Healthcare Delivery and Evidenced –Based Nursing Practice
Healthcare Delivery and Evidenced –Based Nursing Practice
The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample clinical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3)
- Describe how clinical pathways are used to coordinate care of caseloads of patients.
- What is the role of the case manager in evaluating a patient’s progress?
- What are examples of evidence-based practice tools used for planning patient care?
QUESTION 2: Community-Based Nursing Practice
Mrs. Johnson, a 67-year-old female patient, has recently been discharged from the hospital following an admission for COPD. She has a past medical history of a colon resection related to acute diverticulitis. She developed a surgical wound infection that requires daily wet to dry wound packing and IV Zosyn. Mrs. Johnson was discharged with home oxygen. To manage her care at home, home care visits were ordered. (Learning Objective 5).
- What would be involved in setting up the first home care visit?
- Describe the nursing assessments and management that would occur during the visit.
QUESTION 3: Case Study, Chapter 3, Critical Thinking, Ethical Decision Making, and the Nursing Process
1. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her right foot and has a history of diabetes controlled with oral agents. She is confused and the physician has determined that she is unable to make her own informed decisions. The hospice nurse, not realizing that the weekly order for CBC and renal profile had been discontinued, obtained the labs and sent them to the nearby laboratory for processing. The abnormal lab results obtained later that day revealed that the patient needed a blood transfusion. The hospice nurse updated the patient’s medical power of attorney who was distressed at the report. The patient’s wishes were to die peacefully and to not have to undergo an amputation of her right foot. But if the patient receives the blood transfusion, she may live long enough to need the amputation. The patient’s physician had previously informed the medical power of attorney that the patient would most likely not be able to survive the amputation. The patient’s medical power of attorney had made the request to cease all labs so that the patient would receive comfort measures until she died. The patient has no complaint of shortness of breath or discomfort. (Learning Objective 4)
What ethical dilemma exists?
Who are the stakeholders and what gains or losses do each have?
What strategies should the hospice nurse take to resolve the ethical dilemma?
Chapter 4, Health Education and Health Promotion
he community health nurse is planning a health promotion workshop for a high school PTSO (Parent-Teacher-Student Organization). The choice of topics was suggested by the high school’s registered nurse who has observed a gradual increase in student obesity. The two nurses have collaborated to develop this workshop to provide parents, students, and teachers with information about the importance of health promotion. (Learning Objectives 6, 8, and 9)
- Describe the importance of a focus on health promotion.
- According to the health promotion model developed by Becker (1993), what four variables influence the selection and use of health promotion behaviors?
c. Describe four components of health promotion.
QUESTION 5: Chapter 5, Adult Health and Nutritional Assessment
The registered nurse prepares to conduct a nutritional assessment on Mrs. Varner, a 52-year-old Caucasian female who describes herself as “overweight most of my adult life.” The client states that her health is good. She works part time as a receptionist and volunteers about 10 hours per week in her church. The nurse obtains Mrs. Varner’s height as 64 inches and her weight as 165 pounds. (Learning Objective 8)
- What is the rationale for computing body mass index? What is Mrs. Varner’s BMI?
- Calculate her ideal body weight. What is your assessment of her BMI and weight?
- Based on Mrs. Varner’s BMI and weight, the nurse measures her waist circumference. Describe the proper procedure for this assessment.
- Mrs. Varner’s waist circumference is 38 inches. What is your assessment?
- What laboratory values would the nurse review to evaluate Mrs. Varner’s protein levels?
QUESTION 6: Chapter 6, Individual and Family Homeostasis, Stress, and Adaptation
Mary Turner stepped on a nail 5 days ago and sustained a puncture about 1 inch deep. She immediately cleaned the area with soap and water and hydrogen peroxide, and applied triple antibiotic ointment to the site. Today she comes to the clinic with complaints of increased pain and swelling in her foot. On assessment, the nurse notes that the puncture site is red and edematous, and has a moderate amount of yellowish drainage. (Learning Objective 9)
- Describe the sequence of events that caused the local inflammation seen in Mary’s foot.
- What is the role of histamine and kinins in the inflammatory process?
- Which of the five cardinal signs of inflammation does Mary exhibit?
- Because Mary’s injury occurred 5 days ago, the nurse should assess for what systemic effects?
Chapter 7, Overview of Transcultural Nursing
The nurse manager of an ambulatory care clinic has noted an increased number of visits by patients from different countries and cultures, including patients from Mexico and other Latin American countries. Concerned about meeting the needs of this culturally diverse population, the nurse manager convenes a staff meeting to discuss this change in patient demographics, and to query the staff about any learning needs they have related to the care of these patients. (Learning Objective 3)
- What strategy to avoid stereotyping clients from other cultures should the nurse include in this meeting?
- Identify culturally sensitive issues to be discussed in the staff meeting.
- One technician on the staff complains that some patients never make eye contact, and this makes it difficult for him to complete his work. How should the nurse respond?
QUESTION 8: Chapter 8, Overview of Genetics and Genomics in Nursing
Mr. Wayne is a 38-year-old man with a significant family history of elevated cholesterol levels. His father died at age 42 from a massive heart attack secondary to elevated cholesterol and triglycerides, and two of his older siblings are currently taking medications to lower their cholesterol levels. Mr. Wayne makes an appointment to discuss his risk for hypercholesterolemia. The nurse recognizes that Mr. Wayne is at risk for familial hypercholesterolemia because this is an autosomal dominant inherited condition. (Learning Objective 2)
- Describe the pattern of autosomal dominant inheritance.
- Mr. Wayne asks what chance his children have of developing familial hypercholesterolemia. How should the nurse respond?
- Explain the phenomenon of penetrance observed in autosomal dominant inheritance.
QUESTION 9: Chapter 9, Chronic Illness and Disability
Mr. Edwards is 20-year-old male patient who is admitted for treatment of recurring pyelonephritis (kidney infection) and surgical treatment of a urinary stricture, which has decreased the urinary stream. Mr. Edwards has paraplegia; he is paralyzed from the waist down secondary to an automobile accident when he was 16. He came by ambulance to the hospital, leaving his wheelchair and wheelchair pressure-relieving cushion at home. According to the nursing history, the patient is a nonsmoker and he does not drink alcohol or take any illegal drugs. (Learning Objective 5)
- What nursing considerations should be made for Mr. Edwards related to his disability?
- What health promotion and prevention education does Mr. Edwards need?
QUESTION 10: Chapter 10, Principles and Practices of Rehabilitation
You are assigned to care for David Ramsey, a 22-year-old male patient who sustained a back injury secondary to being thrown from a motorcycle. He did not damage the spinal cord, but the computed tomography revealed a compression fracture at L-2 (lumbar area). David complains of severe lower back pain with numbness and tingling in the lower extremities. You identify the following nursing diagnosis: Impaired Physical Mobility.
(Learning Objective 4)
- What assessments are indicated based on this nursing diagnosis?
- List other major nursing diagnoses based on David’s clinical presentation.
Chapter 11, Health Care of the Older Adult
The nurse working at the senior center notices Mrs. Jones, a 78-year-old, crying. The nurse approaches Mrs. Jones and asks if she needs help. Mrs. Jones states “I am so embarrassed. I had another accident and my pants are all wet. It’s like I’m a baby. I never should have come to the senior center.” (Learning Objectives 3 and 4)
- What factors may be contributing to the urinary incontinence?
- How should the nurse respond to Mrs. Jones?
Chapter 12, Pain Management
Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82. (Learning Objective 6)
What are benefits of epidural versus systemic administration of opioids?
- The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. What is the rationale for these frequent assessments?
- The nurse monitors Mr. Rogers for what other complications of epidural analgesia?
- Mr. Rogers complains of a severe headache. What should the nurse do?
- Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation?
Chapter 13, Fluid and Electrolytes: Balance and Disturbance
Mrs. Dean is 75-year-old woman admitted to the hospital for a small bowel obstruction. Her medical history includes hypertension. Mrs. Dean is NPO. She has a nasogastric (NG) tube to low continuous suction. She has an IV of 0.9% NS at 83 mL/hr. Current medications include furosemide 20 mg daily and hydromorphone 0.2 mg every 4 hours, as needed for pain. The morning electrolytes reveal serum potassium of 3.2 mEq/L. (Learning Objective 4)
- What are possible causes of a low potassium level?
- What action should the nurse take in relation to the serum potassium level?
- What clinical manifestations might the nurse assess in Mrs. Dean?
Chapter 14, Shock and Multiple Organ Dysfunction Syndrome
Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)
- What predisposed the patient to develop septic shock?
- What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?
- The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?
- Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?
Chapter 15, Oncology: Nursing Management in Cancer Care
The oncology clinical nurse specialist (CNS) is asked to develop a staff development program for registered nurses who will be administering chemotherapeutic agents. Because the nurses will be administering a variety of chemotherapeutic drugs to oncology patients, the CNS plans on presenting an overview of agents, classifications, and special precautions related to the safe handling and administration of these drugs. (Learning Objectives 6 and 8)
- What does the CNS describe as the goals of chemotherapy?
- How should the CNS respond to the following question: “Why do patients require rounds of chemotherapeutic drugs, including different drugs and varying intervals?”
- In teaching about the administration of chemotherapeutic agents, what signs of extravasation should the nurse include?
- What clinical manifestations of myelosuppression, secondary to chemotherapy administration, should the CNS include in this program?
Chapter 16, End-of-Life Care
Joe Clark, 79 years of age, is a male patient who is receiving hospice care for his terminal illnesses that include lung cancer and chronic obstructive pulmonary disease (COPD). He developed bilateral pleural effusion (fluid that accumulates in the pleural space of each lung), which has compromised his lung expansion. He states that he is short of breath and feels anxious that the next breath will be his last. The patient is admitted to the hospital for a thoracentesis (an invasive procedure used to drain the fluid from the pleural space so the lung can expand). The thoracentesis is being used as a palliative measure to relieve the discomfort he is experiencing. Low dose morphine is ordered to provide relief from dyspnea or discomfort. The patient is prescribed Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent (fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen ordered per nasal cannula as needed for comfort. (Learning Objective 9)
a. What nursing measures should the nurse use to manage the patient’s dyspnea?
- The patient complains that he has no appetite and struggles to eat and breathe. What nursing measures should the nurse implement to manage this physiologic response to the terminal illnesses?
Chapter 17, Preoperative Nursing Management
The nurse in a gynecology clinic is completing preoperative teaching for a patient scheduled for an abdominal hysterectomy next week. The patient states that she is currently taking 325 mg of aspirin daily for chronic joint pain, along with a multivitamin. The patient has type 2 diabetes; she closely monitors her blood glucose levels. Currently, she is taking an oral hypoglycemic agent. The nurse advises her to ask the anesthesiologist whether she should take this medication the morning of surgery. (Learning Objectives 2 and 4)
- The nurse instructs the patient to stop taking the aspirin. What is the rationale for this action?
- Why is it important to assess the patient for use of herbal products prior to surgery?
c. The patient asks how surgery could affect her blood glucose; how should the nurse respond?
QUESTION 18: Chapter 18, Intraoperative Nursing Management
Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40 years. (Learning Objectives 2, 6, and 9)
- What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age?
- Explain the role of the nurse in providing patient safety measures during the intraoperative period.
QUESTION 19: Chapter 19, Postoperative Nursing Management
1. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O2 at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. (Learning Objectives 4 and 7)
- Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed.
- What gerontological postoperative considerations should the nurse make?
2. Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. (Learning Objective 5)
- Explain the wound healing process according to the phase of Mr. Smith’s wound?
- The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain how to perform this dressing change
REFERENCE TEXTBOOK: CHAPTER 1-19
Brunner & Suddarths Textbook of Medical Surgical Nursing Volume 1… 13TH Edition by Janice Hinkle and Kerry Cheever.