Posted: February 21st, 2023
Mrs Soo Hui is a 46-year-old female admission
Preparing the Hospital Room for Mrs. Hui’s Admission to the Ward
To ensure a safe and comfortable environment for Mrs. Hui, the hospital room should be prepared as follows:
Ensure a Clean and Safe Environment: The room should be thoroughly cleaned, and any potential hazards, such as loose wires or clutter, should be removed. The bed must be made with clean linens and pillows, and all equipment in the room should be checked for functionality.
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Set Up Necessary Equipment: Essential equipment such as a bedside table, call bell, overbed table, and chair should be placed in the room. The call bell must be within Mrs. Hui’s reach to ensure she can call for Helpance when needed.
Arrange for Privacy and Comfort: The room’s curtains or blinds should be adjusted to provide privacy. The temperature should be set to a comfortable level, and adequate lighting should be provided. The bed should be adjusted to a position that allows Mrs. Hui to see her surroundings and communicate effectively.
Organize Supplies and Resources: Necessary supplies such as clean towels, washcloths, tissues, and toiletries should be readily available. Monitoring equipment, including a blood pressure cuff and thermometer, should be easily accessible.
Four Pieces of Equipment Needed for Assessment on Admission
Blood Pressure Monitor: To assess and monitor Mrs. Hui’s blood pressure.
Pulse Oximeter: To measure oxygen saturation levels and monitor respiratory function.
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Thermometer: To monitor body temperature for signs of fever or hypothermia.
Neurological Assessment Tools: Including a reflex hammer, tuning fork, and monofilament to assess sensory and motor function, reflexes, and level of consciousness.
Four Components of Correct Nursing Documentation
Objective and Subjective Data: Document both measurable data (e.g., vital signs) and patient-reported symptoms accurately.
Date and Time: Ensure each entry is timestamped to maintain a clear chronology of events.
Relevant Observations: Include any changes in condition, responses to interventions, and concerns.
Signature and Credentials: Each entry should be signed with a legible signature and 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 crucial for:
Baseline Assessment: It provides a reference point to monitor changes during the hospital stay.
Treatment Planning: Accurate measurements help determine medication dosages, nutritional needs, and fluid management.
Risk Assessment: Weight and height contribute to assessing risks for pressure ulcers, falls, and nutritional deficiencies.
Monitoring Growth and Development: In pediatric patients, these measurements are essential for tracking growth.
Clinical Handover Using the ISBAR Format for Mrs. Hui
I (Identity): “I am [Your Name], the nurse caring for Mrs. Soo Hui during this shift.”
S (Situation): “Mrs. Hui is a 46-year-old female admitted with a left-sided ischemic cerebrovascular accident. She is currently on bed rest, receiving anticoagulant therapy, and awaiting a speech therapist review.”
B (Background): “She has a history of hypertension, type 2 diabetes, asthma, and depression. She lives with her husband, two children, and her elderly father. She is currently experiencing right-sided hemiparesis, dysphasia, and dysphagia.”
A (Assessment): “Her current vital signs are BP 150/90, PR 85, RR 24, SpO2 96% on room air, and a GCS of 14. She has a large hematoma on her right hip and a 5cm skin tear on her right elbow.”
R (Recommendation): “Continue monitoring her neurological status every two hours. Ensure she remains nil by mouth until the speech therapist reviews her. The physiotherapist and occupational therapist should also be consulted for rehabilitation planning.”
Explanation of the Two Types of CVA
Ischemic CVA: Caused by a blockage in the blood vessels supplying the brain, leading to reduced blood flow. This includes:
Thrombotic Stroke: A blood clot forms within a brain blood vessel.
Embolic Stroke: A clot or debris travels from another part of the body and blocks a brain blood vessel.
Hemorrhagic CVA: Caused by bleeding in or around the brain due to the rupture of a weakened blood vessel. This includes:
Intracerebral Hemorrhage: Bleeding within the brain tissue.
Subarachnoid Hemorrhage: Bleeding into the space between the brain and its covering tissues.
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: Weakness or drooping on the right side of the face.
Dysphasia: Difficulty speaking or understanding language.
Neglect of the Right Side: Decreased awareness of the right side of the body or environment.
Other Morbidities/Co-morbidities of Mrs. Hui
Hypertension
Type 2 Diabetes
Asthma
Depression
Impact of Depression on a Person in Middle Adulthood (46 Years)
Depression in middle adulthood can lead to:
Impaired Functioning: Difficulty performing daily tasks, reduced productivity, and withdrawal from social interactions.
Physical Symptoms: Fatigue, sleep disturbances, and changes in appetite.
Strained Relationships: Conflicts with family members and a sense of burden on loved ones.
Exacerbation of Health Conditions: Depression can worsen chronic conditions like diabetes and hypertension.
Nursing Care Plans for Mrs. Hui
Care Plan 1: Pain Management
Implementations:
Administer prescribed analgesics as ordered.
Apply ice packs to the right hip and shoulder to reduce swelling and pain.
Rationale: Pain relief promotes comfort and facilitates participation in rehabilitation.
Assessment: Monitor pain levels using a pain scale and document responses to interventions.
Care Plan 2: Nutrition and Hydration
Implementations:
Collaborate with a dietitian to create a diabetic-friendly meal plan.
Ensure adequate fluid intake to prevent dehydration.
Rationale: Proper nutrition supports healing and overall recovery.
Assessment: Monitor dietary intake, weight, and blood glucose levels.
Care Plan 3: Mobility and Rehabilitation
Implementations:
Work with physiotherapists to develop a rehabilitation plan.
Assist Mrs. Hui with range-of-motion exercises.
Rationale: Rehabilitation improves strength, coordination, and independence.
Assessment: Document progress in mobility and ability to perform daily activities.
Care Plan 4: Communication Support
Implementations:
Use picture boards or written instructions to facilitate communication.
Collaborate with a speech therapist to address dysphasia.
Rationale: Alternative communication methods reduce frustration and improve understanding.
Assessment: Monitor Mrs. Hui’s ability to use alternative communication tools and document progress.
References
American Heart Association. (2021). Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke, 52(7), e1-e50.
World Health Organization. (2020). Stroke Rehabilitation: Recommendations for Recovery and Long-Term Care. Geneva: WHO Press.
National Institute of Neurological Disorders and Stroke. (2019). Stroke: Hope Through Research. Bethesda: NINDS.
Jones, M. (2022). Nursing Care Plans for Stroke Patients: A Comprehensive Guide. Journal of Advanced Nursing, 78(3), 456-467..
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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.
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Sample Homework Assignments & Research Topics
Tags:
Clinical Handover,
Co-Morbidities,
Nursing Process,
Patient Admission,
Stroke Care
