Posted: July 12th, 2023

Preparing the hospital room for Mrs Hui’s admission to the ward

Mrs Soo Hui is a 46-year-old female ( identifies as she, her) admitted to your ward at St Elsewhere Hospital, following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. The next-door neighbour found her on the ground outside her front door unable to move or speak.
She has been diagnosed as having a left sided ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.
Family history
Born to Thai parents in Australia
Buddhist & speaks Thai & English
Lives with husband & 2 children, Ty 13 years old & Grace 5 years old. Also her father who is a frail 82-year-old. Medical history
Hypertension, Type 2 Diabetes, Asthma
Depression
Hearing aid left ear
Bi-focal glasses (broken in fall)
Upper dental partial plate
Medication – Amlodipine, Metformin, Salbutamol.
Admission observations
BP 150/90
PR 85 regular
RR 24
To 36.9
SpO2 96% on room air
BGL 8.4 mmol
Weight 69 kg
Height 162 cm
GCS (Glasgow coma scale) = 14
Eyes open to speech
Oriented to time, place, and person (speech slurred, but able to be understood)
Right hemiparesis
PERL (Pupils equal reactive to light) Issues/impacts of the CVA
Pain on movement, mainly right hip & shoulder stated as 7 /10
Large haematoma right hip
5cm skin tear right elbow
Dysphasia
Dysphagia
Right sided facial droop
Mild Right-side hemiplegia
Initial Doctor’s orders and interventions
Rest in bed (RIB)
2nd hourly Neurological observations
Nil by mouth (NBM) until Speech Therapist review
Physiotherapist review
Full Helpance with hygiene
IDC insitu
Intravenous Therapy via cannula in left forearm Discharge Information
Mrs Soo Hui will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.
Provide an answer for each of the questions below in relation to Mrs Hui.
Explain how you would prepare the hospital room for Mrs Hui’s admission to the ward.
List 4 pieces of equipment you would need to conduct an assessment on Mrs Hui’s when she is admitted to the ward.
Identify 4 components of correct nursing documentation ( this also includes electronic documentation)
Why is it important to measure and record a person weight and height on admission?
You are required to provide a clinical handover to the Enrolled Nurse and Registered Nurse who are coming onto the next shift.
Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui?
I
S
B
A
R
Mrs Hui has had an Ischaemic cerebrovascular accident (CVA). Answer the following questions.
Explain the two types of CVA, including where it occurs and what causes it.
Identify four (4) indications of a left sided CVA.
Identify the other morbidities / co-morbidities that Mrs Hui has.
Mrs Hui is 46 yrs of age, discuss how depression can affect a person in middle adulthood.
The RN has created care plans for Mrs Hui and identified four (4) assessment and nursing diagnoses based on the Nursing process concept.
As the EN contributing to the nursing care plan, please provide the following for each of the four (4) care plans.
Two (2)nursing implementations for each care plan.
One (1)rational and one (1) Assessment for each Implementation.

____________________________________
Preparing the hospital room for Mrs Hui’s admission to the ward:

Ensure a clean and safe environment: Clean the room thoroughly, removing any potential hazards. Make sure the bed is clean and properly made, with clean linens and pillows. Check for any broken or malfunctioning equipment in the room.

Set up necessary equipment: Place the required equipment in the room, such as a bedside table, call bell, overbed table, and chair. Ensure the call bell is within reach of Mrs Hui so she can call for Helpance when needed.

Arrange for privacy and comfort: Arrange the curtains or blinds for privacy. Adjust the room temperature to a comfortable level. Provide adequate lighting and adjust the bed to a position that allows Mrs Hui to see her surroundings and communicate easily.

Organize supplies and resources: Ensure that necessary supplies are readily available in the room, including clean towels, washcloths, tissues, and toiletries. Make sure that equipment required for monitoring, such as a blood pressure cuff and a thermometer, is easily accessible.

Four pieces of equipment needed for assessing Mrs Hui upon admission:

Blood pressure monitor: To assess her blood pressure and monitor any changes during her stay.

Pulse oximeter: To measure her oxygen saturation levels and monitor respiratory function.

Thermometer: To measure her body temperature and monitor for signs of fever or hypothermia.

Neurological assessment tools: These may include a reflex hammer, tuning fork, and monofilament to assess her sensory and motor function, reflexes, and level of consciousness.

Four components of correct nursing documentation:

Objective and subjective data: Document both objective data (e.g., vital signs, physical assessment findings) and subjective data (e.g., patient complaints, symptoms) accurately and in detail.

Date and time: Clearly document the date and time of each entry to ensure the chronology of events.

Relevant observations: Include relevant observations, such as changes in condition, responses to interventions, and any concerns or complications.

Signature and credentials: Sign each entry with a legible signature and include professional credentials to authenticate the documentation.

Importance of measuring and recording weight and height on admission:

Measuring and recording weight and height on admission is important for several reasons:

Baseline assessment: It provides a starting point to monitor changes in weight and height during the patient’s hospital stay and track their progress or any deviations from their normal range.

Treatment planning: Accurate measurements help determine appropriate medication dosages, fluid management, nutritional requirements, and other aspects of the patient’s treatment plan.

Risk assessment: Weight and height measurements contribute to assessing the patient’s risk for pressure ulcers, falls, and other complications, as well as evaluating their nutritional status.

Monitoring growth and development: In pediatric patients, regular weight and height measurements are crucial to monitor their growth and development over time.

Clinical handover using the ISBAR format for Mrs Hui:

I (Identity): Introduce yourself and state your role in providing care for Mrs Hui.

S (Situation): Briefly explain Mrs Hui’s current condition, including her diagnosis of a left-sided ischemic cerebrovascular accident, the interventions in place, and any immediate concerns or changes in her status.

B (Background): Provide relevant background information, such as her medical history, current medications, and any notable family history. Mention her functional status, including any limitations or Helpive devices she requires.

A (Assessment): Summarize Mrs Hui’s current assessment findings, including her vital signs, level of consciousness, neurological deficits, and any other significant observations.

R (Recommendation): Discuss the ongoing plan of care and any pending or required actions, such as consultations, investigations, or therapies. Highlight any changes or concerns that may require attention during the next shift.

Explanation of the two types of CVA:

Ischemic CVA: It occurs when there is a blockage or narrowing of the blood vessels that supply blood to the brain, leading to inadequate blood flow. The two main types of ischemic CVA are thrombotic stroke (caused by a blood clot forming within a blood vessel in the brain) and embolic stroke (caused by a blood clot or other debris that travels from another part of the body and blocks a brain blood vessel).

Hemorrhagic CVA: It occurs when there is bleeding in or around the brain, often caused by the rupture of a weakened blood vessel. This type of CVA includes intracerebral hemorrhage (bleeding within the brain tissue) and subarachnoid hemorrhage (bleeding into the space between the brain and the tissues covering it).

Four indications of a left-sided CVA:

Right-sided hemiparesis or hemiplegia (weakness or paralysis on the right side of the body).

Right-sided facial droop or weakness.

Dysphasia (difficulty speaking or understanding language).

Neglect or decreased awareness of the right side of the body or the surrounding environment.

Other morbidities/co-morbidities that Mrs Hui has:

Hypertension (high blood pressure)
Type 2 Diabetes
Asthma
Depression
Impact of depression on a person in middle adulthood (46 years):

Depression can affect a person in middle adulthood in various ways:

Impaired functioning: Depression can interfere with daily activities, including work, relationships, and self-care, leading to decreased productivity and withdrawal from social interactions.

Physical symptoms: Depressed individuals may experience fatigue, sleep disturbances, changes in appetite, and unexplained physical complaints, which can further impact their overall well-being and quality of life.

Family dynamics: Depression can strain relationships with spouses, children, and other family members, potentially causing conflicts, communication difficulties, and a sense of burden on loved ones.

Impact on health conditions: Depression can exacerbate existing health conditions, such as diabetes and hypertension, making it more challenging to manage these conditions effectively.

Nursing care plans for Mrs Hui and two nursing implementations, one rationale, and one Assessment for each implementation:

Care Plan 1: Pain management

Implementations:

Administer prescribed pain medication (e.g., analgesics) as ordered by the physician to alleviate Mrs Hui’s pain.
Rationale: Pain relief improves comfort, promotes rest, and facilitates engagement in therapeutic activities and rehabilitation.
Assessment: Assess Mrs Hui’s pain level before and after administration of pain medication, using a pain scale (e.g., numerical rating scale or visual analog scale). Document her response to medication and any changes in pain intensity.

Care Plan 2: Nutrition and hydration

Implementations:

Collaborate with the dietitian to develop a suitable diet plan that addresses Mrs Hui’s dietary restrictions (e.g., diabetic diet) and promotes optimal nutrition.
Rationale: Proper nutrition is essential for wound healing, maintaining energy levels, and supporting overall recovery.
Assessment: Monitor Mrs Hui’s dietary intake, including calorie count and adherence to dietary restrictions. Document any changes in weight, laboratory results (e.g., blood glucose levels), and signs of malnutrition.

Care Plan 3: Mobility and rehabilitation

Implementations:

Collaborate with the physiotherapist and occupational therapist to develop a customized rehabilitation plan, including exercises and activities to improve Mrs Hui’s mobility and functional independence.
Rationale: Rehabilitation plays a crucial role in restoring strength, coordination, and mobility after a stroke, improving Mrs Hui’s overall quality of life.
Assessment: Regularly assess Mrs Hui’s progress in rehabilitation activities, documenting improvements in range of motion, strength, balance, and ability to perform activities of daily living. Collaborate with the therapy team to modify the plan as needed.

Care Plan 4: Communication support

Implementations:

Use alternative communication methods, such as picture boards, written instructions, or communication apps, to Help Mrs Hui in expressing her needs and facilitating understanding.
Rationale: Dysphasia can significantly impact verbal communication, and alternative methods help ensure effective communication and reduce frustration.
Assessment: Assess Mrs Hui’s ability to use alternative communication methods and document her level of understanding and ability to express her needs. Collaborate with the speech therapist to track progress and adjust communication strategies accordingly.

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