Case study on the incidence of blurred vision, numbness

Case Study – Mrs Anh Thuy

Mrs Anh Thuy is a 43 year old lady admitted following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. A neighbour found her on the ground near her washing line unable to move or speak.

Mrs Thuy was admitted to your ward via Emergency. She has been diagnosed as having a ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.

Mrs Thuy (URN: 30081965) was born to Vietnamese parents in Australia . The family are Buddist and speak both Vietnameses and English. She lives with her husband and 2 children Grace 4 years and Ty 13 years of age.Her parents came to live with her six years ago. Unfortunately her mother passed away from cancer three years ago and since then Anh has struggled to look after the household. He father is frail due to heart failure and arthritis. Mrs Thuy’s sadness and depression has meant that Mr Thuy has had a large workload. Some days Mrs Thuy is unable to get out of bed so Mr Thuy is caring for his family as well as working at night time to make ends meet.

Admission Information

Anh has a medical history of hypertension, type 2 diabetes mellitus and asthma. She is Lactose intolerant and has a mild degree of of hearing loss.She wears a hearing aid in her left ear. She usually wears bi-focal glasses but they were broken in the fall. Mr Thuy has taken them for repair. She has a small upper partial plate.
Other than the birth of her children, this is Anh’s first admission to hospital. Mrs Thuy was taking the following medications prior to admission: Norvasc, Diabex, Ventolin inhaler. She does not have her tablets or inhaler with her today. She is compliant and has had a good understanding of her medications.

Mrs Thuy’s observations were taken on admission:

• BP 170/100
• PR 90 regular
• RR 24
• To 36.4
• SpO2 98% on room air
• BGL 7.4 mmol
• Weight 71 kg
• Height 152 cm • GCS (Glasgow coma scale) = 14
▪ Eyes open to speech
▪ Oriented to time place and person (speech slurred, but able to be understood)
▪ Right hemiparesis but able to move left limbs on command
• PEARL (Pupils equal and reacting to light)

Mrs Thuy appears to have pain on movement.You notice that she grimaced and moaned when she was transferred to her bed particularly when her right hip and shoulder were repositioned.
Mrs Thuy has a large haematoma on her right R) hip.
She also has a 5cm skin tear just below her right R) elbow.
There is marked swelling in both her right arm and right leg following the fall.
Mrs Thuy reports that she only has pain when she moves and only on the R) side.
Mrs Thuy has an IDC (indwelling catheter) insitu.
She has intravenous therapy in progress with the cannula positioned in her left L) forearm.

Due to the right sided hemiparesis, the doctor has requested Mrs Thuy remains resting in bed (RIB). Mrs Thuy will initially require full assistance with her hygiene needs. She is to be assessed by the physiotherapist. The goal would be to improve level of function and mobility to enable her to return to her home safely.

Mrs Thuy is experiencing problems with her speech (dysphasia). She is able to be understood, but her speech is slurred. She reports difficulty swallowing (dysphagia) and has an obvious right sided facial droop. The medical officer has requested a review by a speech pathologist and has asked that Mrs Thuy remains nil by mouth (NBM) until review. Following the assessment the texture of food and fluid may be modified to ensure Mrs Thuy is able to swallow safely. She will be reassessed during rehabilitation and further modifications made according to her progress.

Mr Thuy is Mrs Thuy’s Power of Attorney for all health matters. Mrs Thuy does not have an Advanced Health Directive in place.

Discharge Information

Mrs Thuy will remain in acute care for two 2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.

Part 1

Complete the Nursing Admission Assessment, Waterlow Assessment and Falls Risk Assessment Tools in relation to the information provided in the above scenario. Scan these completed documents and include them with your assignment submission.

Part 2

Answer the following short answer questions in relation to the scenario and assessment documents.

1. Prior to Mrs Thuy’s admission to the Medical Unit it is important to prepare for her arrival. Describe what preparation is required. Your answer should include preparation of the environment, equipment and documentation.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2. Mrs Thuy has the right to privacy and confidentiality during her hospital stay. Outline four (4) strategies the nursing team could use to ensure her privacy and confidentiality is maintained.

1……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 2……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3.……………………………………………………………………………………………………………………………………………………………………………………………………………………………… 4.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. When should discharge planning commence? Please explain your answer. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Consider Mrs Thuy’s discharge home. What might she require assistance with when she returns
home? Complete the following table by identifying three (3) issues she may experience and the community support services that could be arranged to support her in her transition home.

Requires assistance with…
Support /Resource service
1.
2.
3.

5. Mrs Thuy has had a cerebro-vascular accident (CVA). Using your understanding of anatomy & physiology, answer the following questions in relation to this condition. Remember to reference your answer.

a. Breifly describe what a CVA is?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b. What are the signs and symptoms of a CVA?
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6. Refer back to Mrs Thuy’s vital signs and clinical data on admission.
Answer the following questions in relation to this assessment data.

Blood pressure 170/100

1. What is the normal range for adult blood pressure? …………………………………………………
2. Is Mrs Thuy’s blood pressure reading within normal range?……………………………………………….
3. What would you do as a result of this reading?
…………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………..

Pulse rate 90 regular

1. What is the normal range for adult pulse rate?…………………………………………………………………
2. Is Mrs Thuy’s pulse rate within normal range?………………………………………………………………….
3. What would you do as a result of this data?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Respiratory rate 24

1. What is the normal range for adult respiratory rate?…………………………………………………………..
2. Is Mrs Thuy’s respiratory rate within normal range?…………………………………………………………..
3. What would you do as a result of this data?
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………..

Temperature 36.4

1. What is the normal range for body temperature?……………………………………………………………….
2. Is Mrs Thuy’s temperature within normal range?……………………………………………………………….
3. What would you do as a result of this data?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Oxygen saturation (SpO2) 98% on room air

1. What is the normal range for oxygen saturation?………………………………………………………………
2. Is Mrs Thuy’s SpO2 within normal range?…………………………………………………………………………
3. What would you do as a result of this data?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

BGL 7.4 mmol

1. What is the normal range for blood glucose levels?…………………………………………………………..
2. Is Mrs Thuy’s BGL within normal range?………………………………………………………………………….
3. What would you do as a result of this data? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

GCS = 14, PEARL

1. Is this normal?……………………………………………………………………………………………………………..
2. What would you do as a result of this data?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

BMI = __________ (please enter your calculation from the nursing assessment form)

1. Is this normal?………………………………………………………………………………………………………………

7. Mrs Thuy is having difficulties communicating, outline three (3) strategies that could be used to assist Mrs Thuy with her communication.

8. Mrs Thuy identifies strongly with her Vietnamese culture, outline two (2) strategies you could implement to support her cultural, spiritual and religious needs. Where would you document?
1……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 2……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9. Mr Thuy is worried about his wife and the impact hospitalisation has had on the family. He is very distressed about the current situation. Identify three (3) potential causes of Mr Thuy’s distress and strategies that could be implemented to support Mr Thuy during this stressful time.

Stressor Strategies to support Mr Thuy
1.

10. Part of the nurses’ role is to assess how Mrs Thuy is coping with the changes in her functional
status following her CVA. Describe three (3) behaviours that Mrs Thuy might display if she was not adapting to the changes experienced.

11. The RN has identified a number of nursing diagnosis for Mrs Thuy. Develop a care plan based on the following nursing diagnosis.
a)
Care Plan
Nursing diagnosis (NANDA)

Risk of impaired skin integrity related to immobility resulting from CVA
Assessment (client has/has not, data)

Plan (goal, expected outcome, what do you hope to achieve)

Implementation (nursing interventions) Rationale (reason why)
1.

2. 1.

2.
Evaluation (did the plan of care work, how will you know)

b)
Care Plan
Nursing diagnosis (NANDA)

Risk of falls related to immobility resulting from CVA
Assessment (client has/has not, data)

Plan (goal, expected outcome, what do you hope to achieve)

Implementation (nursing interventions) Rationale (reason why)
1.

2. 1.

2.
Evaluation (did the plan of care work, how will you know)

c)
Care Plan
Nursing diagnosis (NANDA)

Risk for aspiration related to impaired swallowing resulting from CVA
Assessment (client has/has not, data)

Plan (goal, expected outcome, what do you hope to achieve)

Implementation (nursing interventions) Rationale (reason why)
1.

2. 1.

2.
Evaluation (did the plan of care work, how will you know)

d)
Care Plan
Nursing diagnosis (NANDA)

Risk for impaired social function related to depressed mood and impact of major health event (CVA)
Assessment (client has/has not, data)

Plan (goal, expected outcome, what do you hope to achieve)

Implementation (nursing interventions) Rationale (reason why)
1.

2. 1.

2.
Evaluation (did the plan of care work, how will you know)

12. The admission process is now complete, you give Mrs Thuy a sponge in bed. Describe three (3) observations or assessments you would make while performing this procedure.
1……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 2……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3.………………………………………………………………………………………………………………………………………………………………………………………………………………………………

13. Mrs Thuy has had her IDC removed. She is complaining of burning and stinging when she passes urine, a urinalysis has been performed with the following results:

Colour Odor Glu Bil Ket SG Blo pH Pro Uro Nit Leu
Cloudy Offensive Neg Neg Neg 1.025 Neg 8.0 Neg Normal +ve ++

a) Based on this information, what is your assessment of the situation? Why? In your answer identify which of these results are outside normal range.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b) Describe two (2) nursing interventions you could implement (do not include administering
antibiotics in your answer) to improve this situation.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

14. Mrs Thuy presses her call bell and tells you she feels “dizzy and has the shakes”, you observe that she is cold and clammy and notice that she has not eaten any of her breakfast as she was unable to reach her breakfast tray.You recognise she has deteriorated .

a) Using the knowledge gained in the assessment process and your knowledge of anatomy and physiology, what would you suspect was the problem?
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b) Outline the steps you would take to manage this situation as a Student Enrolled Nurse. Remember to reference your answer
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15. Because of Mrs Thuy’s medical conditions it is important that her dietary intake is monitiored.
Describe what meal management requirements need to be considered for this lady.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

16. Based on Mrs Thuy’s age, identify which psychosocial stage of development she would be according to Erikson’s theory. Discuss this stage of development in relation to Mrs Thuy’s current situation.
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

17. People are prone to various diseases/conditions depending on their developmental stages. In the table below list a potential health issue that Mrs Thuy may experience related to each consideration.

Consideration Potential Health Issue
Age
Gender
Genetics
Environment
Impact on fertility
Sensory losses/deterioration
Perception of ‘Wellness’

18. Health Assessments are complex procedures for health care workers to preform.
Discuss what you consider are the main principles of health assessment when you are caring for a patient such as Mrs Thuy.
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
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Mr Thuy has taken time off work to care for the family, he asks for your advice regarding a number of issues he’s having at home .He feels he needs emotional and physical support with all the recent changes in his family situation.

19. Mr Thuy is new to the role of caring for young children as this has always been managed by his wife. He tells you “I’m just not sure what to do to entertain my daughter, all she wants to do is play”.
How would you reassure Mr Thuy and describe the role of play in child development.
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

20. Mr Thuy’s son has been exhibiting challenging behaviours since his mother’s admission. To assist Mr Thuy’s understanding of his son’s behaviour outline the major developmental stages and common health issues of adolescence.

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

21. Complete the following table in relation to growth and development to help Mr Thuy understand the stages of childhood.

Stage Physical growth Psychosocial development Cognitive
development Motor development
0–12 months

Toddler

Pre-school

School aged

22. Mr Thuy is providing ADL support to his 82 year old father-in-law who is a frail gentleman with heart failure and osteoarthritis. He also care for his two children.

After observing the nursing team care for his wife and realising he will be also caring for her, he begins to identify the duty of care he has across the 3 generations.

Complete the following table to look at health needs across the lifespan comparing the care needs of Mr Thuy’s 4 year old daughter with his 82 year old father-in-law as well as Mrs Thuy’s. (Some examples have been given to assist you.)

Activities of daily living 4 year old Mrs Thuy
(on discharge) 82 year old
Personal hygiene

• Assistance with hygiene needs as required.

ADD MORE CARES ▪ Shower chair
▪ Hand rails in shower

ADD MORE CARES

ADD CARES
Eating & drinking

• Encourage oral fluids.

ADD MORE ▪ Diabetic diet
▪ Modified diet (thickened fluids, soft diet)
▪ Assistive devices (plate guard, modified cutlery)

ADD MORE • Assistance with food preparation and cutting up food/opening food packets.
ADD MORE
Mobility

ADD CARES ▪ Mobility aids
▪ Non-slip shoes
▪ Handrails
▪ Good lighting
▪ Encourage exercise

ADD CARES
Safety
• Correct food texture

ADD MORE ▪ Use of assistive devices including mobility aids, plate guards, non-slip mats/shoes, handrails
▪ Emergency numbers
▪ Education about signs of hypoglycaemia and CVA
▪ Personal alarm

ADD MORE • Remove trip hazards /clear clutter
• Well fitting dentures
• Eye glasses – clean and in use
• Hearing aid in use
ADD MORE

23. Mr Thuy has taken time off work to care for his family.
What advice would you, as an EN, give him on maintaining his own health? (include his approach to his health, and physiology and phychosocial aspects)
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

24. It is the 18th of February 2018, Mrs Thuy has completed her rehabilitation and is ready to return home. Her discharge planning was commenced on admission. Outline six (6) pieces of information you would ensure Mrs Thuy and her family have prior to discharge.
1……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 2……………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
3.………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………..
4……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 5……………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
6.……………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

25. Prior to discharge Mrs Thuy requires diabetes education. Describe four (4) topics you would discuss during this education session (other than medication).

1……………………………………………………………………………………………………………………………………………………………………………………………………………………………………. 2……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3.………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4…………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

26. Complete the discharge checklist on the Nursing Assessment Form, include appropriate Community Service providers (you have identified these in question 4). All of the appropriate documents have been provided to Mrs Thuy. Remember Mrs Thuy did not come to hospital with her own medications or x-rays and her IV cannula was removed on Day 2 of her hospital stay.