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    healthcare and nursing
    Outbreak at Watersedge Name Institution
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    healthcare and nursing
    Outbreak at Watersedge Name Institution
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    Critical reflection of an ethical situation (Nursing)
    Critical reflection of an ethical situation Assess: What was your initial reaction to the situation? My initial reaction to the situation was to feel sorry for both the patient and his family. Both parties have the right to know the real health condition of the patient, but since the patient’s choice is to keep it secret from his family, the nurse has no choice but to respect the patient’s decision. Identify what you feel is the ethical dilemma/situation from the scenario The ethical dilemma in the scenario is the decision of the patient, Mr. M to keep from his family his devastating health condition. The nurse is caught in the situation where she is at a loss on how to convince the patient to inform his family regarding his health. The nurse is in an ethical dilemma of trying to maintain her honesty and fairness to everybody whilst upholding the rights of the patient to his own choice and confidentiality (College of Nurses of Ontario 2009). What are the client’s values, wishes or beliefs in this situation? Consider cultural beliefs. The patient’s wish is to keep his real health condition from the knowledge of his family. He wishes this because of his beliefs that keeping his family uninformed of his real health condition will also keep them from worries and pains that go with the thought of losing a family member due to a terminal cancer. This belief comes from the cultural belief that “what you don’t know won’t hurt you”. The client patient holds a strong value of being not a burden to anyone, be it in a form of physical burden or emotional burden. What personal values or beliefs were in question during this situation? The personal values or beliefs that were in question are the values of respect for life, maintaining commitments, patient well-being, truthfulness, patient choice, fairness and privacy and confidentiality (College of Nurses of Ontario 2009). Identify and discuss 2 nursing ethical values that were in question in this situation. Refer to the CNO Ethics Standard to identify these values. The two nursing ethical values that were in question in the situation are client choice and respect for life. Client choice refers to the right of a person to make choices, including giving consent or refusal of care. Every person has his own values, wishes and beliefs and when faced in a dilemma, he has the right to exercise his own choice of what is best for him. However, in the field of nursing, nurses are informed that there are certain limitations in following a client’s choice. One, it is beyond the limit if a client patient chooses to risk the safety of others. Also, a client choice is restricted if his choice involves the promotion of restricted policies such as smoking, drugs and the likes. Moreover, practices that are illegal in Canada or Ontario are also restricted to be followed. In cases like these, nurses are not obliged to heed the client-patient’s choice. In the case study, the choice of the patient to keep his real health condition secret from his family does not fall in any of the limitations (College of Nurses of Ontorio 2009). Another is respect for life. Life is so precious and needs to be protected, treated fairly and respected (Keyserlingk 1979). It includes the considerations of having a good quality of life; however, there are some instances when a person has different expectations of what a quality life is for him. Although nurses have their own perception of what a quality life is, sometimes their personal beliefs do not coincide with the patient’s. In cases like this, when the nurse feels that her personal beliefs conflict with that of the patient’s, then she is advised to request for a replacement and withdraw from providing care for the particular patient(College of Nurses of Ontorio 2009). Plan What are some possible options to resolve this ethical situation? Identify at least 2 options. One of the options in resolving this ethical situation is to compassionately tell the patient that it will be for everybody’s good if the family will be informed of his true health condition. If the patient still does not comply and the nurse feels that the client’s view conflicts with her own personal values and the situation hinders her from caring further to the client, then the nurse should request for a replacement who can be more effective in handling the situation. In cases where there is no replacement, the nurse should continue to administer care for the patient whilst she is informing her employers of the situation. It is now up to the employers to act on the matter and decide on what should be the best and fitting management strategy in handling the dilemma/situation (College of Nurses of Ontario 2009; Ham 2004). Another option would be to completely respect the patient’s choice. Part of the rights of the patient is his right for privacy and confidentiality and the right of choice. If the patient’s beliefs and values dictate that it is the best option not to inform his family about his real condition to avoid extending to them the misery and pain that he is suffering, then it should be respected. Anyway, eventually his true condition will be revealed to his family because his health will continuously deteriorate as time pass by. In that event, probably the patient will realize that he needs to say goodbye to his family and his family to him, as well. When that time comes, the initiative to inform his family of his real condition will be coming from the patient himself. What are the ethical and/or legal responsibilities in this situation as the RPN? Please refer to the CNO ethics standards or guidelines that may relate to this situation to guide your understanding of it and your role.
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    Nursing - critical analysis & case study - Electronic Health Record (EHR)
    In this age of technology, change is inevitable and modifications in healthcare systems are significant in ensuring optimum health outcomes. In providing healthcare services, the use of paper-based documentation has been the practice but the recent introduction of digital health initiatives paved the way to the use of computer-based records. Though some literatures suggest that the use of combined paper-based documentation and digital interventions could result to more benefits, further studies are still needed for its reliability (Shaw, Hines & Carroll, 2018). This paper will critically analyse the case of shifting from paper-based documentation to computer-based records which I had experienced whilst working at an aged care facility. I will critique on the impact of the change to the nurse’s performance as well as on his/her learning absorptions. Moreover, I will find the gaps in the transition between the paper-based documentation and digitalised healthcare record when health professionals are educated. I will also apply the knowledge of the Kolb’s learning theory into my case study and suggest recommendations that will help learners to smoothly transit from the traditional to the modern method of documenting health records. Whilst working at an aged care facility, I experienced dealing with a number of policy changes. One of those was the new neuro observation policy where the original paper-based documentation was changed into a computer-based care system. During the handover, I was given a leaflet explaining how to update the information into the new system. However, I experienced difficulties in typing-in the data into the system, resulting to my perception that there was a mismatch in the presentation of the new policy. I also realised that updating the health policy would require a number of requirements for the registered staff to perfect the implementation. I also reflected that trainings and monitoring are key to the successful transition. The Electronic Health Record (EHR) refers to the patient’s stored medical information, including the computerised entry of the physician’s order and the decision support assistance for the patient’s good quality care (Joukes et al., 2016). Though it seems to provide easier access to patient’s health information, earlier studies show that implementing a new EHR could lead to both enhanced (Buntin et al., 2011) and reduced quality of care (Mohan, 2013). This is due to the fact that the new EHR is not a simple technical project but more of a socio-technical task because it requires the active involvement of the end-users (nurses) as well as the organisation. Hence, it is very vital that the end-users are educated on the process to maximise the chances of positive change (Joukes et al., 2016). Furthermore, the use of electronic systems in aged care facilities is aimed towards improving the quality of documentation, information handling, and saving time; but the study made by Wang, Yu & Hailey (2015) showed that it was no better as compared to the paper-based system. This was because their study showed that the nurses had the tendency to change the terms used in the paper-based documentation such as ‘diagnosis’ or ‘nursing problem’ into ‘observation’ when using the computer-based system. The omission of the diagnosis or nursing problem in the computer-based system documentation could affect the qualitative aspect of the care plan and other factors that need to be understood. Meanwhile, in the study made by Meibner & Schnepp (2014), the results showed that in implementing the shift from paper-based to electronic system required the nurse’s know-how in IT since the process needed a different type of processing of information. Hence, the success of this implementation is dependent on the end-users’ IT experience. If the nurses find it difficult to encode health information, then the implementation would result to poor clinical documentation. However, improving the quality of data encoding could result to better documentation and improved quality of care. The more IT experience the nurses have, the better their chances of gaining benefits and overall improvement. However, Munyisia, Hailey & Yu (2012) state that the health care workers in a nursing home find it more comfortable using the computer-based documentation over the paper-based after six months of continuous use. This suggests that the success of implementing computer-based documentation depends on the familiarity of the health caregivers. The study found that six months of continued practice is relatively mature. However, perceived improvements were not consistently maintained after 18 or 31 months and they theorised that to realise the most of the benefits of the new system required more training and education for the end-users. The different studies I have mentioned reflect that the success or failure of the transition is dependent on the skills of the end-users (nurses) to implement the computer-based care documentation. In this regard, education and IT training are highly important in realising the perceived benefits of using the electronic system. And in doing so, applying the knowledge of the Kolb’s learning theory is beneficial in the education of the end-users. Kolb’s theory recognises that there are four phases in the cyclical learning process, namely, concrete experience, reflective observation, abstract conceptualisation and active experimentation (Kolb, 2014). Having the actual experience to perform the encoding of health care information to the computer-based documentation system will provide the nurse to have a feel of the situation and the understanding of how it is done. It will also provide the nurse the impression of the degree of difficulty of the new system, even in following the computerised treatment orders of the doctors. In the second stage, the nurse gets to reflect back about the new experience and develops an understanding about the differences and advantages of paper-based documentation and computer-based care system. The third stage of the cycle is abstract conceptualisation where the nurse develops a new idea based on the reflection he/she made about the new experience. This is also the stage where the nurse conceptualises new idea or modifications that she thinks will help in ensuring that he/she can perform the new computer-based care system and take advantage of its promised benefits. In the fourth stage, which is active experimentation, the nurse or the learner can think of a plan on how to use the computer-based care system for an upcoming experience. The learner uses the new system to all their patients and sees how it would turn out – whether it will simplify their operations or would just complicate things and not realise the promised benefits; or would just result in another new experiences. Based on Kolb’s theory, effective learning happens when the learner progresses through the cycle of having an actual experience, then followed by reflection and understanding of the experience, leading to the learner’s formation of theories and conclusions, which eventually are then used to try the system in future circumstances, resulting in the creation of new experiences (Kolb, 2014). Hence, it is really vital that the learners are tasked to perform the new system so they can assess its useability as well as its importance in helping them become more efficient and effective as healthcare workers. Through time, their continuous use of the system will give them the ideas on how to further improve the process to reach the organisation’s goals. With the growing needs in the medical industry to document health care information, the computer-based care system is such a relief for better delivery of health services. However, Lippincott Nursing Education (2017) reveals that the success of the transition depends on the ability of the nurses to use the computer-based care system efficiently and effectively. And with so many nursing graduates with minimum experience of using the new system entering the healthcare workforce, the potential of errors, additional costs and longer period of transition time are higher. Based on a quantitative descriptive study conducted by Miller et al. (2014), there are 13 gaps on why novice nurses experience difficulty in using EHR when integrated into the workplace and these do not include email use, presentation development, search engine usage or word processing, where most new nurses were seen as strong. The 13 gaps in the skills needed for the electronic health record system were data entry, spreadsheet development, medication administration, graphics documentation and tracking, lab results retrieval, documentation, diagnostics results retrieval, treatment documentation, patient education documentation, accessing electronic charts contents, patient education material retrieval, accessing prior admission data, discharge planning documentation and updates and care plan development and updates (Miller et al., 2014). Just the mere titles of the area of skills suggest complexity that really needs trainings and additional education. This explains why the transition from the paper-based documentation system into computer-based documentation care system would take a while because aside from being technical, these also need connection with other departments. The novice nurses may have the fundamental IT know-how but that would not be enough as the new system requires practical experience (Lippincott Nursing Education, 2017). However, these gaps in the transition can be narrowed if the health professionals are trained and educated on these areas. Recommendations To provide the new nurses smooth transit from the paper-based documentation system into computer-based documentation care system, the organisation should always consider on-site trainings so they can perform the skill of using the new system correctly on a regular basis. There should be enough resources for continuous education in place that can be consulted from time to time until the learners reach their mastery. The knowledgeable RNs in the organisation who are well versed of informatics as well as the new system should be made available for support for the new learners. It is also wise if the organisation would adjust the workload of the learners so they can have time to fully comprehend the new system. It is also significant to include IT courses in the nursing curriculum to make the transition time, as well as training time, shorter. Providing health organisations IT expert educators will also hasten the transition because the trainings and continuous education of the learners will be done on a more regular basis. Moreover, the management should promote the spirit of personal commitment on the part of the nurse (learner) and deepen their professional interest (Rassin, Kurzweil & Maoz, 2015). Applying the Kolb’s learning theory, the learners can learn and understand deeper if they are provided with practical connection, then allowing them to reflect and actually do what they have learned in a real-life setting. In this way, their learning will remain because they exactly know how to do it and how to do it right. In cases where the nurses had no informatics knowledge prior to his/her entry, the employers should have the infrastructure program to help the nurse be EHR-ready. The program should be in a form of a classroom where the new employees can have time to study and learn about the new system. It is also wise to provide valuable supervisor support for the learners on their respective nursing units. Conclusion The Kolb’s learning theory signifies that a learner can better absorb learning if he/she progresses through the holistic cycle of having an actual experience, then reflection and understanding of the experience, resulting to his/her formation of theories and conclusions which he/she can try in future circumstances to create new experiences. Majority of the studies I have mentioned earlier pointed to the fact that the success or failure of the transition of paper-based documentation into computer-based documentation care depends on the skill of the learners (nurses) to implement the new system correctly. And Meibner & Schnepp (2014) state that the learner’s knowledge in IT and Informatics will influence and expedite learning of the new system as they already have the basic skills needed and will just have to train for the 13 gaps mentioned by Miller et.al. (2014). Overall, the learner’s smooth transit from the paper-based to digitalised system still boils down to continuous education and training support from the organisation. Without the organisation’s management support and personal commitment of the learner, achieving the promised benefits of the new system will always fail because it needs commitment, time and lesser workload to perfect the learning.
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  • Design
    Community Nursing Practice (case study)
    Davy, C, Harfield, S, McArthur, A, Munn, Z, & Brown, A. (2016). ‘Access to primary Healthcare services for indigenous peoples: a framework synthesis’. International Journal for equity in health, vol. 15, p. 163. PART1 Summary of findings: Access to primary healthcare is significant in ensuring positive health outcomes yet the indigenous people face greater barriers in accessing these services due to health inequities by inequality factors such as unfair of income, goods and services and visible circumstance of people’s lives which is their access to health care, schools and education. Social determinants of health, including employment, education, housing, transport and income interact with each other and strongly impact on health status and equity, especially among Aboriginal and Torres Strait Islander people. They are experiencing poor communication with healthcare providers, high cost of health care and experiences of racism and discrimination, causing difficulty in achieving high level of health (Aspin et al. 2012). This study was conducted to identify issues that obstruct the indigenous peoples from gaining access to primary healthcare. Results showed that Aboriginal people in Victoria had higher prevalence of poor health. People are with cardiac diseases, diabetes and kidney disease higher than non-aboriginal people. Social and cultural determinants such as low levels of education and unemployment were strong factors that determine whether the indigenous people, their communities and families were able to gain access to healthcare services (WHO 2005). These social factors influence their attitude and perception about healthcare and could have caused by their long-term experiences of racism, injustices and lack of knowledge on their rights to healthcare services (Durey & Thompson 2012). The study also suggested the inclusion of funding in making sure that indigenous health care services are best placed that indigenous people can access to for reducing inequity. Hence, the nurse in the community health practice should educate the indigenous people about the different healthcare services available in their communities, how they can avail of them, encourage them to communicate with the indigenous staff and make them feel culturally safe. Educating them about the availability of healthcare services in their community can arouse their interest to try, resulting to increased access rate and prevent worsening of chronic diseases such as diabetes and hypertension (Durey 2010). Angell, B, Laba, TL, Lung, T, Brown, A, Eades, S, Usherwood, T, Peiris, D, Billot, L, Hillis, G, Webster, R, Tonkin, A, Reid, C, Molanus, B, Rafter, N, Cass, A, Patel, A, & Jan, S. (2017). ‘Healthcare expenditure on indigenous and non-indigenous Australians at high risk of cardiovascular disease’. International Journal for Equity in Health, vol. 16, p. 108. Summary of Findings:
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    Nursing case study: Anorexia Nervosa
    Case Study Analysis Report What are the psychosocial issues for the person in the case study? The psychosocial issues for Katie in this case study relate to her obsession to avoid weight gain, which could perhaps be linked to the peer pressure of always keeping ‘the sexy weight’ among peers; familial relations, sociocultural and interpersonal risks (Davidson 2011). Though dieting is a common practice to lose weight, some over-do this to keep up with what is the “sexy” body endorsed by the media and the “sexy look’ that the images in the media point as the figure that will make a young girl beautiful and happy. What is usually approved is a thin body, so young girls go dieting to be one (Paediatr Child Health 2004). Young girls are influenced to go dieting to change their body into a Barbie doll shape because in most cultures, slimness is idealised as beautiful (Davidson 2011). Further, familial relations is also a contributing psychosocial issue because children are usually taught by their parents that the norms of society in terms of the standards of beauty is thinness; and obesity is always pointed out as a negative quality for females. And this perception is further emphasised on the media (TV, movies, internet, magazines, and billboards) as slim persons are given high distinction and more exposures while those on the bigger (plus) sizes are bullied or turned as the laughing-stock of the group. Since thinness is given more promotion in the media, it somehow delivers a hidden message that being slim is the ideal standard of beauty and the acceptable norm in the society (Becker et al. 2002). Davidson (2011) adds that eating disorders could be blamed from parents’ and peers’ encouragement which usually takes place during their interactions. Some parents use food in showing their love to their children or in asserting their power over them, thus, they use food to reward, to gain control or to implement punishment. However, when the child becomes fat, then that is the time when some parents and peers suggest that the child go on dieting because being fat is not good looking. On the part of the patient, her bad personal experiences related to her body shape could also result to her low self-esteem and dissatisfaction to her body, thereby resulting to her obsession to lose weight. Anorexic patients think that changing their body weight and lifestyle would gain them control on their physical looks and avoid the feeling of being abused (Polivy & Herman 2002). What informal supports are available to the person? Family involvement is a vital informal support in the treatment of the eating disorder of Katie. According to Roles (2005), effective treatment to her condition entails a solid therapeutic alliance between the patient, her family and her GP. The family members can help tremendously in assisting the patient cope with the disorder and deal with the effects of anorexia nervosa. The patient should realise that she lives in the context of a family and should not isolate her problems to herself alone. The Family therapy that is usually given in the treatment of this mental illness helps not only the patient but also other members of the family to understand each other and resolve whatever conflicts they may have (Roles 2005). Treasure, MacDonald & Schmidt (2009) state that during the duration of the illness, high levels of negative emotions between the patient and the carers (family members) may exist as the patient tends to become a bully and raise her voice against her family because a person suffering from anorexia nervosa is most likely to be so persistent and loud and may shout on other family members in reiterating her point of not eating. Clinical trials involving family therapy was found out to be more superior than individual therapy to patients less than 18 years of age and whose anorexia nervosa is less than three years (Davidson 2011). Moreover, other informal supports that the family can ask help from are the close friends of the patient. Friends can help by listening to the grievances of Katie and letting her open-up. Along those interactions that Katie could be advised on eating or getting some professional help.
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    Nursing case study: Neuroleptic Malignant Syndrome (legal, ethical & professional responsibilities)
    Case study – Neuroleptic Malignant Syndrome (NMS) Supplementary Task 4 Introduction All Registered Nurses, whether newly graduates or more experienced, are bound to fulfil their legal, ethical and professional nursing responsibilities in providing care to ensure that the best positive health outcomes are given to patients. Since the newly graduate RNs’ are more vulnerable and need support while making the transition from student to employment, guidelines and programs were set to ensure that all performance of duties in line with their professional obligations are based on the standards of providing care (State Govt. of Victoria, 2003, p. 20). This paper will explore the legal, ethical and professional nursing issues and responsibilities inherent in the case study involving the case of Jill, a woman who was previously diagnosed with schizophrenia. The assessment will centre on the identification and examination of legal, ethical and professional nursing issues, such as in the scope of practice for new graduate RNs, management of the deteriorating patient and effective teamwork. Issues identified in the scope of practice for new graduate RNs Based on the case study, Alex was the newly graduate RN who was assigned to care for Jill, a 44-year old woman who was earlier diagnosed with schizophrenia. Based on Alex’s assessment of Jill’s condition, the patient was tachycardic, diaphoretic, tachypneoeic and febrile. These observations were just mildly outside, excluding her 39.1 body temperature. Jill has been commenced on clozapine to help manage the symptoms associated with her previous bouts of schizophrenia. Alex believed that Jill’s observations were because of Jill’s anxiety caused by her mental illness. However, the condition of Jill continued to deteriorate all through the shift, precipitating Alex to mention her anxiety theory to the Clinical Nurse Educator (CNE) and the specialist registrar on shift. The CNE told her to look at Jill’s file and review all the available information. It was only then that Alex realised that Jill may be suffering from Neuroleptic Malignant Syndrome (NMS) which is a possibly life-threatening response to medications for antipsychotic therapy, including clozapine. The legal issue that I identified in the case study is the failure to implement the supervision guidelines for newly graduate nurses as per standards set by the Nurses and Midwifery Board of Australia. The Nursing and Midwifery Board of Australia (NMBA) penned a supervision guidelines intended for nurses and midwifes in line with their duties in supervising nurses and midwives and in making decisions. This was provided under section 39 of The Health Practitioner Regulation National Law, which focuses on the principles of supervising, requirements and responsibilities of supervisors, levels of supervision, responsibilities of supervisees and reporting requirements (NMBA 2015, p.1). Based on the law on supervision, patients have the right to anticipate competent, safe and evidence-based nursing care all the time, including those times when care is provided by midwives and/or nurses who are under supervisory arrangements. This right ensures the patients that their health and safety are not placed at risk and effective supervision is received from a nurse and/or a midwife at all times (NMBA 2015, p. 1). However, based on the details of the case, Alex did the assessment on her own without her mentor so she just assumed the condition of the patient based on the symptoms that she observed. As a registered nurse, she violated the right of the patient to expect a safe, competent, evidenced-based nursing care. Alex should have studied the side-effects of clozapine and patient’s history before doing the assessment of Jill’s observations to minimise error and prevent putting the life of the patient in danger. There was also an ethical issue in the scope of practice of the newly graduate RN because Alex centred her assessment of Jill’s observation based on her assumptions of what was going on with the patient and did not base her judgment on the history of the patient, medicines that were prescribed, as well as the side-effects of the medicine. As a registered nurse, Alex should not provide care based on gut feel or assumption but should at all time practice person-centred and evidenced-based decision making and nursing care (NMBA, n.d., p. 7). Nurses are held responsible in ensuring that the nursing actions and medication given will not harm the patient. Hence, RNs should be familiar of the side effects of drugs, normal doses, drug correlation with blood results and therapeutic effects (NIA, 2014, p. 1). Moreover, I also identified some professional nursing issues such as the challenges that newly graduate RNs face; in example, their new accountability and responsibilities to provide the best care for the patient though they are still in the stage of learning and trying to develop their range of skills and knowledge needed to be highly competent and autonomous (State Govt. of Victoria 2003, p. 15). On the part of the more experienced nurses, it could be their excessive clinical workloads that hinder them to provide appropriate supervision to new RNs, hence, health organisations can address this by ensuring that RNs get realistic workloads to be able to perform what is expected from them (State Govt. of Victoria 2003, p. 14). If the transition of new graduate RNs will not be addressed appropriately, this could take toll on the new RN and could eventually translate into work dissatisfaction and/or possible law suits due to nursing errors (Lynch et al. 2009, p. 133). Some of the cases filed against nurses in Australia, New Zealand and Europe involve nursing errors and negligence caused by inadequate monitoring on assessment due to short staffing and confused handovers (Savage 2016, p.1). And in the case of Alex, she received inadequate monitoring on assessment from the more experienced nurses so she committed error. Issues identified in the management of deteriorating patient The legal issue that I identified in the management of the deteriorating patient is the failure of the newly graduate RN, Alex, to provide the appropriate assessment of Jill’s condition, hence, endangering the life of the patient. This endangerment of the patient’s life could be a ground for a legal issue or a malpractice case especially if the action taken bore negligence whilst performing duty of care, dereliction of duty and damage (Lynch et al. 2009, p. 133). As I mentioned earlier, some of the cases filed against nurses were involving nursing errors in line with assessment of the patient’s condition, failure to review patient’s history and/or failure to read notes at handover (Opie 2016, p. 1). The case of former Socceroo Stephen Herczeg who died due to a nursing error in the hospital is a classic example of how failure to check the patient’s history and progress notes could lead to adverse events (Opie 2016, p. 1). And a simple neglect like this could be a big health issue that can possibly bring the nurse to court. In addition, there was also an ethical issue identified in the management of a deteriorating patient which was seen in the action of Alex, the newly graduate RN, who preferred to use her gut feel and assumptions rather than adhere to the standards of providing person-centred care and evidence-based nursing practices. Furthermore, Alex showed unprofessionalism when she just left the deteriorating patient just because she was new to her job and she did not want to be involved in any trouble. On the part of the more experienced nurses, they had been too complacent on Alex’s skills that they did not even bother to check whether she was doing her assessments per standards. Their actions constituted failure to observe one of the values in the code of ethics for nurses which is to value a culture of safety in providing health and nursing care (NMBA 2008, p. 1). Alex, on her part, practised beyond the limitations of her skills and knowledge, hence, her ability to provide quality care to Jill was compromised, resulting to the endangerment of the patient’s life (NMBA 2008, p. 5). It should be noted that Jill had experienced symptoms associated with Neuroleptic Malignant Syndrome but Alex did not notice it at once because she did not review the background of the case prior to her assessments. According to Australian Commission on Safety and Quality in healthcare (2008, p. 2), the issues that contribute to the failure of nurses to recognise properly the deterioration of patient are the skills and knowledge of staff, the method of the delivery of care, attitudes, communication of information and organisational systems. These all factored in the deterioration of the health condition of Jill whilst under the care of Alex. Moreover, the issue related to professional nursing that I identified was lack of monitoring by senior RNs to the actions taken by the new graduate RN in providing care. This negligence could lead to the likelihood of committing error (Croke 2003, p. 54). Based on the guidelines set by the NMBA, 2015 (p. 6), it is the duty of nurse supervisors to make reasonable actions, such as providing new graduates RNs direct supervision, to make sure that he/she is performing safe practice. But since the senior RNs failed to provide direct supervision to Alex during assessment of Jill’s observations so an error was committed resulting to the deterioration of the patient’s condition. Since clinical deterioration is sometimes difficult to recognise, it is important that contributing factors to the recognition of patient’s deterioration whilst in hospital, such as skills and knowledge of staff, attitudes, organisational system, communication of information and delivery of care, be addressed and improved to ensure safety and quality of care (ACSQH 2008, p. 2) Issues identified on effective teamwork Teamwork is essential in providing the best healthcare (NSW Govt. 2014, p. 1); however, as seen on the case study, collaborative teamwork was not practiced because Alex was left on her own during the assessment of Jill’s condition. This lack of effective teamwork could increase the chances of error or malpractice which could lead to law suits. According to Croke (2003, p. 54), some of the factors that cause errors and malpractices are policies in hospitals such as giving increased responsibility and autonomy to nurses and too much delegation. When nurses are given increased responsibility and autonomy beyond their nursing skills, risks of committing liability and error on the part of the nurses are also increased. The same is true in too much delegation. When experienced nurses delegate more of their works or tasks to new or inexperienced nurses due to overload of works or cost-containment program of the hospital, team work and monitoring of delegated tasks are sometimes neglected, resulting to increased risk of committing errors and possible law suits. The ethical issue that I identified in providing effective teamwork is the failure of the senior RNs to perform their supervisory duties such as attending to routine observations on the performance of the new graduate RN on duty. The CNE who also happened to be the mentor of Alex should have at least oriented Alex on the case of the patient before letting her do the assessment of Jill’s observations. On the part of Alex, she should have sought the opinion of her mentor first regarding her assessments before taking action. As a mentor, the CNE has the obligation to work with Alex and correct whatever wrong assessment she has made as provided in the supervision guidelines intended for midwives and nurses (NMBA 2015, p. 1). The issue on effective teamwork related to professional nursing that I identified is the ongoing problem of shortage of staff and overload workloads of nurses in hospitals that cause less or no time at all for senior RNs to attend to other essential duties of registered nurses, such as monitoring and doing routine observations on the performance of new graduate nurses (Armstrong 2009, p. 22). Shortage of nursing staff and overload workloads contribute to nurses’ reduced ability to provide all the necessary care needed by the patient. In addition, these factors increase the likelihood of nurses’ risk of committing errors due to their increased activities and fatigue. Hence, to promote effective teamwork among healthcare providers, it is important to determine not only what the nurses do to achieve the patient’s optimum care but to also check on what they have not done due to overloads that hinder them in providing the best nursing care (Armstrong 2009, p. 22). In our case study, Alex failed to ask for support during the assessment whilst the senior nurses failed to monitor Alex’s actions, so they were not able to work as a team in ensuring that Jill was given the utmost nursing care.
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    Nursing case study: palliative care
    Case Study – Betty Introduction Betty is a 79 year-old woman, married and has a daughter named Cheryl. She was first diagnosed to have Stage 3 Chronic Kidney Disease (CKD) but her illness progresses to stage five. Her medical history reveals that she has type-2 diabetes, ischemic heart disease and peripheral vascular disease and had a myocardial infarction some years ago. Some of the symptoms that she is experiencing are lethargy, shortness of breath, oedematous legs and nausea in the mornings. Betty identifies nausea and lethargy as the two most difficult symptoms that she is suffering from. Nausea is defined as the nasty feeling caused by the discomfort in the upper abdomen, accompanied by the impulse to vomit (Mandal, 2014). On the other hand, lethargy refers to the feeling of weariness, tiredness, lack of energy or fatigue. Lethargy can be accompanied by apathy, decreased motivation or depression (Kiasco, 2011). Betty understands that she is not going to get any better and she insists not to have dialysis; she just wants to have peaceful death at home. She emphasizes that she wants conservative management with supportive palliative care. This essay will discuss and develop a care plan which outlines potential nursing interventions for managing nausea and lethargy, the two symptoms that Betty is experiencing. Moreover, it will provide an evidence-based rationale for the proposed interventions through the use of relevant literature, systematic reviews, clinical care guidelines and other appropriate materials. Further, it will provide a description of how the effectiveness of the interventions within the context of palliative care will be monitored and evaluated before finally concluding. Nausea Nausea is defined as “an unpleasant feeling of the need to vomit, often accompanied by automatic symptoms such as pallor, sweating, salivation and tachycardia” (Twycross et al., 2009 as cited in Kelly & Ward, 2013, p. 17). Patients with advanced diseases often experience nausea which somehow reduces their quality of life. To improve patient’s experience of end-of-life, palliative care intervention is suggested (Kelly & Ward, 2013). Statistics show that around 33% of patients with end-stage renal failure experience nausea (Murtagh, et al. 2006). According to Twycross et al. (2009), occurrence of nausea increases as the disease progresses, intensifying as much as 70% in the last week of life of the patient. Effective management of nausea requires a multidisciplinary approach coupled with good communication between the patient and his family and all the members of the healthcare team in-charge of the patient. In the case of Betty, since she emphasizes conservative management with supportive palliative care at home, the care plan would be the following: Nursing staff should ensure that support for the patient are made available at all times and the team should be fully informed of whom to contact for queries and other concerns (Glare et al., 2011). Simple measures like making sure that the patient has easy access to tissues, large bowl and water are helpful. Regular mouth care should be offered habitually. Small, simple meals are better and carbohydrate-based meals are best tolerated. Cool, frothing drinks are more enticing than hot drinks and should be offered to patient (Kelly & Ward, 2013). If the patient is having difficulties in taking oral medications like what Betty is experiencing, the nursing staff should try other forms of delivery such as through patches and syringe drivers (Glare et al., 2011). Moreover, current medications of the patient should be reviewed to determine what triggers the occurrence of nausea. Non-steroidal anti-inflammatory drugs are known to aggravate nausea so it should be changed or stopped (NICE, 2012). Likewise, the patient and his family should be educated so they will understand the multiple causes of nausea and the many strategies to manage it. The nursing staff should see to it that both the patient and his family understand the need to cut out on intolerant foods such as spicy, salty, fatty and those with strong odors. Also, the need to restrict intake when there is gastric distension – starting with sips, ice chips or popsicles. When the nausea settles, the intake should gradually increase from fluids to semi-solid then to full food. If nausea returns, repeat the same procedure until nausea disappears (Fraser Health, 2006). They should also be advised that mixing liquids and solids should be avoided. When the patient is hungry, small frequent, bland meals should be served. Furthermore, the nursing staff should emphasize to the family that making the patient lie flat after eating will aggravate nausea due to acid reflux (newhealthguide.org, 2014). Other non-drug approach in the management of nausea is the behavioral approach such as distraction and relaxation. The nursing staff should try to refocus the attention of the patient on something else to reduce psychological distress and arousal and provide the patient the feeling of control over the symptoms (Glare et al., 2011). For drug management, a dose reduction of levomepromazine and haloperidol may be needed and if antiemetics are used, it should be reviewed every 24 hours and only be continued if the symptoms have not resolved (Kelly & Ward, 2013). Lethargy Regnard (2004) defines lethargy as the feeling of being in low mood and depressed. For patients like Betty who has chronic kidney disease but refuses to have dialysis, having palliative care at an early stage results to better symptom control and end-of-life care. Possible causes of lethargy in renal patients are loss of independence, anxiety of facing eventual death, and too much dependency on carers (NHS, 2013). Being depressed results to feeling lethargic causing the patient to be inactive. On the other hand, inactivity leads to fatigue and muscle weakness. Constant fatigue and tiredness are two of the symptoms of lethargy (Goldstein, 2008). Moreover, O’Shaughnessy (2010) states that as kidney function drops, the number of erythropoietin produced by the kidneys also decreases resulting to anemia. The feeling of lethargy is usually caused by anemia. The care plan in the management of Betty’s lethargy would be the following: First, the nursing staff should identify what causes the lethargy. If the lethargy is caused by anemia, the anemia must be corrected by providing iron supplements (usually intravenous), erythropoiesis stimulating agents (ESA) injection and aiming for hemoglobin 10 – 12g/dl (NHS, 2013). If it is due to dietary deficiencies, eating habits of the patient should be regulated and the patient should be provided with a diet that gives high energy level. Also, simple, little daily exercises is a good compliment to the high energy-giving diet.
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    Nursing case study - myocardial infarction
    1. Risk Factors and Health Promotion The aspects that led to Mr. Gulyas’ myocardial infarction condition were his age, smoking, lack of exercise, job stress and psychosocial factors like negative emotions and social isolation. At 49, Mr. Gulyas is at risk of developing myocardial infarction because men after the age of 45 are at a higher risk (Macon & Guy 2016), which is normally experienced 9 years earlier than women (Anand et al 2008). His smoking habit of consuming 15 cigarettes per day is also a major factor because it causes plaque build-up in the arteries that damages the function of the heart (NHI 2015). Lack of exercise or physical activity due to constant sitting also triggers the development of myocardial infarction because immobility decreases blood circulation whilst having some physical movements or exercise increase blood circulation and eventually, helps in clearing arteries (Kivimaki et al. 2012). Since Mr. Gulyas is a computer programmer in an office so he is more likely always physically engrossed with his work and most of the time confined in his area, leaving him a good candidate for job stress and psychosocial factors like negative emotions and social isolation. Negative emotions and social isolation due to workplace stress are considered as heart stressors that increase the risk of getting myocardial infarction (Steptoe & Kivimaki 2012). I would approach Mr. Gulyas regarding his condition by explaining and educating him about the pathogenesis of myocardial infarction and the negative effects of his lifestyle to his health. Firstly, I will explain that the risk factors are alterable and the development of the disease can be prevented. Since studies show that myocardial infarction is familial (Shen et al. 2014) yet Mr. Gulyas has no known history of atherosclerotic heart disease, so his case is more likely due to his lifestyle, which could be modified to prevent further advancement of the disease. The first thing that he should change is his habit of smoking. He should be advised to quit tobacco smoking and avoid second-hand smoke altogether. Any type of smoking – whether occasional or light – damages the blood vessels and the heart, so it should be avoided as soon as possible. Mr. Gulyas should also stay away from second-hand smoke as it also contains the toxic chemicals that smokers inhale whilst smoking. At his age, 49, he should be doing exercises to increase physical activity. Some of the exercises recommended are swimming, walking, running or other cardiovascular exercises that increase strength of skeletal muscles and endurance (Metkus, Baughman & Thompson 2010). He could join group exercises to increase his motivation to exercise on a regular basis. Increasing his physical activity will increase his blood circulation which eventually will lead to clearing of arteries. To prevent work stressors like being emotionally down due to work pressures or social isolation due to too much work, he should allot some time to unwind, relax and breathe some fresh air. When the body is relaxed, the muscle tension decreases; and the heart rate is also lessened, easing the load on the heart (Metkus, Baughman & Thompson 2010). 2. Activities of Living Among the 12 activities of living listed in the Roper Logan & Tierney Model of Nursing, these activities should be influenced in managing Mr. Gulyas’ health condition: eating and drinking, controlling temperature, working and playing, breathing and sleeping. Definitely, Mr. Gulyas should be eating healthy, balanced diet and should be avoiding animal fats because highly fatty foods increase both triglyceride and cholesterol levels, causing the build-up of plaque and eventually leading to myocardial infarction. However, moderate consumption of healthy fats such as fish oil, and oils from avocado, seeds and olive help in taking care of the heart (Paula 2015). He should also drink more water because the high level of magnesium in hard water has shown positive anti-stress benefits against heart diseases and cardiovascular mortality (Sengupta 2013). Furthermore, the registered nurse could assist Mr. Gulyas by controlling his temperature because his exposure to either cold or heat temperature can increase the severity of his condition (Madrigano et al. 2013). Too much cold causes the loss of body heat resulting to increased heart rate and increased risk of myocardial infarction. On the other hand, exposure to too much heat may cause dilation of blood vessels, causing the heart to increase pumping to sustain blood pressure (Madrigano et al. 2013). Mr. Gulyas’ working and playing should also be altered because long hours of sitting and lack of playing or body movements through sports and exercise contribute to increasing his risk of myocardial infarction. As mentioned in the case study, being an office computer programmer who has very little exercise could have contributed to the health condition of the Mr. Gulyas. Long hours of sitting causes the muscles to burn fewer fats and slower the flow of blood, thus, increasing the chances of fatty acid clogs in the heart. Berkowitz & Clark (2014) state that those having sedentary time have more than twice chances of getting cardiovascular disease than those who have active lives. To alter this, Mr. Gulyas should be doing yoga poses such as ‘cat pose’ and ‘cow pose’ to improve the flexion and extension in his back and always make it a point to walk from time to time to increase body movements (Berkowitz & Clark 2014). Furthermore, the breathing and sleeping activities of the patient should also be altered to improve his condition and minimise the chances of a heart attack. It should be explained to the patient the importance of sleep in giving the heart the chance to slow down because the heart pumps around 2,000 gallons of blood and beats on the average of 100,000 times per day (UCLA 2016). However, people with heart disease find it hard to sleep because of the feeling of shortness of breath due to more blood flowing back into the heart. It is best that the registered nurse educate Mr. Gulyas on how to get good sleep such as following a good bedtime routine and wearing comfortable sleep clothes. 3. Nursing Care The most obvious presenting symptom of Mr. Gulyas was his central chest pain that radiated to his shoulders and extended to his left arm. The nurse should observe and record the specific of pain including unspoken gestures such as restlessness, groaning, clutching of chest or crying. The blood pressure and the changes in heart rate should also be documented for proper assessment. The patient may be asked to do relaxation techniques such as breathing slowly to help him relax a bit. Mr. Gulyas should be put to constant cardiac observing and reperfusion therapy (Vera 2014). He should be asked to describe the type of pain he is experiencing to acquire a reference point for evaluation and help in defining eventual efficiency of the resolve, therapy or advancement of the health issue. In this case, Mr. Gulyas was able to describe his pain as 10 out of 10, an indication that his pain was extreme. After initial assessment, the patient should undergo a 12-lead ECG within 10 minutes of his arrival to the nursing station. All ECGs must be transferred to the assigned doctor for analysis. The patient’s vital signs should be checked prior and post administration of narcotic as hypotension and respiratory depression may happen as a outcome of the management, which will surely lead to increased myocardial damage. In the case of Mr. Gulyas, his vital statistics were normal except for his quite high respiratory rate (18 breaths/min), an indication that he really was sick. Since the patient has no noted contraindication, he should be administered with oxygen and medications such as aspirin (Duksta & Younker 2015), nitroglycerin, morphine and beta-receptors antagonists (O’Gara et al. 2013). Oxygen is connected to relieve discomfort brought by tissue ischemia and to prevent arterial hypoxaemia which usually happens in the initial 24 hours post MI. Aspirin is used to lessen platelet load and minimise the chances of re-formation of a partly dissolved clot. Studies show that an initial dosage of 160 – 325 mg aspirin significantly lessens death due to heart attack and is recommended as among the first treatments at the start of chest pain for suspected myocardial infarction (Duksta & Younker 2015). Nitroglycerin is given to control pain and increase the circulation of blood to the blood vessels of the heart. Nitrates also provide peripheral vasodilation effects that lessen myocardial workload and demand for oxygen. The beta blockers serve as second-line mediator for controlling pain through blocking sympathetic stimulation effect, thus, decreasing heart rate, demand for oxygen and systolic blood pressure. However, this should only be given if Mr. Gulyas’ ability to self-contract has not been severely damaged, otherwise it may further lessen his capacity to contractility. Analgesics such as morphine are only used for acute stage and/or recurring chest pain not relieved by nitroglycerin to minimise severe pain (Vera 2014; Kingsbury 2013). Since Mr. Gulyas’ ECG indicates an acute STEMI (ST elevation myocardial infarction), and his Troponin result is 2.4, an indication that he had a significant myocardial injury since it is already more than 2.0 ng/mL level. This also indicates that the patient is at a higher risk of succumbing to future serious heart occurrences. Since the plan for Mr. Gulyas was to admit to cardiac ward for monitoring and thrombolysis, hence, the major role of the nurse would be to provide care during the pre-infusion, during the infusion and post-infusion, which mostly include assessment and recording of vital signs, evaluation of the infusion site for hematoma, performing cardiac monitoring and keeping updates about the procedures to the patient and relatives. 4. Pathophysiology There are two types of myocardial infarction or heart attack, namely STEMI and non-STEMI. STEMI stands for ST-segment elevation myocardial infarction whilst non-STEMI is non-ST segment elevation myocardial infarction. The two are identified through the results of the ECG because STEMI has ST-segment elevation in the ECG whilst non-STEMI has ST-segment depression. ST-segment elevation in the ECG findings occurs because of the full thickness injury damage to the muscle of the heart which could eventually progress into a Q-wave. Q-wave is a sign indicating that there was earlier myocardial infarction and this develops several hours to days after a heart attack (Thygesen et al. 2007). Non-STEMI has no ST segment elevation in the ECG findings and indicates that the patient’s heart muscle has sustained partial thickness injury only. The thickness of injury shows the damage acquired from the swift interruption of blood supply to the parts of the heart. Hence, between the two types, STEMI indicates a more severe damage to the muscles of the heart.
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    Nursing case study - Medication Management
    Questions Q1a. Assess Mr. Fazio’s medication chart and identify and explain two significant risks that may be associated with the use of these medicines. (Expect approximately 400 words) Mr. Fazio’s medication chart shows that he was prescribed with 1-2 mg of morphine for pain, glyceryl trinitrate for chest pain and ondansetron for nausea. Although intravenous morphine is generally prescribed for the management of patients with acute coronary syndrome and chest pain, it may be associated with significant risks, such as death. Conti (2011) states that the use of intravenous morphine alone or in combination with nitroglycerin in patients with non-ST elevation ACS was linked to higher mortality as compared to those who were given nitroglycerin alone. Morphine only masks the pain brought by myocardial ischemia and even worsens the condition. According to Abdikarim & Basgut (2016), the association of morphine to mortality could be due on the effect of reducing the harshness of angina without improving first the primary cause of the chest pain, such as coronary hypoperfusion. Some of the side effects of morphine in ACS patients are nausea, respiratory depression and hypotension (Buchholz &Solanki, 2012). Glyceryl trinitrate could encourage mitochondrial swelling, cause loss of respiratory control of heart mitochondria and stimulated oxygen consumption. Continued use of glyceryl trinitrate reduces aldehyde dehydrogenase activity in the weakening heart. Prolonged use could increase cardiac dysfunction and infarct size due to ALDH2 inactivation (Ferreira & Rosen, 2012). It may also bring excruciating headache and lightheadedness. The authors add that continued use of glyceryl trinitrate worsens damage caused by ischemia because the medicine decreases ALDH2 activity. Sublingual glyceryl trinitrate should not be given to patients with history of current use of phosphodiesterase-5 inhibitor such as sildenafil, nor to patient with potential right ventricular infarction and with hypotension (BP of <90mmHg) as it may widen the venous system resulting to decreased preload, and thus, causes hypotension to patients with right side myocardial infarction (Buchholz & Solanki, 2012). The significant risks of IV ondansetron with a dosage of 4mg with a frequency of 4/24 PRN are lightheadedness, headache, tiredness, fever (Dayan & Huys, 2008) and chest pain (ADRAC, 1998). The risk of getting these side effects increases if the patient is also taking medicines that could increase serotonin as this encourages nausea and increases heartbeat (Dayan & Huys, 2008). Furthermore, a warning was issued by the US Food and Drug Administration regarding the use of this medicine as it has the ability to cause prolongation of QT- interval in ECG, increasing the risk to fatal arrhythmia (NPS Medicinewise, 2013; Doggerell & Hancox, 2013) Q1b. Describe the nursing strategies a nurse may implement to prevent/manage the risks you have identified in Question 1a. (Expect approximately 400 words) To manage the risk of death due to the use of morphine, the nurse should first assess the primary cause of the chest pain of the NSTEMI patient, if whether the cause is due to coronary hypoperfusion or if it was really chest pain due to myocardial infarction. If it was due to hypoperfusion, then correcting it should be the primary end goal as this could lead to death. The nurse should check full set of vital signs. The patient should be placed in supine position, elevating the legs to 8 – 12 inches. The patient must be given oxygen. The body temperature must be kept normal; blankets could be used to decrease heat loss. If chest pain was due to myocardial infarction, then the nurse should make sure that the patient is refractory to the approved guideline in the use of morphine for acute coronary syndrome. The guideline is geared towards reducing myocardial oxygen demand and enhancing myocardial oxygen supply (Conti, 2011). If morphine was to be used, the nurse must ensure that the dose is within the approved dosage as follows: 2 – 4 mg IV with increases of 2 – 8 mg IV recurring at 5 to 15 minutes rests. In the case of Mr. Fazio, the doctor’s order was 1-2 mg IV morphine with an hourly frequency of 1/24 PRN and with a maximum PRN dose/24 hours of 24mg, which is within the approved dosage. For the risk of experiencing headache when taking sublingual glyceryl trinitrate, suitable painkiller could be given to the patient. The nurse should also advise the patient to avoid actions or tasks that need alertness when taking this medicine as this can cause dizziness and lightheadedness. The patient should also be advised not to drink alcohol as this will increase the possibility of experiencing lightheadedness. Since the medicine has the potential to effect sudden drop of blood pressure, the nurse should monitor the BP of the patient and in the case of Mr. Fazio, whose BP was 103/60 mmHg, he should be given measures to increase blood pressure such as increasing his fluid volume, elevating the patient’s legs, and IV infusion of saline or other similar fluid (Boyle, 2007). With regards to the risks of intravenous ondansetron, specifically if the person has a history of QT prolongation, then the medicine should be ceased, and the findings reported to the GP for further assessment. Q2a. Explain the clinical benefits of patient participation in medication management during hospitalisation All patients have the right to safety, to be informed, to choose and to be heard, thus, patient participation is significant in ensuring that these rights are enjoyed and the patient is included in the decision-making process on the management of his illness during hospitalisation. According to Bucknall et al., 2016, patient participation helps in improving quality of care and in preventing medical errors. In patient participation, patients are involved in making decisions and in some aspects of care, such as in monitoring their improvement, monitoring the effects of care and in giving suggestions as to how to improve care. Hence, some of the clinical benefits are better health outcomes, improved safety of patients, and more encouraging experiences of care. Patient participation promotes better relationships between the health worker, patient and relatives; easier workload on the nurse because some control and power are surrendered to the patient; easier sharing of information and know-how (Bucknall et al., 2016). If patients are properly informed on the effects, adverse reactions and benefits of their medicines, then they can easily give their informed decision on what to choose among the available medicines on the management of their medication while in the hospital. In the case of Mr. Fazio, he could give his choice regarding the use of morphine, sublingual glyceryl trinitrate and IV ondansetron to manage his chest pain. Patient-centred care was also the concern of the Australian Commission on Safety and Quality in Health Care when they required all health services to establish a PCC-focused system to ensure that all health organisations are observing active partnerships with patients (Bucknall et al., 2016). One of these is the promotion of hand hygiene by health care workers to prevent healthcare associated infection which can easily endanger patients’ safety if not addressed (Longtin et al., 2010. Q2b. Describe the nursing strategies that could be implemented to enhance Mr. Fazio’s participation in his medication management (Expect approximately 400 words)
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    Bio-nursing
    Explain how the patient might have developed a urinary tract infection (UTI) and justify the initial administration of Ticarcillin Clavulanate. The patient has developed a urinary tract infection because he had indwelling catheter right after his aortic valve replacement surgery. Having a catheter in the bladder puts the patient at high risk of developing a urinary tract infection due to bacteria related to being attached to a catheter. The risk of acquiring a urinary tract infection whilst the catheter is in place ranges from 3 to 7%, but this usually goes with antibiotics (Norrby, 2011). The initial administration of Ticarcillin Clavulanate is used to treat the UTI due to “beta-lactamase-producing isolates of E. coli, Citrobacter spp, Klebsiella spp, Enterobacter cloacae, P. aeruginosa, S. aureus or Serratia marcescens” (Medscape, 2013, p. 1). The combination connects the extended spectrum of ticarcillin with beta lactamase activity of cluvalanic acid. The mixture of ticarcillin and clavulanate offer treatment to serious bacterial infections caused by predisposed organisms. It is indicated for the treatment of serious infections in the urinary tract, lower respiratory tract, skin, joints and bones (Livertox 2012). Discuss two of the most likely predisposing factor for this man’s Clostridium difficile infection The two predisposing factors for the patient’s Clostridium difficile infection are the patient’s exposure to broad-spectrum antibiotic (Ticarcillin Clavulanate) and his advanced age. Persons who have advanced age (more than 65 years old) are at risk of developing C. difficile (Brazier, 2005). According to Deneve et al (2009), broad-spectrum antibiotics, predominantly those that fight against anaerobic bacteria, change the intestinal microbiota, resulting to dysbiosis - a condition characterized by microbial imbalances inside or on the body - and interrupt its blocking effect. During antibiotic treatment, an imbalance happens as Bacteroides Porphyromonas Prevotella group increase and the Clostridium coccoides Eubacterium rectale group decrease simultaneously. This process causes diarrhea and favors the colonization of C. difficile (Deneve et al 2009). The hospitalisation of a person with advanced age (more than 65 years old) is also a high risk factor because of their vulnerability. Debilitated elderly patients in nursing homes and hospitals are particularly affected and studies showed that the colonisation rate is as high as 73% (Deneve et al 2009). Explain how the clostridium difficile infection may have developed in the patient’s gut starting from two different sources of contamination.
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    Nursing essay : case study
    Assessment Task 4 Every registered nurse has legal, ethical and professional responsibilities in performing his/her duties and these professional obligations are based on the standards related to providing care, as well as in collaborating with other medical practitioners in achieving patient’s optimal positive health outcomes (Nursing & Midwifery Board of Australia 2006, p. 2). This paper will analyse the legal, ethical and professional responsibilities of the registered nurse on duty. The analysis will focus on the case of Mrs. Spring and will explore the three key issues identified in assessment 1, such as, failure to detect a deteriorating patient, extensive workload (communication with PACU unit), and insufficient handover. Failure to detect a deteriorating patient Brief Summary Based on the case study, RN Tracey, who was the night shift registered nurse on duty, failed to collect current information of Mrs. Spring because she was “flat out the whole night” so she had overlooked her duty care to Mrs. Spring. Due to her having too much work to do, she was unable to carry out new investigation on the condition of Mrs. Spring, and therefore, also failed to make assessments and issue reports valuable to the next shift staff. The only health information that was documented by RN Tracey during her shift was the patient’s temperature at 38.9 (which means the patient was already febrile), Pulse at 126 (Tachycardia), Respiratory Rate at 28 (Tachypnea), and Blood Pressure at 105/70, an indication that the patient was not really feeling well as she had mild fever, abnormal pulse rate, shallow, rapid breathing and quite low BP that could make her feel a little dizzy when standing up (Min. of Health 2015, p. 1; Pulsevital.com 2017, p. 1; Flenady et al. 2016, p. 1 & Haiken 2017, p. 1). Her failure to make current assessments of the patient led to her failure to detect the deteriorating condition of Mrs. Spring. If only RN Tracey performed on-time assessment of Mrs. Spring, she should have detected the patient’s alarming vital signs and have done some actions such as escalating the problem to Rapid Response call, such as Pace call, to reverse the patient’s clinical deterioration (NSW Govt. 2013, p. 10). Legal According to the 3.2.1 provision (Frequency of Observations in the Policy) Directive of NSW Ministry of Health, the frequency of observations of patients should be performed at a minimum of three times a day, with eight hours interval. When the condition of the patient worsens, the frequency of observation must be increased depending on his/her colour zones on the Standard Observation chart (NSW Govt. 2013, p. 13). Blue zone is used for new-borns and paediatric indicating that the frequency of observations should be increased and calling for an initial clinic review should be considered. Red zone indicates that a rapid response call is needed because the observations indicate patient’s warning signs of deterioration. Yellow zone indicates that the patient needs consultation with the midwife or nurse on-duty because of the early warning signs of deterioration that the patient is showing. In this case, the nurse or midwife on duty should decide if a CERS call or clinical review is needed. In the case of Mrs. Spring, it could be that she was already exhibiting a yellow zone signs but since RN Tracey had too much work to do, so the proper protocol of deciding whether to make a CERS call or a clinical review was missed, thus, endangering the life of the patient. Based on the study by Van Galen et al. (2016, p. 1), nearly half of the unexpected admissions to ICU by patients from the general ward were due to healthcare worker’s failure to monitor patients who were clinically deteriorating. This study was also consistent with previous study (Bapoje et al. 2011, p. 70) theorising that unexpected ICU transfers were not due to the patient’s underlying disease, but possibly caused by the ward’s healthcare workers suboptimal care and insufficient monitoring and assessment of the patient’s condition. The negligence that RN Tracey committed resulted to the unnoticed deterioration of health of Mrs. Spring, which can be a ground for a legal issue under the Civil law. RN Tracey’s negligence bore the four elements of negligence that constitute for a ground for a civil case, such as duty of care, dereliction of duty, direct and damage (Lynch et al. 2009, p. 133). Ethical and Professional Neglecting other patients that led to the patient’s deterioration of health is both unethical and unprofessional because this negligence could lead to serious adverse effects such as major complications or even death (Van Galen et al. 2016, p. 1). The authors add that some major complications were due to errors in nursing care and could be prevented if proper care was given. The conduct exhibited by RN Tracey could be considered as an “unsatisfactory professional conduct” of an RN as described in the NSW Government legislation under Health Practitioner Regulation National Law (NSW 2016, 139B.). Demonstrating neglect to provide duty care or judgment by the practitioner to patients can be considered below the professional standard that is expected from a registered nurse in providing care for his/her patients. Given that she was ‘flat out’ the whole shift, she still failed to use the protocol of requesting for assistance to ensure that all the patients were properly taken care of. Van Galen et al. (2016, p. 1) suggest the use of a Track and Trigger System to track the condition of the patient and alert nurses on the event that the health status of the patient reaches deteriorating levels. Extensive work load (communication with PACU unit) Brief Summary During the shift of RN Tracey, the 15-bed surgical ward was at capacity and there were only two (RN Tracey and Enrolled Nurse) who were scheduled to work on night shift. Unfortunately, in the ward, two male patients who had surgeries were distressed: one was unceasingly vomiting and the other one, a dementia patient who just had a fall on that afternoon, was restless and kept on walking to other patient’s rooms. In addition, a female patient was also very upset because her wish of not being put in a room where she had to share with male patients was not observed. Since it was not surprising to have fully-occupied ward, the hospital management had installed the proper procedure on how to address this problem by allowing the adjacent PACU unit staff to assist the surgical ward whenever needed. In fact, the RN on –duty at the PACU unit had contacted RN Tracey for five times during the night shift to provide assistance if necessary. However, RN Tracey was too occupied to pick-up the phone and just carried on the task with the Enrolled Nurse. This, however, resulted to Mrs. Spring’s deterioration of health. Though her vital signs that were documented at 0210 of 22 May 2017 showed that she had mild fever (38.9) and could be having an infection, there was no course of action provided to reverse deterioration. Legal The failure of RN Tracey to observe the protocol of requesting assistance in cases of overloaded work could be considered as a breach to work health and safety law. Based on the Health and Safety law in Queensland, a breach is committed when a person’s life is put to danger or death or illnesses result from the incidence; there was a failure to follow existing regulatory requirements, and steps were not taken to prevent the occurrence of a risky situation (Queensland Govt. 2016, p. 1). Unfortunately, all the mentioned factors were present in the acts of RN Tracey and these constituted to the worker’s breach of the WHS Act of 2011. Based on the penalties provided in the WHS Act, RN Tracey falls under the penalties due for category 2 offence, where there was failure to follow health and safety duty causing a person to be exposed to serious injury or illness or even risk of death, thus an individual worker (nurse) is penalised of up to $150,000 if proven guilty. Failure to pay the corresponding fine could lead to the issuance of a warrant of arrest and imprisonment (Queensland Govt. 2016, p. 1).
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    Nursing essay : All nursing stereotypes are damaging...
    “All nursing stereotypes are damaging and undermine the value of contemporary nursing”. Critically discuss with reference to three (3) common nursing stereotypes Introduction Nursing stereotypes are not only offensive but undervalue the profession and the nursing professionals who averred to save lives. Being associated to a negative generalised image does not only weaken the morals of nurses but also discourages others to aspire to become nurses because of the disrespect and misconceptions that are thrown to the profession. This paper will discuss three of the most common nursing stereotypes, such as ‘nursing is only for female and male nurses are gay’, ‘nurses work for doctors’, and the sexual connotation of a ‘naughty nurse’ and how these stereotypes smear the good image of nurses and undermine the value of contemporary nursing. The term stereotype will be used to mean “label” and “typecast”. ‘Nurses work for doctors’ stereotype The Nursing profession is a recognised health care sector that provides care, not only to individuals but also to communities and families, so as to sustain the best of health or recover optimum quality of life (Coulehan, 2005). Though nurses can practice independently depending on their training level, they are traditionally seen providing care within the doctor’s ordering scope, creating an impression to others that nurses are ‘doctor’s handmaiden’ or ‘working for doctors’. However, this is not true; they are not doctor’s handmaiden nor working for doctors but they are working with doctors in providing care for patients. According to Brown (2009), nurses are not doctors’ helpers because physicians and Registered Nurses are independent and separate. It is not the doctors who hire and fire nurses but another nurse who acts as a unit manager, who in turn, also follows instructions set by senior nursing officers. This stereotype is not only downgrading to the ego of nurses but also considered as bad for health because one of the reasons behind the independent status of the nurse is to save lives. Saving lives can be achieved by giving nurses the opportunity to perform an independent check on the doctor’s care plans and make sure that patients are properly protected and optimum care is provided (Brown 2009). Nursing is an independent profession but it is always best that nurses communicate with doctors and work with them in providing the best care. Studies show that the care provided by a nurse with advance practice is at least as effective as the doctors’ care (Summers & Summers 2010). However, stereotyping nurses as more caring whilst the doctors as more leadership-oriented and competent affect their working relationship, prevents inter-professional collaboration and influences how one group behave with the other (Sollami et al. 2015). This is probably the reason why outsiders perceive nurses as doctors’ helpers whilst doctors as the ones who have the full responsibility of taking care the patient. Yet, it is best to always recognise the 2 sectors of health providers as coworkers who are expected to maintain their professional working relationship to the best interests of the patients. McKay & Narasimhan (2012) state that this stereotype is based on how nurses were regarded during the pre-Nightingale’s time where the nursing job is considered laborious yet measly-paid and most of the applicants were those who were unfit for other jobs. Nurses at that time were mostly vagrants, immoral women or criminals, thus, their status were looked-down whilst doctors enjoyed a godlike and well-regarded clinical position. Hence, even when the nursing profession was professionalised, some still regard them as the lowly medical helpers, resulting to the continued stereotyping of nurses as ‘doctor’s handmaiden’ or ‘they work for doctors’. However, this stereotype must be corrected to give the nurses their due respect and encourage them to stand on their ground and be an effective checker of the doctor’s care plans. ‘Nursing is only for females and male nurses are gay’ stereotype Since the early times of nursing, female nurses always outnumber male nurses but this does not mean that the profession is only for females and the few males that took the course are gays. According to Hutchison (1998), one profession that needs robust health and strength is nursing because caring for the sick requires powers of resistance, suppleness of movement and with physical attractiveness to positively manage a stubborn patient. The stereotype that nursing profession is only for females stemmed from the situation way back the war period where men were more active in the military than in the work force, giving women more chances to advance as nurses, which at that time was one of the socially accepted jobs (Mehta, 2016). Further, it was only in 1930 when males were accepted as nurses, making the stereotype stronger because even today, the ratio of women over men in the nursing profession is 16:1 (Mehta, 2016). But this stereotype is damaging to the career choice of students as it limits the profession to one gender, thus, stripping patients the chance to be served by qualified men who also want to save lives. The stereotype also does a disservice to the nursing profession because it limits the profession to one gender resulting to problems like under-staffing, shortages of qualified personnel and possible abuse to nurses and patients due to overworked and burned-out nurses. Furthermore, this stereotype led to another stereotype that ‘male nurses are gays’. This perhaps was based on the assumption that since nursing is a female profession so any man who chooses this career is effeminate. However, this is not true because the job of a nurse is physically exhausting and needs emotional stability to manage her daily exposure to suffering, death and pain. It also needs physical endurance to beat long periods of standing, lifting heavy things and sometimes, the sick. Though the job can be handled well by a woman, this type of job seems not quite attractive for gays as they are known to be more inclined to enjoy doing beauty and glamourous roles. This stereotype is also damaging to the pride of the individual male nurse as he is automatically judged and discriminated just because of his profession. With regards to the nursing profession, the stereotype undermines the true undertaking of the profession, which is to help save lives. The labelling that ‘male nurses are gays’ also suggests that if a person is not a gay then he is not qualified to save and care for the sick because only gays are allowed to be male nurses. The expectation of people of male nurses as gays also hinders straight men from pursuing the profession as they fear that some patients will not like them because they are not effeminate and construed as less compassionate and less caring than gays and females (Olin 2011). Hence, this stereotype is not only damaging and insulting to the individual but also limits the nursing profession in attracting straight males to pursue nursing. ‘The naughty nurse’ stereotype There are some television programs or movies where women clad in a nurse uniform are portrayed as nursing characters with sexy naughtiness; some are even nymphomaniacs. Though some argue that the sexual connotation on the role of the nurse is for the persona of the nurse only and not about the nursing profession, still people associate the screen image of the naughty nurse to the actual hospital nurse caring for patients. This is quite degrading to the real nurse who braves the night and tiredness just to help save lives. This is also demeaning to the nursing profession as it is being used for mockery yet disguised as entertainment but indirectly disrespects the profession and the professional. If nurses will be routinely portrayed as morally naughty then people will see the profession as a joke and would not attract others to become future nurses. Allowing the stereotype to continue is just like allowing the return of the pre-Nightingale time where nurses were vagrants, criminals and immoral women. In this time of nurse shortages and regulatory changes, damaging the image of nurses will only result to less nursing enrolees, less nurse aspirants, less nursing clinicians, less nurse researchers and administrators and less compassionate professionals willing to sacrifice their time and energy just to save lives. If this type of stereotype is continuously portrayed on TV and cinemas, then the good quality of the real caring healthcare provider will be overshadowed by inaccurate character depictions of people who are not even real nurses. Furthermore, this stereotype is derogatory and should be addressed by nurses themselves by showing to the world their real goals and the importance of their practice in patient care. Whilst media is a good venue in information dissemination, using it in portraying the stereotypes will bring the opposite result to the profession and reduces the significance of nurses in the eyes of the viewing public. According to Bishup (2009) when nurses are depicted as a ‘naughty nurse’ in television programs, especially if they were featured as having sex scandals with their doctors, then the general disrespect of the people towards the nurses will increase particularly if the viewer has no knowledge of what nursing really is and just gets information from the television dramas. When this happens, then the profession will gain a negative image in the public consciousness overpowering the truth that nurses are valuable decision makers in providing health care. Conclusion Nurses are valuable healthcare providers but their historical situations pre-Nightingale time seem like a ghost that keeps on haunting their images and they are typecasts as ‘doctor’s handmaiden’, ‘for-females only profession and male nurses are gay’ and ‘naughty nurse’ throughout their long history. Though nursing has been professionalised already, many in the society are still unaware that nurses are not working for doctors but working with doctors as equal co-workers in achieving their goal of providing optimum care. Being typecast as doctor’s handmaiden downgrades the ego of nurses and is also bad for health because it suggests abandoning one of the duties of nurses, which is to do an independent check on the doctor’s care plans and make sure that the patient gets optimum care and protection. Being tagged as the doctor’s helper also insinuates that the nurse is only second best to the physician, which again, is misleading as their functions are different – the nurse is to care whilst the doctor is to cure. Further, being tagged as a doctor’s handmaiden strips the nurse the chance to improve her skills and academic knowledge. It also hinders the nurses’ chance to explore wider range practice in the field of nursing, such as becoming a nursing manager who is directly in-charge of hiring and firing a staff nurse; clinical nurse specialist, educators, practitioners, administrators or researcher. The stereotype that nursing is for females’ only and male nurses are gay also put both the nurse and the nursing profession in a bad light. For the nurse, it may contribute to problems like understaffing, shortages of qualified personnel and abuse to nurses and patients because the stereotype may lead to limited career choices of students, thus, limiting the chances of patients to be cared by qualified men who also want to save lives but are hindered because of the gender issue. It also discourages straight males to pursue nursing as patients may not like them because they are not effeminate. This situation may lead to loss of potential hard-working and dedicated male nurses in the profession that could possibly make a difference in the field of nursing. The last stereotype, ‘naughty nurse’ is not only degrading to the moral values of the nursing professionals but also reducing the integrity of the profession itself. If the nurses and the nursing profession allow this to continue, then it only shows that all the efforts of those who courageously fought to professionalise the profession and uplift the images of nurses were put to vain. The sexual connotation on the images of nurses is a proof that the viewing public is not taking nurses with respect and does not value the nursing profession’s contribution to healthcare. Allowing the media to portray nurses as someone who is immoral, unethical, timid and dumb is just like allowing the people to continuously believe all the stereotypes hurled at nurses and the nursing profession.
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