario questions will be discussed in the seminar. Remember the practical workshops are compulsory.

Consider the following scenario for your tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. Peter is a 78 year old nursing home resident. He has been resident in the home for ten years following the death of his wife from liver cancer. Peters daughters rarely visit and he insists on remaining in his room alone most of each day. His physical mobility is poor and he remains in his wheelchair rather than walking. He has significant osteoarthritis in his hips and left knee. He has Type 2 diabetes resulting in lower leg ulcerations and hypertension. Peripheral neuropathy is also present in his lower legs. Peter will not take hypoglycaemic medication as he says he doesnt eat enough nor wants to take such tablets. The nursing home RN performs BSL monitoring twice weekly. Two months ago he had a suprapubic catheter (SPC) inserted following numerous incidents of urinary tract infections. Medical investigations revealed a neurogenic bladder with associated low bladder wall compliance. His tolerance of having such a urinary catheter has been low and he refuses to be involved in its care and maintenance. Such low involvement has contributed to the numerous cases of (urinary tract infections) UTIs. Three days ago the nursing home staff noticed an increase in his agitation and confusion; he frequently refused to have carers attend to his hygienic needs. An increase in flank pain, discomfort, agitation, and development of a fever led to his emergency department admission where a severe recurrent upper UTI with related urethritis were diagnosed. Misuse and nonhygienic maintenance of his SPC in the nursing home are the determined causes. A dipstick urinalysis confirmed the presence of nitrates and leucocytes. Peter is on your ward undergoing treatment for his infections and the assessment and management of his SPC. You are assigned his care: IVT N/S 1000mls 8 hours Diabetic diet. Encourage fluids IV AB Penicillin 1.2gms 8/24 BSL random daily Panadol 1gm QID prn Metformin 850mg nocte Oxybutynin 10 mgs prn. Metaprolol 25mgs mane Serenace 1.5mg prn SPC maintenance and assessment 2/24

48

FBC Agitation and confusion management.

Please come to the tutorial prepared to discuss the following questions:

Define a urinary tract infection.

Detail the aetiology and pathophysiology of UTI development.

Detail Peters recurrent upper UTI tendency, including his presenting clinical manifestations which suggest this diagnosis.

How do the nitrates and leucocytes in his urine confirm infection presence?

49

Detail the nursing management of a patient with a UTI and SPC insitu focus on Petes case.

Formulate a nursing care plan for Peter including the following:o o o o

need/problem/nursing diagnosis outcome statement nursing interventions including rationale possible changes to the nursing care plan if required List the psychosocial needs Peter may have in the near future

o

Discuss the most probable link with Peters reluctance to participate in the management of his SPC with his recurrent upper UTI states.

Discuss how nursing staff at the nursing home could attempt to encourage Peters participation in his SPC maintenance.

50

Detail why Peter is administered each of his medications:


Week 9: Nursing Management of Gastrointestinal Disorders Large Bowel Obstruction1The gastrointestinal system is under study this week. The scenario focuses on a patient who develops a large bowel obstruction from cancer and undergoes a resection with a temporary colostomy. Her consequential clinical nursing care will be covered in the workshop.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: 1 apply critical thinking to the case study presented 2 apply primary health principles to the case study presented 3 apply biophysical and pharmacological knowledge to the case study presented 4 develop your application of nursing research to the case study presented 5 expand on your GIT nursing assessment skills

51

6 develop your knowledge base in the nursing management of an elderly person undergoing major GIT surgery 7 extend your knowledge of nursing management of clients with a diagnosis of cancer, major surgery, loss of independence, and a chronic illness 8 practise nursing skills relevant to the area under study including: NG tube drainage and LPS, colostomy/ileostomy care, revision of PEGs, assessment of bowel sounds, faecal impaction, constipation/diarrhoea, nausea and vomiting.

What you need to do to meet your learning outcomesAttend the lectures, one tutorial and one workshop session as well as the following activities. Read the case study, ask the critical questions and then refer to the relevant pages in the following texts to answer those critical thinking questions. 9 Complete these activities Please refer, refresh, read and/or note the relevant pages in the following chapters and other relevant areas in your texts.

Text readingsBrown, D & Edwards, H 2005, Lewiss medical-surgical nursing assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters 38 Nursing assessment: gastrointestinal system 41 Nursing management: lower gastrointestinal problems Crisp, J & Taylor, C 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Chapters 45 Bowel elimination 49 Care of surgical patients

Extra readingsPlease read and refer to the following readings that are available electronically on eReserve in the library or on hard copy.

Reading 8.1 on eReserveSargent, C & Murphy, M 2003, What you need to know about colorectal cancer, Nursing; Feb, vol. 33, no. 2, pp. 36-42.

Reading 8.2 on eReserveRobinson, ES 2002, The truth about colorectal cancer, Nursing, April, pp. 4-7.

Reading 8.3 on eReserve

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Paula Erwin-Toth, P 2001, Caring for a stoma is more than skin deep, Nursing, May, vol. 31, no. 5, pp. 36-40.

Reading 8.4 on eReserveWeerakoon, P 2001, Sexuality and the patient with a stoma, Sexuality and Disability, vol. 19, no. 2, Summer.

Reading 8.5 on eReservePontieri-Lewis, V 2000, Colorectal cancer: prevention and screening, Medsurg Nursing, February, vol. 9, no. 1, pp. 9-14.

Further references Extra text readings (for pertinent information)McCance, K & Huether, S 2005, Pathophysiology. The biological basis for disease in adults & children, 5th edn, Mosby, St. Louis. Chapters 38 Structure and function of the digestive system 39 Alterations of digestive function

Consult the additional texts listed in the Topic information/Topic details for additional information pertinent to the case studyfurther specific reference will given to these texts during the semesterThere are always more references that can extend your knowledge in any area.

0Suggested websiteshttp:////www.beyondblue.org.au/ http://www.depression.com.au http://www.cancerscreening.gov.au/bowel/ http://www.cssa.org.au/patientarticle.asp?ArticleNo=10 http://www.cancerresearch.org.au/faq.html http://www.gutdisorders.com/welcome.cfm http://www.cancercouncil.com.au/editorial.asp?pageid=17

Research the following medications and complete the pharmacology worksheet before coming to the tutorial.

53

54

Trade and Generic Name

MODE OF ACTION

PRECAUTIONS

SIDE EFFECTS

NURSING IMPLICATIONS

MAXALON

CEPHALOTHIN

55

Trade and Generic Name METRONIDAZOLE

PRECAUTIONS N

MODE OFACTIO

SIDE EFFECTS

NURSING IMPLICATIONS

GENTAMICIN

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Consider this scenario for the tutorial Gastrointestinal SystemRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial Mrs Carsons is a an 86 year old woman who was admitted to the ward two days ago with mild abdominal pain, anorexia, slight nausea and chronic constipation for investigation via her GP. She has no significant past medical history and is taking no medications. Her GP had done a Haematest on her stool in the surgery and found it to be positive for occult blood. On admission Mrs Carsons seems very anxious. She says she has never been in hospital before and she is frightened that shell never get out. When you ask her why, she says shes sure shes got cancer and shes going to die. She also tells you that she lives alone since her husband died six years ago, but her only daughter, who is 58 and married, visits her every day and they are very close. Her admission observations are T 37.5C, P92 (reg), R22, BP 145/90 On examination, Mrs Carsons tissue turgor is poor, her tongue is dry and coated, her lips are cracked and her skin is dry and frail. Her abdomen is distended and she pulls away when you try to palpate it. On auscultation you hear no bowel sounds in the left upper and lower quadrants but hyperactive sounds in the right upper and lower quadrants. Her admission weight is 50 kgs and she is 160 cm tall. She tells you she used to be quite a big woman, weighing about 10 stone a year ago. She has no explanation for this weight loss, however. About two hours after her admission Mrs Carsons calls you over urgently and says she thinks shes going to be sick. She promptly vomits about 150 mls of green bile into the bowl you offer her. After making her as comfortable as possible you administer the injection of IM Maxalon 10 mgs 4-6 hourly that has been ordered. Unfortunately this has no effect and Mrs Carsons continues to vomit large amounts over the next two hours culminating in a large brown offensive vomit. The total amount she has vomited is 680 mls. Her observations are T 38C, P118 (reg), R 26, BP100/55. You call the RMO, who after examining Mrs Carsons diagnoses a large bowel obstruction. He inserts a NG tube and asks for it to be on free drainage, inserts a Jelco with Normal Saline 1000 mls running over four hours and he asks you to prepare Mrs Carsons for emergency surgery. During surgery Mrs Carsons is found to have Bowel Ca Dukes Category C. The surgeon goes on to perform a Left Hemi-colectomy and creates a temporary colostomy. During the procedure the bowel was perforated distal to the anastomosis but this was repaired during the operation. She returns to the ward with a NG tube, an IDC and IV line in situ. Her midline abdominal wound is clean and dry and covered by combine and Hyperfix. She is receiving O2 via nasal spectacles and she is drowsy but rousable. When asked, she states she is experiencing pain at a level of 8 out 10. Her post-op orders are: 0 routine post-op obs 1 naso-gastric tube on free drainage. 2 oxygen @ 2L/min via nasal specs 3 nil orally 4 measure urine output 2 hourly 5 IVT: 5% Dextrose 1/5 Normal Saline 1000 ml in 8 hours (current bag) 6 normal Saline 1000 mls in 8 hours

7 5% Dextrose and 1/5 Normal Saline 1000 ml in 8 hours. 2 3Medications: o o o o o o Morphine 5-10 mgs S/C 24 hourly PRN. Maxalon 10mg IV 6-8 hourly PRN. Cephalothin 1 gm TDS IV. Metronidazole 500 mgs TDS IV. Gentamicin 160 mgs IV daily. Panadine 500 mg-1000 mgs 4 hourly PRN.

128. Consider these questions relating to the scenarioPlease come to the tutorial prepared to discuss the following questions: Define a Large bowel obstruction, Bowel Ca, and Left Hemi-colectomy.

Discuss and detail Mrs Carsons presenting clinical manifestations which result in her large bowel obstruction diagnosis requiring a Left Hemi-colectomy.

Discuss the aetiology and pathophysiology of colorectal cancer and resulting large bowel obstruction.

Outline the reasoning for the ordered emergency surgery for Left Hemi-colectomy.

58

Detail the necessary Left Hemi-colectomy and the need for a temporary colostomy.

Describe what risks are present following the intra-operative distal bowel perforation.

Prioritise Mrs Carsons care postoperatively and give a rationale for your answer.

Formulate a nursing care plan for Mrs Carson including the following:

need/problem/nursing diagnosis patient aims nursing interventions including rationale outcome statement possible changes to the nursing care plan if required.

59

Discuss the issues you need to consider when providing discharge planning for Mrs Carson.


Week 10: Nursing management of Hepatobilary DisordersThis week involves the study of the hepatobiliary system. The tutorial focuses on a woman who develops acute pancreatitis secondary to cholelithiasis; she is admitted for an open cholecystectomy. The workshop will focus on the nursing skills associated with caring for patients with such hepatobiliary problems.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: apply critical thinking to the scenario presented apply primary health care (PHC) principles to the scenario utilise your knowledge of physiology and pharmacology (from 1st & 2nd year) in your analysis of the scenario appreciate the relevance of cultural safety in the nursing context plan the nursing management of a patient with pancreatitis secondary to cholelithiasis Plan and implement the post operative open cholecystectomy nursing management

What you need to do to meet your learning outcomes29. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 42 nursing management: liver, biliary tract and pancreas problems

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17 Nursing management: preoperative care 19 Nursing management: postoperative care Additional pertinent reading can be found in the following: Crisp, J & Taylor, C (eds) 2005, Potter & Perrys fundamentals of nursing, 2nd edn, Elsevier, Sydney. Chapters: 47 Skin integrity and wound care 49 Care of surgical patients Skills: 34-9 Adding medications to IV containers, p. 874 (also on CD) 40-2 Regulating intravenous flow rate, p. 1136 (also on CD) 454 Inserting and maintaining a nasogastric tube, p. 1360 (also on CD) 473 Applying dry and wet-to-dry moist dressings, p. 1482 (also on CD) 491 Demonstrating postoperative exercises, p. 1556 (also on CD) Client teaching box: Box 47-19 Dressing application, p. 1485 Sample nursing care plans: Skin integrity and wound care, p. 1459 Peri operative patient, p. 1542 McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults and children, 4th edn, Mosby, St Louis, Missouri. Chapter: 38 Alterations of digestive function


Consider this scenario for the tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorialMrs Justine Oliver (aged 32 years and single mother of two girls) is seen in Accident & Emergency with the following clinical findings:

Acute RUQ pain Severe nausea & vomiting T 37.8C P - 114 R 28 BP 110

/60

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Mild jaundice Some abdominal distension

Her medical history is

She has been having episodes like this for about a month, but none of them have been this bad. She cant really say if they have been associated with any particular food intake. The only medication that she tales is the Pill which is oestrogen based. Her alcohol intake is an average of 3 Standard Drinks a week

The MO orders the following tests

Serology

o o o o CXR

CBP LFT Electrolyte levels C-reactive Protein

Abdominal X-ray Abdominal Ultrasound ERCP

The results show

Raised White Cell Count Raised creatine Raised SGOT, LDH & ALT Raised BUN Enlarged & swollen CBD & Pancreatic Duct with stones in evidence Raised CRP Raised BGL

The provisional diagnosis is acute pancreatitis due to cholelithiasis and she is to be admitted for an open cholecystectomy. She arrives in the ward with the following orders

N/G tube in situ on free drainage IVT 3 Litres in 24 hours alternating Hartmanns with N/Saline N/G tube to be aspirated with IV replacement of N/Saline IV Antibiotics Metronidazole 500mg/100mls TDS & Ticacillin 1g 8/24 Analgesia

o

S/C Morphine 2.5-5mg 2/24

62

o

IM Hyoscine butylbrmide 20mg/ml

Nil Orally

You are assigned to look after her the next day when she has just returned from theatre after her open cholecystectomy with

IVT with 2 lines

o o

the main IV line is running at 3L/24 hrs, this can be reduced once her nasogastric fluids have been reduced & bowel sounds have returned the second line is for replacement of her naso-gastric fluids which you will need to calculate 4/24ly

IV ABs are to continue Wound drain (Haemovac) in situ T-tube in situ S/C Morphine 2.5-5mg 2/24 for pain relief RIB with toilet privileges as tolerated for 1st 24 hours, then mobilise as tolerated N/G tube in situ on free drainage

o o

Aspirate 2/24ly replace with IV fluids if > 50mL an hour To be removed once drainage < 50 mls an hour for 4 hours

Free fluids once N/G tube is removed Light diet once N/G tube removed and bowel sounds are present

31. Consider these questions relating to the scenarioPlease come to the tutorial prepared to discuss the following questions: Define pancreatitis, cholelithiasis, and cholecystectomy.

Detail Mrs Olivers presenting clinical manifestations which result in her pancreatitis diagnosis.

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Discus the aetiology and pathophysiology of pancreatitis and cholelithiasis.

Outline the reasoning for the ordered medical tests.

Outline what is involved in an open cholecystectomy.

Describe the differences between open and laparoscopic cholecystectomy.

Prioritise Justines care postoperatively and give a rationale for your answer.

Formulate a nursing care plan for Justine including the following:

need/problem/nursing diagnosis patient aims nursing interventions including rationale outcome statement

64

possible changes to the nursing care plan if required

Discuss the issues you need to consider when providing discharge planning for Justine.


Week 11: Nursing Management of Haematological DisordersThis week focuses on problems relating to the haematological system. Knowledge of haematology is useful in clinical environments to assess the patients ability to transport oxygen, carbon dioxide, and other blood-borne considerations. The tutorial will focus on various haematological problems and their management options. The workshop will involve a number of activities focussed on the OSCE assessment later in the semester. These will involve wound management, patient education, pain management, and infection control and prepare the student for this item of assessment.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient with haematological problems. Iron-deficiency anaemia, Neutropenia, and Thrombocytopenia will be discussed

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Describe the preoperative and postoperative nursing management for the patient with haematological considerations Explain the essential functions of the haematological system Describe age-related changes in the haematological system and differences in assessment findings

What you need to do to meet your learning outcomes32. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 29 Nursing assessment: haematological system 30 Nursing management: haematological problems [Please note that you may use the 5th edition of Lewis, Heitkemper & Dirksen. The chapter numbers may differ but the chapter titles are the same but it does not have an Australian focus.]

33. If you wish to read more widely you may wish to revise these chapters.Galbraith, A, Bullock, S & Manias, E 2004, Fundamentals of pharmacology, 4th edn, Pearson Education Australia, Prentice Hall Health, Frenchs Forest, NSW. Chapters: 46 Anticoagulants, Thrombolytics and Antiplatelet Drugs, pp. 482-496. 50 Antianaemic Drugs, pp. 546-552. 51 Drugs used to Maintain Gas Exchange, pp.553-570.

34. Visit these websitesThe following websites have useful information for health professionals and patients. Access the sites and note what you found most interesting for the tutorial discussion. Haematological sites: www.uq.edu.au/vdu/HDUIntro.htmwww.imvs.sa.gov.au/haematology/index.htm

Iron deficiency Anaemia site: www.virtualbloodcentre.com/diseases.asp?did=60 Thrombocytopenia site: www.merck.com/mmhe/sec14/ch173/ch173d.html Neutropenia site: www.virtualbloodcentre.com/diseases.asp?did=704

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35. Attend the lecture, tutorial and workshop for this weekElements covered in the lecture, tutorial and workshop will relate to the scenario below. The scenario questions will be discussed in the tutorial. Remember the workshop and tutorial sessions are compulsory.

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Consider these questions for the tutorialThe tutorial this week examines the haematological system. Please consider the following questions and be ready to discuss your answers in the tutorial. Haematological Foundations Define the structures and functions of the haematological system

Discuss the objective data used in the assessment of the haematological system.

Discus the gerontological considerations in the haematological system

List and describe the full blood count (FBC) diagnostic studies.

List and describe the clotting diagnostic studies.

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Haematological Problems Describe iron-deficiency anaemia and its clinical manifestations.

Describe the nursing management of this haematological condition.

Describe Neutropenia and its clinical manifestations.


Describe Thrombocytopenia and its clinical manifestations.

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Week 12: Part 1 - Nursing management of Reproductive Disorders Female FocusThis week focuses on two problems relating to the female reproductive system. The tutorial examines endometriosis and its management options. The workshop will involve a number of activities related to the post operative management of an abdominal hysterectomy.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient with endometriosis Describe the preoperative and postoperative nursing management for the patient requiring major surgery of the female reproductive system Explain the functions of the major hormones essential for the structure and function of the female reproductive system. Describe age-related changes in the female reproductive system and differences in assessment findings. Describe the nursing and collaborative management of the patient undergoing an abdominal hysterectomy.

What you need to do to meet your learning outcomes36. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 49 Nursing assessment: reproductive system 52 Nursing management: female reproductive problems [Please note that you may use the 5th edition of Lewis, Heitkemper & Dirksen. The chapter numbers may differ but the chapter titles are the same but it does not have an Australian focus.]

37. If you wish to read more widely you may wish to revise these chapters.Galbraith, A, Bullock, S & Manias, E 2001, Fundamentals of pharmacology, 3rd edn, Pearson Education Australia, Prentice Hall Health, Frenchs Forest, NSW. Chapters: 34 Non-steroidal anti-inflammatory, antipyretic and analgesic drugs, pp. 371-385. 53 Adrenocortical and gonadial pharmacology, pp. 609-630. 71

or Lehne, RA 2001, Pharmacology for nursing care, 4th edn, WB Saunders Co, Philadelphia. Chapter: 61 Drug therapy for infertility, pp. 705-713.

38. Visit these websitesThe following websites have useful information for health professionals and patients. Access the sites and note what you found most interesting for the tutorial discussion. Hysterectomy sites: www.womhealth.org.au/factsheets/hysterectomy.htmwww.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Hysterectomy_surgical_proce dures?open www.mja.com.au/public/issues/feb17/tsaltas/tsaltas.html

Endometriosis sites: http://www.ecca.com.au/home.html http://www.endometriosisassn.org/endo.html


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Consider this scenario for the tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial.Tracey is 38 years of age and has been in a stable relationship with her partner David for 11 years. They live in Pasadena and both work full time in the hospitality industry. Tracey has been living with endometriosis, dysmenorrhoea and dyspareunia. she was first diagnosed following a diagnostic laparoscopy at 20. She has undergone another two laparoscopies which involved laser surgery to remove the many chocolate cysts found in her peritoneal cavity. Tracey has also tried a six-month course of danazol but was unable to tolerate the acne side effects. Tracey and David have been unsuccessful in becoming pregnant after trying for seven years with IVF. Tracey is now fed-up with the pain and disruption to her life and the lost time from work. Together they have discussed the options and Tracey has decided to have an abdominal hysterectomy so that laser oblation of the endometriosis can occur at the same time. While the nurse is alone with Tracey, she tells the nurse that prior to her relationship with David she become pregnant and had a termination. She does not want David to know about this. Tracey is prepared for theatre and David walks beside her until he reaches the transfer bay. The ward RN walks David back to Traceys room to await her return. Four hours later, Tracey returns to the ward very sleepy with the following postoperative care orders: Routine postoperative vital signs and wound/rain checks:

morphine PCA and purge IVT for hydration 4% dextrose and 1/5 normal saline IDC wound drain wound covered and dry RIB fluids when bowels sounds return and passage of flatus.

40. Consider these questions relating to the scenarioPlease come to the tutorial prepared to discuss the following questions: Define endometriosis, dysmenorrhoea and dyspareunia

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List the psychosocial issues for Tracey and David at this time. Discuss how you could assist them?

Discuss the ethical issues surrounding patient confidentiality concerning this case.

Outline how Danazol works in the body & its main side effects.

Outline what is involved in an abdominal hysterectomy i.e. operative approach and organ removal

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Describe what laser oblation of the endometrial implants entails.

Prioritise Traceys care postoperatively and give a rationale for your answer.

Formulate a nursing care plan for Tracey including the following:

need/problem/nursing diagnosis patient aims nursing interventions including rationale outcome statement possible changes to the nursing care plan if required.

Discuss the issues you need to consider when providing discharge planning for Tracey.

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Week 13: Part 2 - Nursing management of Reproductive Disorders Male FocusThis week focuses on problems relating to the male reproductive system. The tutorial will examine Benign Prostatic Hyperplasia (BPH) and its management options. The workshop involves a number of activities relating to the post-operative management of bladder irrigation following a transurethral resection of the prostate (TURP) secondary to BPH.

Learning outcomes for this weekUpon the successful completion of this section you should be able to: Describe the clinical manifestations, complications, collaborative care, and nursing management of the patient BHP Describe the preoperative and postoperative nursing management for the patient requiring major surgery of the male reproductive system Explain the functions of the major hormones essential for the structure and function of the male reproductive system Describe age-related changes in the male reproductive system and differences in assessment findings Describe the nursing and collaborative management of the patient undergoing a transurethral resection of the prostate

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What you need to do to meet your learning outcomes41. Before attending your tutorial, read this weeks scenario and complete the readings belowBrown, D & Edwards, H (eds) 2005, Lewiss medical-surgical nursing: assessment and management of clinical problems, Elsevier Mosby, Sydney. Chapters: 49 Nursing assessment: reproductive system 53 Nursing management: male reproductive problems [Please note that you may use the 5th edition of Lewis, Heitkemper & Dirksen. The chapter numbers may differ but the chapter titles are the same but it does not have an Australian focus.]

42. If you wish to read more widely you may wish to revise these chapters.Galbraith, A, Bullock, S & Manias, E 2001, Fundamentals of pharmacology, 3rd edn, Pearson Education Australia, Prentice Hall Health, Frenchs Forest, NSW. Chapters: 34 Non-steroidal anti-inflammatory, antipyretic and analgesic drugs, pp. 371-385. 53 Adrenocortical and gonadial pharmacology, pp. 609-630.

43. Visit these websitesThe following websites have useful information for health professionals and patients. Access the sites and note what you found most interesting for the tutorial discussion. Prostate cancer site: http://www.prostate.org.au/ TURP sites:www.health.qld.gov.au/informedconsent/PatientInformationSheets/patient_infosheet_08.pdf

www.barwonhealth.org.au/periop/urology/trans.htm www.medicalobserver.com.au/patienthandout/displayhandout.asp?ID=198 www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Prostatectomy?OpenDocument


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Consider this scenario for the tutorialRead through this scenario and consider the questions that follow. Please be ready to discuss your answers in the tutorial. Mr Gregory Roller first went to his GP with a 1 year history of decreased force and volume of his urinary stream, difficulty in starting urination, and dribbling at the end of urination. He also reported an incomplete feeling on emptying his bladder. He now has frequency, nocturia, and dysuria and he has had 2 Urinary Tract Infections (UTI) in the past 2 months. He has had a pre-operative C&S of his urine and is currently free from infection. He also has the occasional indigestion and dyspepsia which respond well to antacid medication. Mr. Roller is 65 years of age and weighs 102kgs. Mr Roller has been admitted to your ward to undergo a Trans-urethral-resectionprostate gland (TURP) procedure secondary to benign prostatic hypertrophy (BPH). Pre-operatively Mr. Roller was visited by an anaesthetist and the attending surgeon. The doctor has ordered that he have the following tests done CBP and Cross Match CXR ECG PSA

Nursing assessment on admission revealed that he is quite anxious about surgery, and his indigestion has been troubling him. His urinalysis: Ph 5.5 NAD Post op orders Routine post operative care Standard triple lumen catheter and continuous bladder irrigation (CBI) with N/Saline 2000ml flasks. Check patency of catheter and CBI flow 1/24ly & prn Change CBI flasks prn to maintain continuous bladder irrigation. FBC IVT: Hartmanns running at 100 120mls/hr Pain relief Morphine 10-15mg sc 4/24ly Antiemetics as per post-op pathway for nausea & vomiting Check wound 1/24ly IV ABs IV Oxybutin 5mg 8.24ly prn oral Ceftriaxone (Rocephin) 500 mg BD Oral stool softeners Breathing, coughing and leg exercises

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Frequent changes of position Pelvic Floor Exercises

45. Consider these questions relating to the scenarioPlease come to the tutorial prepared to discuss the following questions: Define Benign Prostatic Hyperplasis (BPH), nocturia, dysuria, and trans-urethral resection of the prostate (TURP).

Discuss the aetiology and pathophysiology of BHP.

Discuss Mr Rollers clinical symptoms and their relevance to diagnosis of BHP.

List the psychosocial issues for Mr Roller at this time. Discuss how you could assist him?

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Discuss the diagnostic studies employed to confirm BPH.

Outline the reasoning for the performance of a TURP on Mr Roller.

Detail what is involved in a TURP.

Prioritise Mr Rollers care postoperatively and give a rationale for your answer.

Formulate a nursing care plan for Mr Roller including the following:

need/problem/nursing diagnosis patient aims nursing interventions including rationale outcome statement possible changes to the nursing care plan if required

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Discuss why confusion is frequently experienced post-operatively with TURP procedures.

Discuss the issues you need to consider when providing discharge planning for Mr Roller.

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