Dynamics Of Practice

Nursing work is informed by a multiplicity of theoretical positions. In order to render theory useful, nurses combine theory with specific practices to make clinical and professional decisions. Various forms of evidence support these practice decisions. In this assessment, students will explore those theories that directly inform the nurse-patient relationship in various clinical contexts; demonstrate how to develop logical and reasoned positions on clinical and professional issues using evidence and communication theories to guide and analyze nursing practice with individuals and groups.

This assignment will focus on a choice of nursing issue/priority for Mrs Green. Each student will choose one issue/nursing priority from Mrs Green's post-angioplasty period, and is required to critically analyse and discuss relevant patient care required and provided around the chosen nursing issue/priority, including rationales and evidence to support their decisions and recommendations. The students' rationales must demonstrate knowledge of best practice, patho-pharmacology, relevant clinical pathways, and inter-professional roles within the context of the chosen issue. Students should also make appropriate reference to law and ethics and mental health.

Whilst making links to Mrs Green's case scenario, students should go beyond the case scenario and explore the issue in depth in a general context. Students should refer to relevant independent learning pods in developing their rationales and discussion. Students are also required to incorporate and reflect on how their critical analysis provides support for their achievement of the Registered Nurse Standards for Practice (NMBA 2016) Standard 7: Evaluates outcomes to inform nursing practice and 7.2 Revises the plan based on the evaluation, and 7.3 determines, documents and communicates further priorities, goals and outcomes with the relevant persons. The generic skills specifically explored in this assessment are: 1. Communication 

2. Analysis and inquiry
3. Problem solving 
4. Working independently and with others 
5. Professionalism and social responsibility

 Assignment 2 Instructions Essay – NURS3001 2 Students are required to:  

Make connections to the client scenario for Mrs Green (see excerpt below, for full case information see Caseworld)

.  Reflect on the information presented, and through the process of clinical reasoning, problem solve and determine effective priorities for interventions that will appropriately support Mrs Green in the specific nursing issue/priority chosen as a focus for Assignment 2

 . Document findings and develop a comprehensive plan of care (to be attached to the essay)

♣  use clinical reasoning as the clinical decision making framework to analyse and present the essay and a plan of care for Mrs Green (see♣ details of the clinical reasoning decision making framework in Modules 1, 2 and 6)  provide a rationale for the problem solving undertaken and the priorities of care determined for Mrs Green

♣  Substantiate all arguments in the essay by drawing upon contemporary evidence from reputable scholarly texts and other peer reviewed literature using the Harvard referencing style as per SoNM guidelines.

For detailed information that will guide you in the preparation of your critical reasoning assignment, you are directed to the marking rubric. Assignment 2 Instructions Essay – NURS3001 3 Case Excerpt: As a Registered Nurse working in the Cardiac Care Ward, you have just met Mrs Green who is back from surgery. Mrs Elizabeth Green is a 78-year-old lady who lives alone in a single storey unit. Elizabeth has one son and daughter and 5 grandchildren. Elizabeth was washing the dishes at home this morning when she experienced 10 minutes of unrelieved central chest and left shoulder pain. After calling an ambulance Elizabeth was admitted to the ED and after review by the Cardiac Team. 

Mrs Green is a retired widow, living alone in her own ground floor unit. She utilises a Webster pack for medication, and employs a private cleaner once a week. She does not drive and prefers to use a taxi for transport. Mrs Green has one daughter (Rose) and one son (James) who are very supportive and pay for the cleaner. Her son and daughter live some distance away and work full time and are only able to visit on weekends. Elizabeth has 5 grandchildren (Eloise, Bianca, Elizabeth, Matthew and Jeremy). Mrs Green's beloved pet is Matilda who is a Terrier cross. 

Mrs Green has the following health history: Former smoker (quit 5 years ago), GORD, HT, hypercholesterolemia, osteoarthritis, Type 2 Diabetes (diet controlled). She had a Hysterectomy 30 years ago. Mrs Green's mother had cardiac disease (deceased), Father Rheumatic Fever as a child, which contributed to long term health problems (deceased), Sister breast Ca (deceased). Her current medication regimen comprises:

Esomeprazole 20mg nocte

Metoprolol 25mg mane

Simvastatin 20mg nocte, 

Vitamin D and calcium tablet 1 daily,

Paracetamol 1g 6/24 prn no more than 4g per day

Mrs Green has had a femoral angioplasty performed. A blockage is found in Mrs Green's Left Anterior Descending artery, which is able to be successfully stented. Other cardiac vessels viewed have 10-20% occlusion. Mrs Green is diagnosed with an anterior MI with LAD occlusion. Mrs Green is transferred from the Angio Suite Recovery area to the Cardiac Care Ward at 1250. Handover from Angio Suite Recovery Nursing Staff states that Mrs Green has had an unremarkable recovery post procedure. GTN has been ceased prior to returning back to the ward. The pump with the GTN is turned off, but remains connected to the IV cannula. Cardiac monitoring to continue for 24hrs.Mrs Green's medical orders state that she is to remain supine for 4 hours, then sheath removal. Post sheath removal Mrs Green can sit up 30 degrees for 2 hours, and then at 45 degrees for 2 hours and then to mobilise as tolerated. 

1250 On arrival to the ward her observations are: 

BP 145/90 HR 85 beats per minute RR 24 respirations per minute Temperature 35.8C SpO2 98% on 6L O2 via CIG BGL: 5mmol Pain: No reported chest pain RIGHT foot is warm, pink with normal movement and sensation, pulse present LEFT foot is pale, cool, with normal movement and sensation, pulse present. Puncture site soft, bleeding on dressing noted to be a size of a '10 cent size'

1300 Observations: 

BP 155/90 HR 85 beats per minute RR 26 respirations per minute Temperature 35.8C SpO2 99% on 6L O2 BGL: 5mmol Pain: No reported chest pain RIGHT foot is warm, pink with normal movement and sensation, pulse present Puncture site soft, '5 cent size' of bleeding on dressing. No pain reported Assignment 2 I Cardiac Care Ward-1400 

Cardiologist Review The cardiologist reviews Mrs Green at 1400, approximately 1hour post procedure due to Mrs Green’s Left foot being pale and cool. Eliza attends the Cardiologists round and review of Mrs Green. She highlights to the Cardiologist that the Left Foot remains pale and cool and that Dorsal and Pedal pulses are present. The Cardiologist performs a Doppler ultrasound on the Left foot, and determines that there is adequate blood flow, but requests that half hourly neurovascular observations to continue for another 2 hours to monitor for any changes.

At 1400 Mrs Green's observations are: BP 140/80 HR 88 SaO2 99% on 6L via CIG Pain: No reported chest pain LEFT foot pale, cool, normal movement and sensation, pulse present RIGHT foot is warm, pink with normal movement and sensation, pulse present Puncture site soft, no bleeding.

Cardiac Care Ward-1430

At 1430, Mrs Green asks John who has just come on for the late shift, if he could disconnect her GTN infusion as it is restricting her arm movement. John has not received handover as of yet and is relieving on the ward. Nevertheless John agrees to disconnect the GTN infusion as it appears to be turned off. Whilst disconnecting the infusion, Mrs Green states that '…the cannula is very sore and could he do something about it?' John advises Mrs Green that he will flush her cannula. When the cannula is flushed Mrs Green shouts out to John that this is very painful, however he persists and slowly the discomfort around Mrs Greens IV cannula site eases. 1450 Mary the late shift RN introduces herself to Mrs Green. Mrs Green advises Mary that she is feeling very light headed. Mary assesses Mrs Green.

1450 Observations:  BP 100/50 HR 80 beats per minute RR 18 breaths per minute SaO2 99% on 4L O2 via nasal specs Pain: No reported chest pain LEFT foot pink, warm, normal movement and sensation, pulse present RIGHT foot is warm, pink with normal movement and sensation, pulse present Puncture site soft, no bleeding

1500 Observations: BP 110/66 HR 88 beats per minute RR 20 breaths per minute SaO2 99% on 4L O2 via nasal specs Pain: No reported chest pain LEFT foot pink, warm, normal movement and sensation, pulse present RIGHT foot is warm, pink with normal movement and sensation, pulse resent Puncture site soft, no bleeding

Introduction

The presented clinical scenario effectively describes the state of cardiovascular health of 78 years old Mrs Elizabeth Green, who had undergone femoral angioplasty in relation to the treatment of a blockage in the left anterior descending artery. Mrs Green further experienced 10%-20% stenosis in cardiac vessels and diagnosed with the pattern of LAD occlusion and MI. The clinical scenario confirms the unremarkable recovery of the patient following the administration of angioplasty intervention. The co-morbid states, including hypercholesterolemia, hypertension, diabetes, osteoarthritis and oesophageal reflux, predispose her towards the development of various cardiovascular, neurophysiological as well as metabolic complications. This research paper will effectively discuss the pattern of the patient’s diabetes management and care processes undertaken by the registered nurse professional during the post-angioplasty period. The patient experiences the risk of developing infectious episodes, fatigue, renal complications, impairment of skin integrity, disturbance in sensory perception, hypovolemia, nutritional imbalance and hyperglycaemia under the influence of underlying diabetic condition leading to various challenges for the nurse professionals during nursing management. This research paper will effectively explore these aspects of patient care and provide a detailed rationale regarding the requirement of undertaking the care and management of the pattern of diabetes in relation to reducing the risk of development of diabetes manifestations during the post-angioplasty period that might deteriorate the patient outcomes. The paper will also describe the pathophysiology of patient's diabetes and associated clinical pathways while concomitantly exploring the role of nurse professionals in relation to administering person-centred, holistic and psychosocial approaches for controlling the adverse health outcomes emanating from patient's diabetic manifestations during the post-angioplasty duration. The research paper will emphasize the requirement of implementing NMBA 2016 standards in clinical practice with the objective improving the psychosomatic outcomes experienced by the patient in relation to her diabetes complications arising during the post-operative care interventions in the hospital.