Clinical Reasoing Cycle Textbook Answers Tracy-Levett Jones

Answers to Clinical Reasoning questions
Chapter 2
Scenario 2.2
Changing the scene
1. Right client education, right to refuse, right assessment, right evaluation (effect), right
equipment, right person/s administering. Additionally, the right reason (i.e. indication) and any
contraindications should also be checked.
2. Patient ID (name, address, DOB, medical record number); time, date, month and year of
prescription; generic drug name (spelt accurately and written clearly); dose/strength/amount of
drug; route of administration; directions for administration (including frequency); prescribers
name and signature; approved abbreviations only.
3. Check the label when getting the drug from storage; check the drug label with the drug order;
recheck the drug order and drug again before administration.
4. Yes, it is important to monitor patients responses to medications prior to and following
administration. This is particularly important when administering digoxin, as pulse rate, rhythm
and regularity can indicate toxicity. Vitals signs can be used as keys to decision making
related to medication administration.
2. Collect cues/ information
(b) Gather new information
1. To determine whether Giuseppe had postural hypotension, as this may be a reason for his
dizziness; postural hypotension can be caused by cardiac arrhythmias and dehydration (as
well as a number of other factors).
2. Manual blood pressure measurements are more reliable and accurate than electronic blood
pressure devices, which need to be calibrated regularly for accuracy. Additionally, electronic
blood pressure devices cannot tell you the feel of the pulse (e.g. weak and thready or full and
bounding) and rarely identify an irregular pulse rate.
3. Giuseppes blood pressure recording indicated postural hypotension, that is, a 20 mm Hg (or
more) drop of systolic BP, a 10 mm Hg (or more) drop of diastolic BP (or both) at 13 minutes
after standing up from supine position.
4. The apical pulse should be checked when an irregular pulse is found.
5. b, c, h
6. and 7. Examples of cues and questions: When did Giuseppe start feeling dizzy? Had he felt
dizzy before? When? Did he know what caused it? How much is he able to drink now? Does
he feel thirsty? Is his mouth dry? Is his tongue furrowed? How much has he been voiding?
Does he have any other symptoms? Can he describe what he means by his eyes are shot?
Has he had any falls in the past from dizziness (has a fall risk assessment been done)? Who
will he be staying with when he is discharged? Has he had any blood taken for pathology? If
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so, when? Is there anything he is worried about, or anything else he would like to report about
how he is feeling?
(c) Recall knowledge (Quick quiz)
1. those who prescribe (doctors), dispense (pharmacists), administer (nurses), and consume (i.e.
patients/clients)
2. b; 3. c; 4. b; 5. c; 6. c; 7. b; 8. b; 9. b; 10. c 11. Anorexia, nausea (vomiting and diarrhoea have
settled), blurred vision, dizziness, irregular pulse but needs to be confirmed by ECG
3. Process information
(a) Interpret a, d
(b) Discriminate a, c, e, f, g, h, j, k
(c) Relate T, F, T, F, F, T, F, T
(d) Infer a, d
(e) Predict c, d
4. Identifying the problem/ issue
That Giuseppe may be having a reaction to one of his medications (he had some of the
symptoms of digitalis toxicity, in particular an irregular pulse; side effects of enalapril include
hypotension and dizziness when standing, and this medication and frusemide should not be given
to dehydrated or hypovolaemic patients); that he may still be dehydrated; that his postural
hypotension puts him at risk of falls; that he was due to be discharged shortly.
5. Take action
Identify
Self: name, position,

location.
Patient: name, age,
gender.
Can I talk to you about Giuseppe Esposito in room 14B,

please.
Situation
Briefly explain the reason

for the call.
Background
Patients diagnosis,
relevant history,
investigations, what has
been done so far.
I am concerned about his condition. He is feeling dizzy. I

checked his BP and it was 120/70 sitting and 110/65
standing. I think this is postural hypotension. His pulse
is 64. Its weak, thready and irregular. I checked his
apical pulse to be sure.
As you know, he is meant to be discharged this morning
as his gastro is much better.
Assessment
Summarise the patients

current condition or
situation.
Explain your assessment
of the problem.
Request/
recommendation
State your request.
He is not drinking a lot and his mouth is dry. His fluid

balance chart was ceased yesterday, so it is hard to
determine his fluid balance. His temp and resps are
normal.
I am not sure what is wrong with him, but I wonder
whether it could be one of his medications, perhaps the
digoxin or enalapril.
Can you please come with me to see him?
Copyright 2013 Pearson Australia (a division of Pearson Australia Group Pty Ltd)
9781442556621/Levett-Jones/Clinical Reasoning: Learning to Think like a Nurse/1e
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Chapter 3
Scenario 3.1
Day of admission
1. Mr Barrett is considered to be at high risk because of his age, co-morbidities and type of
surgery.
2. Other information needed is his management of COPD, and that Mr Barrett uses a salbutamol
puffer occasionally.
He gave up smoking four years ago but started again last year when his son died. He smokes 25
cigarettes a day.
Baseline oxygen saturation level? 96 per cent on room air.
Results of his routine pre-operative urinalysis? haematuria ++; specific gravity 1016.
Weight: 82 kg
Height: 1.67 m
Management of diabetes: Type 2 diabetes (diet controlled) diagnosed 24 years ago. Mr Barrett
does not pay particular attention to his diet, nor does he check his blood glucose regularly.
Currently his BGL is 7.8 mmoL.
Pre-operative pathology results: haemoglobin (Hb) 9.5 g/L; sodium (Na) 140.0 mmol/L; potassium
(K) 3.9 mmol/L; serum albumen 26 g/L.
3. Assessments required: falls risk, pressure area and nutrition assessment.
1. Consider the patient situation (Quick quiz)
1. b; 2. c; 3. b; 4. a; 5. c; 6. b; 7. a; 8. a
(b) Gather new information: b, c, e, g, h
(c) Recall knowledge (Quick quiz): 1. d; 2. b; 3. d; 4. d; 5. c; 6. a; 7. c; 8. d
(a) Interpret: 1. a, c; 2. d; 3. a (As Mr Barrett is an older person, his bodys compensatory
mechanisms are less effective at excreting excess fluids. For this reason, 3540 mL per hour is
considered adequate, but his hourly urine output should still be monitored very carefully; 4. a
(b) Discriminate a, d, g, j
(c) Relate F, F, T, F, T, F, T
(d) Infer d, g
(e) Predict a, c, e, f
3
4. Identify the problem/ issue 1. e

2. Factors that may have contributed to Mr Barretts deterioration:
Mr Barrett was given two picopreps on the night before his surgery. Picopreps cause
osmotic diarrhoea and many litres of fluid can be lost from the circulating volume through
the wall of the intestine as the bowel is evacuated. The major electrolytes sodium and
potassium are also lost in this way.
Following routine protocol, Mr Barrett was nil orally from midnight on the day of surgery to
prevent the risk of aspiration during surgery. Being nil orally for this extended period of
time contributed to his hypovolaemia.
Mr Barrett was unable to tolerate the clear fluid diet he had been ordered to offset the
fluid losses from the picoprep.
The first stage of wound healing is the inflammatory stage. During this stage there is
increased capillary permeability to allow fluid and molecules that assist in haemostasis,
prevent infection and promote healing of the wound to leave the bloodstream and
surround the site of trauma. A large surgical area such as Mr Barretts results in
significant third-space fluid shift which further depletes the intravascular volume.
Blood loss during surgery and through drainage from the bellovacs further depleted the
intravascular volume.
Mr Barretts hypotension caused decreased glomerula filtration rate and resulted in
decreased urine output.
A hypovolaemic stage is not unusual after major surgery. For most people this lasts 24
72 hours or until IV fluid replacement and the bodys own compensatory mechanisms
have been effective in increasing circulating volume. During this stage, it is essential to
monitor your patients condition carefully as any deterioration could be critical.
5. Establish goals c
6. Take action 1. a, d, f, g, I, j, k
Explanation for incorrect responses:
(b) Monitor Mr Barretts level of consciousness. [The cues provide no evidence of cognitive
impairment (at this stage).]
(c) Monitor Mr Barretts pain score. [Important, but not related to current signs and symptoms.]
(e) Monitor the condition of Mr Barretts drain, stoma and wound. [Important; however not an
immediate action.]
(h) Check that the urinary catheter is not kinked or blocked. [Catheter blockage is not likely as
there is some urine output.]
2.
Nursing action
Document all nursing observations and
actions accurately and
contemporaneously.
Daily weight (same scales, same
Rationale
To ensure clear, accurate and
timely communication between all
health professionals caring for Mr
Barrett.
This is the best indication of fluid status.
4
clothes).
Check cognitive status regularly.
Check UEC (urea, electrolytes and
creatinine) as ordered.
Regular position change.
Maintain patent IV access and monitor IV
site regularly.
Encourage oral fluids as ordered/
tolerated by patient.
Maintain oxygen therapy via nasal prongs
or Hudson mask and hourly oxygen sats.
Monitor haemodynamic status closely.
Reassure patient.
Provide regular oral care.
Check specific gravity of urine.
Anxiety and restlessness may indicate

worsening fluid status.
Sodium, potassium, urea and creatinine are
important indicators of fluid status and renal
function.
To prevent pressure areas due to dry skin.
To ensure fluids are administered as ordered.
To increase fluid intake.
To ensure adequate oxygen delivery.
To identify improvement or deterioration in Mr
Barretts condition.
To maintain psychosocial wellbeing.
To manage dry mouth and tongue and to
promote patient comfort.
To monitor changes in fluid status.
7. Evaluate
1.
2. d
Cognitive status unchanged

Level of thirst improving
Pulse improving
Urine output improving
Oral mucosa unchanged
Oral intake unchanged
BP improving
Colour unchanged
Skin condition unchanged
Scenario 3.2
(b) Gather new information 1. a, d; 2. c, e, g, I, l, m, n
(c) Recall knowledge (Quick quiz) 1. b; 2. T, F, T, F; 3. b, d, e, g, h, j, k, l, m; 4. d; 5. a; 6. c
(a) Interpret 1. positive balance; 2. b; 3. c; 4. b, c, e, f, h; 5. a, c, d; 6. b, c, e, f, h, j, k; 7. c
(b) Discriminate, (c) Relate, and (d) Infer b, d, e, i
(e) Predict a, c, e, f
5
4. Identifying the problem/ issue 1. b, e, f; 2. d

3 factors that contributed to Mr Barretts hypervolaemia:
1. His age, weight, history of hypertension, smoking and diabetes may have caused
impaired renal function, and thus the IV fluids that he has been having for the last 2436
hours may not have been excreted effectively (indicated by the fact that his urine output
is not excessive).
2. The IV rate should have been reduced once his fluid status had initially improved.
3. Usually after 2448 hours, when the inflammatory stage of wound healing resolves,
plasma typically returns to the circulating blood volume. This can cause a significant
increase in blood volume adding to the likelihood of hypervolaemia.
4. c
5. Establish goals b, e, f, h
6. Take action 1. a, d, f, h, m
2.
I
Hello .. This is .I am .........., an RN working on .... ward.

I am calling about Mr Barrett.
I am concerned about his deteriorating fluid status. His condition is serious. His
oxygen sats are 90%, resps 31 per minute, he is confused, his BP is 150/90, pulse
rate 102, and its irregular, full and bounding. He is confused and is reporting a
headache.
Mr Barrett is a 74-year-old man who is day 3 following a colorectal resection. He has
a history of diabetes type 2. His IV was 125 mL/hour but Ive reduced it to TKVO
pending your orders. Ive increased the oxygen to 6 L per minute and an ECG is
being done now.
His sodium is 128 mmol/L and potassium (K) 3.3 mmol/L. Urine output is low: 1530
mL/hour. He is afebrile.
I need you to see him immediately. Will you come now?
A
R
3. b, d, f
7. Evaluate
1.
2.
3.
4.
5.
6.
7.
8.
Decreased BP
Increased urine output (as a results of the diuretic)
Increased oxygen sats (> 94%)
Decreased pulse and respiratory rate
Normal cognitive status
Headache resolved
Normal ECG
Normal electrolyte levels
6
Chapter 4: Caring for a person experiencing respiratory

distress
Scenario 4.1
Admission to the ED 1. a, e, f
1. Consider the patient situation (Quick quiz)
1.
Diaphoretic
Sweaty
Febrile
High temperature
Tachycardic
Increased heart rate
Tachypnoeic
Increased respiratory rate
Sats
A test of the oxygen-saturated haemoglobin
ABGs
A test of gases and pH in arterial blood
Coarse rales
A series of short low popping sounds, also called crackles
Haemoptysis
Coughing bloody sputum
Cyanosis
Bluish tinge around lips due to lack of oxygen in blood
Consolidation Increased areas of density due to fluid, mucous and oedema on a CXR
2. c; 3. FiO2 0.44 or 44% (approximately 4 x rate + 20); 4. d; 5. b
2. Collect cues / information
(a) Review current information Q. b
(b) Gather new information 1. b, f, g, i, j; 2. a; 3. b; 4. B and d; 5. b; 6. hypoxia,
hypoventilation, ventilation and perfusion mismatch, diffusion abnormalities; 7. b; 8. a; 9. closed;
10. yes or no
(c) Recall knowledge (Quick quiz) 1. a, c, e, h
2.
Build up of fluid in the space between the lung and chest
wall
Pockets of pus that form in the space between the lung
and chest wall
Sputum material coughed up from the lungs
Pockets of pus that form in the lung itself
Secondary bacterial lung infection after a viral infection
Bacteria in the bloodstream or throughout the body
Clinical sign of hypoxia, manifested by a feeling of
breathlessness
Subjective sensation of a patient reporting loss of
endurance
Generalised feeling of being unwell
Pleural effusion
Empyema
Productive cough
Lung abscess
Secondary infection due to
medication
Bacteraemia or septicaemia
Dyspnoea
Fatigue
Malaise
7
(a) Interpret
1. a; 2. 80 and 100; 3. 35 and 45, 7.35 and 7.45; 4. b; 5. b
(b) Discriminate 1. c, f, k, i; 2. a
(c) Relate - 1. T, T, T; 2. c
(d) Infer 1. c, e; 2. a, c, j, k, i; 3. b, d
(e) Predict 1. c, d; 2. c
4. Identify the problem/ issue 1. a; 2. a, b, c; 3. b
5. Establish goals Q. c; immediate resolution of Trents symptoms is the desired goal
6. Take action
1.
Nursing action
Monitor oxygen saturations and ABGs
regularly.
Position in semi- or high Fowlers.
Teach patient deep breathing and
coughing.
Keep patient well hydrated.
Maintain oxygen therapy via nasal prongs
or Hudson mask.
Instigate chest physiotherapy.
Reassure patient and reduce anxiety.
Give patient paracetamol.
Rationale
Changes may indicate worsening hypoxia.
worsening hypoxia.
To reduce oxygen demand.
To aid in removal of secretions.
To help loosen secretions.
To increase partial pressure of oxygen in
alveoli and increase diffusion into capillaries.
To reduce lung consolidation and prevent
chance of atelectasis.
To maintain psychosocial wellbeing.
To reduce and pain and increase comfort.
2. c, d, e; 3. b, c, d, e, j, k, l; 4. b, c, f
5.
Oxygen delivery device
Nasal prongs
Hudson mask
Non-rebreather mask
Flow rate
24 litres per minute
FiO2
0.24-0.36
0.4-0.6
0.6-0.9
7. Evaluate
1. a
8
2.
Changing Hudson mask to a non-rebreather
mask to increase available oxygen to improve
Trents oxygenation.
Position Trent in a high Fowlers to assist lung
expansion.
Monitor Trents vital signs every hour.
Promote adequate rest to support Trents
recovery.
SpO2 increases from 94% to 97%.

Trent is able to expectorate
secretions effectively.
Changes in condition are identified
early and associated actions initiated.
Trent reports adequate sleep and
rest.
3. b, c, d
Scenario 4.2
1. Consider the patient situation 1. c; 2. a, b, e, k; 3. a, c, e, g
(a) Review current information 1. Pulse, respirations, SpO2, wheezing; 2. b
(b) Gather new information Q. d, e, f, h, i, j, k,
(c) Recall knowledge (Quick quiz) 1. c; 2. c; 3. b; 4. b; 5. a
(a) Interpret, (b) Discriminate, and (c) Relate 1. d; 2. a; 3. c; 4. b, c, e, h
(d) Infer
Presence of coarse rales
Worsening symptoms after taking aspirin or
beta-blockers
Worsening signs and symptoms after
exposure to an identified allergic trigger
A previous allergic reaction of any kind
True
False
(e) Predict Q. a, c, e, f
4. Identifying the problem/ issue Q. c, e, f
5. Establish goals 1. a, b, f, i; 2. c
6. Take action
Place in high Fowlers position.
Administer oxygen.
To reduce the work of breathing and increase

lung expansion
To reduce hypoxaemia
9
Administer nebuliser/spacer treatments as

ordered.
Provide humidification as ordered.
Monitor vital signs and laboratory results.
Assist with ADLs as needed.
Provide rest between scheduled activities
and reduce excessive environmental
stimulus.
Assess level of anxiety.
Assess level of understanding of asthma
and management.
To aid in bronchodilation
To help loosen secretions
To detect increasing tachynoea, tachycardia,
and increasing respiratory distress
To converse energy and reduce fatigue
To promote rest
To decrease the chance of panic attacks
To promote self-management in the recovery
and rehabilitation phase
7. Evaluate 1. oxygen saturations > than 95%, respiratory rate >10 and < 20, heart rate 60, <
100, signs of anxiety absent or decreased; 2. a, c, d, f, g
Chapter 5: Caring for a person with a cardiac condition

Scenario 5.1
Admission to the ED (Quick quiz) 1. d; 2. b. 3. There is a window of time (6 hours) for
thrombolytics to be given to maximise the potential for them to reduce myocardial damage from
the ischaemia.
1. Consider the patient situation (Quick quiz) 1. c; 2. a; 3. b, c; 4. b; 5. a
2. Collect cues / information 1. a, c, d, e, g; 2. d; 3. a
(b) Gather new information 1. d; 2. c; 3. a
(c) Recall knowledge (Quick quiz) Q. a, d, e, g, h
(a) Interpret 1. a; 2. c; 3. d, a; b, c; 4. c; 5. c
(b) Discriminate 1. d; 2. a
(c) Relate 1. T, F, T, F; 2. d
(d) Infer Q. b
(e) Predict, and (f) Match
Outcome
Mr Parker may gradually improve
over the next few days and have
no adverse effects
Condition
if his myocardial demand can be
reduced through oxygen supply,
medication and bed rest
Mr Parkers vital signs may
if he experiences no further
10
continue within normal

parameters
Mr Parker may experience signs
of heart failure
Mr Parker may experience more
chest pain as a result of his
anxiety about his farm
arrhythmias
if his heart has not suffered
damage and the pumping ability
of the left ventricle is not
compromised
unless his family can identify a
management strategy to address
his concerns
4. Identify the problem/ issue 1. b; 2. e

5. Establish goals Q. a, b, c, e, g, i
6. Take action:
Short-term nursing goal
For Mr Parker to have no pain within 20
minutes
Nursing action
Assess for pain using a visual analogue scale
(1 to 10). If any pain does occur, include
location, intensity, duration and factors that
affect it in the reported description. Administer
morphine as required.
For Mr Parkers to be euvolaemic
Monitor IV and complete an accurate fluid
balance chart and daily weight. Maintain
average hourly urine output > 30 ml/hour.
For Mr Parker to have no evidence of
Maintain oxygen saturation levels of greater
impaired gas exchange
than 95% and a respiratory rate < 20 on
exertion and < 16 at rest. Administer oxygen
as ordered or by protocol.
For Mr Parker to be normotensive and
Monitor vital signs continuously keeping his
have a pulse rate in acceptable
blood pressure within his normal levels and
parameters
continue his preadmission antihypertensive
therapies. Maintain his pulse rate > 60 bpm
and < 100 bpm. Maintain a restful, supportive
environment, enabling rest periods and
freedom of strain during elimination.
For Mr Parkers ECG to show no signs of Monitor rhythm continuously using rhythm
ishcaemia on his next ECG
strips and obtain a 12-lead ECG during any
symptomatic event. Continue post
thrombolytic regime of aspirin and LMWH.
For Mr Parker to be alert and orientated
Monitor his LOC when doing vital signs.
7. Evaluate
Sign or symptom
e.g. BP
Pulse
Desired observation
Stable with no postural drop
> 60 bpm and < 100 bpm
11
Respirations
Temperature
Oxygen saturations
Level of consciousness
Pain level
Urine output
< 20 on exertion and < 16 at rest.

Normal range
> 95%
Alert and orientated
Nil
> 0.5 to 1.0 mL/kg/hr
Scenario 5.2
1. Consider the patient situation (Quick quiz) 1. b; 2. a; 3. a; 4. b; 5. c; 6. a, c, f
(a) Review current information 1. b, c, h; 2. d
(b) Gather new information Q. f
(c) Recall knowledge (Quick quiz) 1. b; 2. a; 3. d; 4. b; 5. c; 6. b; 7. lungs; 8. peripheries
(a) Interpret, (b) Discriminate, and (c) Relate 1. d; 2. b, c, e, f; 3. b; 4. b; 5. weigh; 6. a, d, e
(d) Infer
Smoking cessation
Maintenance of a low-salt diet
Appropriate activity and rest periods
A decrease in stress, through stressmanagement programs
Compliance with diabetic and healthy heart
diet
True
False
(e) Predict Q. a, c, d
4. Identifying the problem/ issue c, d, f, h
5. Establish goals Q. b, d, f, h, j
6. Take action
Long-term nursing goal
For Mr Parker to maintain his daily fluid
restriction
Nursing action
Continue his daily weigh.
For Mr Parker to participate in education

and adhere to a self-care program
Commence an education program to provide

information on nutrition to manage type 2
diabetes mellitus and a cardiac condition.
Include in Mr Parkers education program
For Mr Parker to be free from anxiety by
12
using stress-reduction techniques

For Mr Parker to understand the rationale
for all his medications
For Mr Parker and his family to obtain
support from the community
how to recognise and manage stress through

relaxation/meditation techniques. Referral to
an appropriate therapist for ongoing support.
Educate him in rationale for his cardiac
medications, including recognition and
management of possible side effects.
Provide Mr Parker and his family with
information on cardiac rehabilitation
programs, local support groups and Heart
Foundation.
7. Evaluate Q. Outcomes should focus on managing stress, maintaining fluids through

adhering to restriction, maintaining daily weighs within his normal weight, managing his diabetes,
maintaining glucose levels between 4 and 8 mmol/L, adhering to medication schedule,
maintaining a healthy heart diet.
Chapter 6: Caring for a person with an acquired brain injury

Scenario 6.1
On admission to the ward Q. b, c, d, h, i
1. Consider the patient situation (Quick quiz) 1. b; 2. d; 3. c; 4. b; 5. d; 6. a; 7. a;
8. c; 9. b; 10. F, T, T, T, F; 11. b; 12. d; 13. Myocardial infarct and ischaemic stroke are due to
blockage of an artery by the build-up of atherosclerosis and resulting clots. tPA is a thrombolytic
agent; it can lyse a clot, break it up, and hence help to restore circulation and reperfuse tissue.
Nurses should be aware of the important side effects of tPA, mainly bleeding and severe
hypotension if an allergic reaction occurs. Monitor for signs of bleeding and for hypotension.
(a) Review current information 1. c; 2. c; 3. d; 4. 3; 5. Pulse pressure has increased, pupil
reaction has become sluggish on the left side and pupil size on left has increased; other vital
signs not noticeably different.
(b) Gather new information Q. a, e, f, k
(c) Recall knowledge (Quick quiz) 1. (a) increased arterial pressure; (b) increased hydrogen
ions from increased carbon dioxide; (c) a fall in PaO2; 2. Cerebral, vertebral; 3. d;
4. c (raised/widening pulse pressure, f (decreased pulse) and h (abnormal breathing pattern); 5.
a; 6. brain, CSF, blood; 7. Monroe-Kellie; 8. c
(a) Interpret 1. a, b, c, e, f; 2. Higher blood pressure may increase blood flow through stenosed
or partially occluded blood vessels and help maintain perfusion to the brain tissue.
3. c
13
(b) Discriminate 1. a, b, d, h, I; 2. d, e, m; 3. Assess patient for any underlying conditions

known to cause confusion, full history where appropriate, blood tests taken and vital signs; cluster
information to rule out possible causes.
(c) Relate Q. d
(d) Infer 1. b, c, e, g; 2. b, c, f; 3. c
(e) Predict Q. If Mr Apulus increasing confusion is not considered and actions taken to
determine the cause, he may die. His increasing confusion may be an early sign of increasing
intracranial pressure. If left untreated, his intracranial pressure may continue to rise, putting
pressure on his brainstem which may herniate. This can lead to a cardio-respiratory arrest.
4. Identify the problem/ issue Q. d
5. Establish goals Q. a, b, d, g, i
6. Take action
Nursing action
Notify Mr Apulus doctor or rapid response
team of his condition.
Rationale
The medical officer should be
notified immediately of a change of
2 points in the GCS; the Rapid
Response Team (if available) can
also be called.
Reassure Mr Apulu.
Emotional distress can raise ICP.
Check that the IV cannula is not kinked or

blocked.
Administer IV mannitol as ordered.
To ensure patency and delivery of IV fluids.
Raise the head of Mr Apulus bed to 30

and keep his head in midline.
Facilitates venous drainage, and prevents

obstruction of the jugular veins which could
raise ICP.
ICP can be elevated by noxious stimuli
including noise and emotional upset.
To ensure patient is not retaining more fluid
and/or dehydrating after the osmotic diureticaim for normovolaemia.
Care procedures and frequent patient
interruptions can raise ICP.
Vital signs and changes in behaviour can
indicate a further rise in ICP and further
deterioration.
Maintain a quiet environment.

Strictly monitor Mr Apulus input and
maintain hourly urine measures.
Cluster nursing care activities.
Monitor Mr Apulus level of consciousness.
This osmotic diuretic draws fluid out of the

brain cells by increasing the osmolality of the
blood.
14
Monitor Mr Apulus pain score.
Severe headache can indicate worsening

condition and can also cause anxiety, raising
ICP.
Monitor Mr Apulus vital signs, oxygen

saturation level and behaviours.
Establish baseline observations; sudden

changes in neurological condition can indicate
deterioration.
Excess carbon dioxide and hypoxaemia can
cause vasodilation and further raise ICP.
Patients experiencing raised ICP can suffer
from seizures and need to be kept safe from
injuring themselves if they have a seizure.
Constipation and bladder distension can raise
ICP and impair venous drainage.
Monitor Mr Apulus ABGs and electrolytes.

Instigate seizure precautions.
Monitor bladder distention and bowel
constipation.
7. Evaluate
unchanged
improving
unchanged
unchanged
improving
improving
unchanged
unchanged
unchanged
Cognitive status
GCS
Pulse
Urine output
Pupil size
Pupil reaction
BP
Speech
Oxygen saturation level
Scenario 6.2
(a) Review current information 1.
Term
1. Hemiplegia
2. Aphasia/dysphasia
3.
4.
5.
6.
7.
8.
Dysarthria
Hemianopia
Unilateral neglect
Agnosia
Diplopia
Dysphagia
Definition
e. Paralysis of the left or right half of the body
g. difficulty speaking/incomprehensible speech or inability to
understand speech
d. difficulty speaking/pronouncing words
h. loss of half of the visual field of one or both eyes
c. unaware of and inattentive to one side of the body
a. the inability to recognise previously familiar objects
b. unilateral or bilateral double vision
f. difficulty swallowing
2. b, c, d, h, k, I, m, n, o, p
3. The nurse seems to have assumed that if she talks louder Mr Apulu will be able to understand
her better, even though he is not deaf or does not have hearing difficulties. This tends to be a
15
common response when someone does not understand what is said. It is an example of
ascertainment bias.
(b) Gather new information Q. c, e, f, h, j, l, n, o
(c) Recall knowledge (Quick quiz) 1. c; 2. c; 3. a; 4. c; 5. b; 6. F, T, T, F, T, F; 7. b;
8. Speak in single sentences, use gestures or communication aids, allow him time to respond,
remain calm.
(a) Interpret 1. T; 2. F; 3. F; 4. T; 5. T
(b) Discriminate, (c) Relate, and (d) Infer 1. b; 2. c; 3. b; 4. b, e
(e) Predict
Complication
Shoulder dislocation
Bleeding
Aspiration pneumonia
Seizures
Pneumothorax
DVT (deep vein thrombosis)
Hepatic coma
Pulmonary oedema
Further stroke
At risk
x
X
X
X
X
X
Not at risk
X
X
X
4. Identify the problem / issue Q. a, b, c, e, f, h, I, j

5. Establish goals Q. b, d, g, I, k, m, n, o
6. Take action
1.
Health professional
Social worker
Psychologist
Dietician
Speech pathologist
Physiotherapist
Occupational therapist
Physicians: neurologist,
general practitioners
Role and responsibilities

Help patient organise such things as finance, vocational
aspects, referrals
Help assess cognitive abilities of patient and emotional state
Help determine right food choices for patients and also right
food consistency
Help patients with aphasia relearn how to communicate, and
assess ability to swallow
Help patients retrain motor and sensory impairments, and
assess strength and endurance
Help improve motor skills and such things as grooming,
preparing meals and house cleaning
Primary responsibility for managing and coordinating care
16
Rehabilitation nurse
Help patients to relearn to carry out activities of daily living and

educate patients about routine self-care
2.
Action
Pulmonary care, chest physiotherapy.
Anti-embolic stockings and early mobilisation.
Monitor vital signs and respiratory status.
Assess for warmth, redness and increase in
size of calves.
Face patient, speak slowly and allow time for
answers.
Encourage fluids and high fibre diet (high fibre
nasogastric feeds were appropriate).
Mouth care, including suctioning on affected
side.
2nd-hourly turns.
Use picture boards, gestures, writing boards
and computers.
Instigate range of motion exercises and
support joints and limbs at rest.
Encourage patient to void on schedule, every 2
hours using positive reinforcement.
Rationale
To prevent chest infections such as aspiration
pneumonia
To revent thrombophlebitis and contractures
To detect early developing complications such
as pneumonia, bleeding
To monitor for development of thrombophlebitis
To maintain patients dignity and decrease
frustration with communication
To prevent constipation
To keep mouth clean and prevent infections
and aspiration pneumonia
To prevent pressure areas developing
To assist in communication
To maintain and improve muscle strength and
joint flexibility
To help promote bladder tone and retraining
7. Evaluate
Q. Actions has been effective if Mr Apulu remains free of infections, does not become
constipated, has reduced frustration in communicating, does not develop pressure areas,
maintains muscle strength and joint flexibility within the constraints of his disability, does not
develop thrombophlebitis, and begins to regain bladder tone and control of urination.
Chapter 7: Caring for a challenging patient

Scenario 7.1
1. Consider the patient situation
1. The tone and content of the handover is likely to adversely affect the care Shawn receives.
Nurses will be attuned to the negative aspects of his behaviour and are likely to interpret all of
Shawns behaviour in a negative light (this is called ascertainment bias). This in turn will affect
the way Shawn interacts with them, which sets up a vicious cycle. The nurses may also fail to
look after his clinical needs adequately.
2. No. With regard to the ANMCs Boundaries of Practice, the nurses under involvement lies to
the left side of the continuum; this includes attributes such as distancing, disinterest, coldness
17
and neglect. No. With regard to the Code of Ethics value statement, nurses value access to
quality nursing and health care for all people: Nurses valuing non-harmful, non-discriminatory
care provide nursing care appropriate to the individual that recognises their particular needs
and rights. They seek to eliminate prejudicial attitudes concerning personal characteristics
such as race, ethnicity, culture, gender, sexuality, religion, spirituality, disability, age and
economic, social or health status.
3. Check all observations, conduct a full assessment, talk with Shawn about how he is feeling,
and work out a mutually agreeable plan.
(a) Review current information If Shawn was withdrawing from alcohol, his temperature, heart
rate and respiratory rate are likely to be raised.
(b) Gather new information 1. Assess for nausea, tremor, increased blood pressure and
pulse, agitation, sweating, vomiting and headache. Assess whether there are perceptual
disturbances. Ask about past episodes of severe alcohol withdrawal including delirium and
seizures, other medical or psychiatric problems or benzodiazepine dependence. 2. a
(c) Recall knowledge (Quick quiz) 1. a; 2. The missing word is alcohol in every case. 3. a; 4.
a T, b F, c T, d T, e F, f T, g T; 5. c; 6. a; 7. c
8.
i. Drowsiness
ii. Agitation
iii.
iv.
v.
vi.
Tremor
Diaphoresis
Slurred speech, ataxia
Pinpoint pupils
c. Alcohol, benzodiazepines, opiates

a. Sedative withdrawal, or stimulant
toxicity
f. Alcohol, benzodiazepine withdrawal
b. Alcohol and opioid withdrawal
d. Alcohol, benzodiazepines intoxication
e. Especially opiates
9. a F, b T, c T, d T, e F, f T
(a) Interpret Q. a, c, d, e
(b) Discriminate 1. a, b, f, h, I, m, n
(c) Relate Q. a F, b F, c F, d F, e F, f T, g T
(d) Infer Q. d
(f) Predict
(a)
(b)
(c)
(d)
(e)
high likelihood
possible
possible
low likelihood
high likelihood
18
(f) high likelihood

4. Identify the problem/ issue Q. f, h
5. Establish goals Q. b, c, d
6. Take action Q. b, d, f, h, j, k
Which of these actions could be counterproductive? c and e. They are likely to make him more
anxious and possibly frustrated; g. crosses a professional boundary.
7. Evaluate Q. c, e, f, g
8. Reflect 1. clinical reasoning errors: ascertainment bias, confirmation bias, fundamental attribution
error. 2. full assessment at the beginning, being aware of transference issues, stigma and stereotyping
Scenario 7.2
(b) How common are anxiety disorders? Q. a, d, e, f, g, h, k
(c) Recall knowledge 1. a F, b F, c T, d T, e F, f T, g T, h F
2. Stress is a normal reaction to a situation where a person feels under pressure, whereas an anxiety
disorder involves more than just feeling stressed; it affects peoples wellbeing and day-to-day
function.
3. An anxiety disorder involves more than just feeling stressed and anxious; it affects peoples
wellbeing and day-to-day function.
4. Fear is a feeling of agitation and dread caused by the presence or imminence of danger. It
differs from anxiety in that it is a response to a known and specific threat.
5. Medication side effects, hyperthyroidism, asthma, cardiac problems, withdrawal from alcohol,
anaemia
(a) Interpret
Predisposing
factors
Precipitating
factors
Perpetuating
factors
Misuse of alcohol
Psychological
Family history of
anxiety
Anxious personality
Social
Peer pressure
Leaving
school/leaving
Misuse of alcohol
and nicotine
Low self-esteem
Avoidance of
situations that
made him anxious
Mother has not
always been able
Biological
Anxiety
Poor relationship
with father
Prognostic
indicators
(including
protective)
Intelligent
Smart and keen to
access help
Contemplative
Support from mother
19
home
to assist in the
most useful way
(c) Relate Q. a F, b T, c F, d T, e T
(d) Infer Q. a, b, c, d
(e) Predict Q. a, b, d
4. Identifying the problem/ issue Q. f
5. Establish goals Q. a, b, c, e, i
6. Take action Q. a, e, f, g, h, l
7. Evaluate Q. Evaluation might be about whether you used Shawns crisis as a catalyst for
change by relating to him in a therapeutic way and using the teachable moment. People using
substances do often change their behaviour when faced with increasing consequences such as
job loss, relationship problems, financial difficulties and physical deterioration. Emergencies
related to drug and alcohol abuse can serve as learning experiences. You might also consider
whether Shawns long-term prognosis is improved because of your intervention.
Chapter 8: Caring for a person with an autoimmune condition

Scenario 8.1
Setting the scene (Quick quiz) 1. b; 2. a; 3. c; 4. b; 5. a
(b) Gather new information 1. a, b, c, d, g
(c) Recall knowledge 1. a, b, c, d; 2. a; 3. e; 4. b, c, e; 5. d; 6. c; 7. a, b, d; 8. b, c, d
(a) Interpret 1. a; 2. b; 3. b; 4. a
(b) Discriminate Q. b, e, f, h, j
(c) Relate Q. a F; b T; c T; d F; e T; f F; g T; h F; i T
(d) Infer Q. a, c, e
(f) Predict Q. a, c, d, e, g
4. Identify the problem/ issue 1. a, c, d
2. Potential factors contributing to inadequate management to date:
Lack of continuity of medical and nursing care.
Elsie has had limited education to assist her in managing her symptoms.
20
Coexisting Sjgrens syndrome had not been diagnosed.

Health professionals may have been unaware of the impact of what appear to be minor
symptoms such as dry eyes and oral dryness.
5. Establish goals Q. a, c, f (subject to time available, or schedule follow-up appointment)

6. Take action Q. After reviewing with Elsie the issues you have identified, it is important to
check with Elsie about which issue she would like addressed first. This discussion will then inform
the prioritising of the rest of the activities.
7. Evaluate
Symptom
Nocturnal cough and choking
Quality of sleep
Ulcerated finger
Oral dryness
Eye irritation
Raynauds phenomenon
Unchanged
Improving
X
X
X
Deteriorating
X
X
Scenario 8.2
1. Questions that might help you understand more about her distress:
Are you still sewing and going out with your friends?
Is there anything that has happened since we met last that is upsetting you?
Have you been worried about what has been happening with your health?
You said you dont see the point of going on. Have you been perhaps thinking of killing
yourself?
2. Other factors that could be contributing to her sadness:
The still-birth of Nicholas on Christmas Day many years ago and the silence between
Elsie and her husband regarding this has been a source of chronic sorrow for Elsie.
Since the death of Nicholas, Doug has not once participated in Christmas celebrations
with the rest of the family. Over the years, Elsie, her daughters and now her
grandchildren have celebrated Christmas together without Doug.
3. Screening questions:
Over the past two weeks, have you felt down, depressed or hopeless?
Over the past two weeks, have you felt little interest or pleasure in doing things?
(Arroll, Goodyear-Smith, Kerse, Fishman & Gunn (2005, p. 884).
(c) Recall knowledge Q. a T, b F, c F, d F, e T, f T, g T, h F, i T, j F
(b) Discriminate, and (c) Relate Q. c, e, h, k, l
21
(d) Infer, and (e) Match Q. b, d, g

(f) Predict Q. b, d, e, g
4. Identify the problem/ issue Q. c, d, f
5. Establish goals Q. b, c, e
7. Evaluate
Ask Elsie about her appetite and her sleep and how she would describe her mood now
compared with how she was feeling when you last met.
Have Elsies symptoms that prompted referral to the mental health nurse been resolved?
Also review Elsies capacity to manage her physical symptoms related to scleroderma and
whether she has returned to previously enjoyed activities.
Chapter 9: Caring for an older person with impaired cognition

Scenario 9.1
Setting the scene
1. Vietnamese names are traditionally written using the surname first then the given name. Vietnamese
people often prefer to be addressed using their title followed by their given name. For example, Mr Dang
Tien would be referred to as Mr Tien.
2. Fever in older people with pneumonia is frequently absent.
Person-centred care
Q. Negative stereotypes about and illness trajectories for older people both contribute to the increased risk
of them being treated as cognitively incompetent. It is widely accepted by society that any cognitive
decline with increasing age is seen as expected, irreversible and untreatable. It is poorly recognised that
both acute and chronic illnesses contribute to a temporary alteration in the cognition of an older person.
Therefore, when a nurse encounters an older person in hospital they may incorrectly assume that the
person is not able to make decisions or be actively involved in their own care.
1. Consider the patient situation (Quick quiz) 1. c; 2. a; 3. c; 4. b

(a) Review current information

1. Mr Tiens vital signs and oxygen saturation level
2. Blood and sputum culture results
3. Mr Tiens prior cognitive abilities
4. Social (cultural) history
5. Hydration/nutritional status
1. Mini mental status (MMSE) The night nurses report suggested issues with cognition that required
further investigation. She thought Mr Tien had dementia, yet he did not have a history of dementia. Tricia,
the day nurse, would be thinking she would need to assess his cognition and the MMSE is a tool for this.
22
But she also was told he had not slept much, was agitated and there were difficulties with Mr Tiens
communication. Tricia chose the AMTS as it is shorter and the questions and tasks are less complex than
the MMSE and therefore there was more likelihood of Mr Tien being able to respond.
The AMTS delivers information about memory, attention and calculation.
Glasgow coma scale (GCS) Mr Tien has not suffered a head injury.
Geriatric Depression Scale (GDS) He does not have a history of depression and his condition
deteriorated during the night, which suggests a short duration not consistent with depression.
2. f, h
(c) Recall knowledge
1.
Alteration
in cognition
Onset
Level of
consciousness
Mood
Selfawareness
Dementia
Chronic;
months
years
Alert
Fluctuates
Unaware of
deficits
Delirium
Acute;
hours
days
Weeks
months
Fluctuates
Fluctuates
Fluctuates
Drowsy
Low,
apathetic
Chronic;
Months
years
Alert
No change
Aware of
cognitive
change
Aware of
cognitive
changes
Depression
Cognitive
decline
Activities
of daily
living
Early: intact
but impaired
as disease
progresses
May be
intact or
impaired
May neglect
basic selfcare
No change
2. d; 3. c; 4. a; 5. c; 6. d
7.
Cultural aspect
Example: Language
Food and diet
Attitudes to illness and
pain
Cultural beliefs
Family (living
arrangements)
Mr Tien
Speaks Vietnamese and French. Usually
speaks Vietnamese with family and English
outside the home.
He rarely eats western food. Eats
Vietnamese food. Uses chopsticks.
Stoicism: suffers in silence, does not
complain.
Use of alternative medicines: acupuncture
and herbal medicines.
Lives with daughter.
Eldest son is the family spokesperson. He
lives around the corner from sister.
(a) Interpret
Temperature: 36.9C (normal)
Abnormal results for Mr Tien:
Pulse rate: 95 beats per minute (normal 6090)
Respiratory rate: 23 breaths per minute (normal 1620)
Blood pressure: 175/90 (normal blood pressure < 140/< 90)
SaO2: 92% room air (normal SaO2 is above 95%)
Lung sounds: Crackles in left lower lung bases (lungs should have no crackles)
23
(b) Discriminate
1. d, e, h, i (The g response if also important, but only in establishing that Mr Tien probably does not have
a urinary tract infection which could be contributing to his alteration in cognition.)
2. a, b, c, d, f, i, j, k
3. F, F, T, F, F, F
4. If Tricia has an understanding of what is normal for older people, then any alterations in cognition noted
will be explored thoroughly. This will lead to an accurate diagnosis and appropriate person-centred care.
(c) Relate, and (d) Infer
1. T, F, F, F, T, T, F, T, T
2. Yes
3. a, c, d
(f) Predict Q. b, e, f, h
4. Identify the problem/ issue Q. b, c, f, g, h, i, j, k

5. Establish goals Q. b, c, h, j, k, l, m
6. Take action
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
(u)
(v)
(w)
(x)
(y)
Notify Mr Tiens doctor of his condition. 1

Educate Mr Tien about how to breathe deeply. 2
Physically restrain Mr Tien so that he does not climb out of bed and hurt himself. 3
Check that the IV cannula is patent. 2
Lower the bed rails on Mr Tiens bed. 1
Monitor Mr Tiens level of consciousness. 2
Regularly orientate Mr Tien to the hospital environment. 2
Chemically restrain Tien so that he does not climb out of bed and hurt himself. 3
Administer inhalers as charted. 2
Ensure Mr Tien is wearing his nasal prongs. 1
Communicate via phone with Mr Tiens daughter. 2
Maintain Mr Tiens fluid balance chart. 2
Engage the interpreter service to assist with communication strategies. 2
Adjust bed to lowest position. 1
Leave the television on in Mr Tiens room so that he does not feel lonely. 3
Ask daughter or other family member to sit with Mr Tien. 2
Administer IV antibiotics as charted. 2
Prompt and assist Mr Tien with drinking and eating. 2
Monitor Mr Tiens vital signs and oxygen saturation level. 2
Transfer Mrs Tien to a residential aged care facility until he recovers. 3
Move Mr Tien to an area where he can be closely observed. 1
Communicate with family to start discharge planning. 2
Ask Mr Tiens family to bring in his favourite foods for each meal. 2
Ensure Mr Tien is not disturbed once he settles for the night. 2
Schedule the taking of observations when Mr Tien is awake during the night. 2
Physically restrain Mr Tien so that he does not climb out of bed and hurt himself.
and
Chemically restrain Tien so that he does not climb out of bed and hurt himself.
24
Both forms of restraint are not considered appropriate treatment strategies for an older person
who is experiencing delirium. Both can exacerbate a delirium and are associated with adverse
outcomes: pressure area development, incontinence, falls and death.
Leave the television on in Mr Tiens room so that he does not feel lonely.
This is the opposite of what is required when nursing Mr Tien at this time. A quiet, calm and
comfortable environment is what is recommended when nursing an older person with delirium. It
is important for Mr Tien to be monitored closely and continuously and, where appropriate, to use
validation or reality orientation communication strategies.
Transfer Mr Tien to a residential aged-care facility until he recovers.

Mr Tiens delirium will improve as he recovers from pneumonia. A diagnosis of delirium does not
lead to a transfer to a residential aged-care facility.
2.
Nursing action
Document all nursing observations
and actions accurately and
contemporaneously.
Reassess using the CAM.
Engage interpreter service to
assist with the other cognitive
assessments.
Prompt and assist Mr Tien with
toileting.
Prompt and assist Mr Tien with
oral fluids.
Monitor psychomotor activity.
Rationale
To ensure clear, accurate
and timely communication
between all health
professionals caring for Mr
Tien
To identify the progress of the delirium
To determine Mr Tiens level of
cognition
To prevent episodes of incontinence
Encourage gentle ambulation and

regular position change.
To ensure adequate fluid intake and

prevent dehydration
Restlessness and lethargy are
indicators of continuing acute
confusional state.
To assist with communication, to
improve safety and provide comfort for
Mr Tien
To ensure clear, accurate and timely
updates are received by family from all
health professionals
To prevent pressure areas
due to reduced mobility
Monitor oxygen saturation levels.
To ensure adequate oxygen delivery
Encourage family to stay with Mr

Tien.
Communicate Mr Tiens progress
to his family.
7. Evaluate
Fluctuating
Language ability
Not speaking
25
Fluctuating
Fluctuating
Improving
Improving
Improving
Improving
Improving
Improving
Psychomotor activity
Mood
Pulse
BP
Respirations
Oxygen sats
Urinary incontinence
Oral intake
Lethargic
Withdrawn
88
150/70
18
96%
Using a urinal with prompting and assistance
Eating and drinking food brought in by daughter
Scenario 9.2
(a) Review current information Q. b, d e, g, h, k, l, m

The incorrect responses, a, i and j, contain information that is currently not available for Kristy to review.
All this information is required, but she will have to conduct a series of assessments to gather this new
information. The incorrect responses, c and f, although both are very important information, are not
essential for Kristy to come to an understanding of Mr Tiens current problems/issues.
1. Level of cognition; level of consciousness; degree of orientation; ability to be attentive, concentrate and
to recall recent events; level of psychomotor activity; language ability; comprehension and calculation
abilities.
Urinalysis
Vital signs, respiratory assessment
Duration of cognitive alteration
Regularity of bowels
Mood
2. h
(a) Interpret Q. d, g, h, I, j, k, l
(b) Discriminate Q. d, e
(c) Relate, and (d) infer Q. F, F, F, F, T, F
(e) Predict Q. f
4. Identify the problem/ issue Q. a, c, e, f

5. Establish goals Q. b, d, g, i
6. Take action
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Ring Mr Tiens eldest son. 2

Discuss the results of the assessments with Mrs Qui. 1
Explain to Mr Tien that he is not to speak to his daughter in a negative way. 3
Suggest some strategies for Mrs Qui to help with Mr Tiens personal hygiene. 1
Plan for readmission to hospital. 3
Make a referral to Aged Care Assessment Team. 2
Arrange for Meals on Wheels. 3
26
(h) Suggest communication strategies to help Mrs Qui receive positive responses from Mr Tien. 1
(i) Discuss the need to organise Mr Tiens admission to a residential aged-care facility in the near future.
3
(j) Suggest strategies that Mrs Qui can use to ensure Mr Tien is eating and drinking adequately. 1
(k) Notify Mr Tiens GP of his condition. 1
Explain to Mr Tien that he is not to speak to his daughter in a negative way. Traditionally, Vietnamese
women will submit to their fathers wishes and obey their husband. Despite some moderation of this
cultural value occurring when Vietnamese people move to a Western culture, there is still the expectation
that Mrs Qui will obey and respect her father. It is not appropriate for Kristy to discuss with Mr Tien his
behaviour towards his daughter.
Plan for readmission to hospital. Mr Tien is not acutely ill and does not require admission to hospital.
Arrange for Meals on Wheels. Mr Tien is forgetting to eat. He does not have an issue with access to food
as it is being provided.
Discuss the need to organise Mr Tiens admission to a residential aged-care facility in the near future. A
decline in cognition such as Mr Tiens does not signal admission to residential aged care. Even as Mr Tien
declines, his family will take care of him at home. They will require help and this can be provided by agedcare community services.
7. Evaluate
1.
Unchanged
Unchanged
Improving
Improving
Improving
Improving
Improving
Improving
Improving
Improving
MMSE: 19/30
CAM: Negative
Mood: Calm
Pulse: 86
Respirations: 16
BP: 150/75
SaO2: 96%
Personal hygiene: Family successfully assisting
Communication: Mrs Qui has not been called a bad daughter
Nutrition/hydration: Mrs Qui reports Mr Tien is eating and drinking
2. b, c, f, I, j
Chapter 10: Caring for a person experiencing pain

Scenario 10.1
(a) Review current information Q. c
(b) Gather new information 1. a, c; 2. b; 3. a, b, c, e, g, h, j, k, m
(c) Recall knowledge (Quick quiz) 1. c; 2. , , no change, , , , no change, , ; 3.
d; 4. b
27
(a) Interpret Q. infrequently, T, infrequently, T, T, infrequently, T, T, F, F, infrequently
(b) Discriminate, and (c) Relate Q. T, F, F, F, T, F, F, F, F, F, F, T, T
(d) Infer Q. c
(f) Predict Q. a, b, c, e, f, g, h, j, l, m
4. Identify the problem/ issue Q. b, c, f, g
5. Establish goals 1. b, e; 2. b, d, e
6. Take action
1.
P = Provokes
What is causing the pain?

What has made it better previously?
Does anything make it worse?
Does it hurt on deep inspiration?
What was the patient doing when it started?
What does it feel like? Ask your patient to describe the pain.
Is it sharp, dull, aching, stabbing, burning, crushing?
How does it affect ADLs, sleep, concentration, relationships, mood?
Where is the pain?
Does the pain radiate or is it in just one place?
Did it start elsewhere and is now localised to one spot?
How severe is the pain on a scale of 1 to 10?
What time did the pain start? How long has it lasted?
Q = Quality
R = Radiates
S = Severity
T = Time
2. e, g, c, f, d, a, b
3. b, d, f
7. Evaluate Q. a, d, e, f, g
Scenario 10.2
(b) Gather new information 1. a, c, e, g; 2. b, d, e, g, j
(c) Recall knowledge (Quick quiz) 1. d; 2. F, T, F, T, F, F, F, F; 3. a; 4. a, c, d, f, h, I, j;
5. a, c, e, g, j; 6. d
7.
Diagnosis
Acute pain
Usually clear
Persistent pain
Unclear
28
Duration
Temporary
(few days or
weeks)
Pain
descriptors
Sharp,
stabbing
Persists for
indefinite
period > 3
months
Aching,
burning,
sometimes
sharp
(a) Interpret 1. F, T, T, F; 2. a
(b) Discriminate, and (c) Relate Q. a, d, f, g
(d) Infer Q. b
(f) Predict Q. a, b, d, e, h, j, k
4. Identify the problem / issue Q. Mrs Simpson is no longer interacting with her family
as she once did; Mrs Simpson is finding it difficult to sleep due to pain; Mrs Simpson is receiving
sub-optimal relief from her medications.
5. Establish goals and 6. Take action
GOAL
Review
date
Short term
2 weeks
1. Sitting for up to five
minutes without
flaring pain
2. Hanging out the
washing without
flaring pain
Daily strength
exercises
Timing
activities and
recording
results
3. Making breakfast
without flaring pain
Medium term
1. Sitting for up to 20
minutes without
flaring pain
2. Joining local
seniors Tai Chi club
and attending once a
week
3. Spending more
Mrs
Simpsons
actions
Daily stretches
2 months
Taking regular
paracetamol
Continue daily
stretches and
strengthening
exercises
Attend Tai Chi
HCP actions
Medication
review
Review pain
diary
Investigation of
available Tai
Chi groups
Review pain
diary
Physiotherapy
review
Organise
transport to
social club
29
time with
grandchildren
Long term
1. Sitting for up to 40
minutes without
flaring pain
2. Attending the local
librarys genealogy
classes
3. Attend Christmas
dinner at daughters
house
Review plan
and goals
[6 months]
Increase
physical
activity
Monitor
progress
Review plan
and goals
7. Evaluate 1. a; 2. d
Chapter 11 Caring for a child with type 1 diabetes

Scenario 11.1
Family-centred care Why is it necessary for Haley to monitor her carbohydrate intake?
Understanding that carbohydrates convert to glucose after digestion and knowing which foods are
high in carbohydrate will enable Haley and her family to calculate her carbohydrate intake and
adjust her insulin requirements accordingly. The flexibility of this management system improves
Haleys quality of life significantly and helps to remove the label of being different.
Patient education How would you explain to Hayley why she needs injections when her
grandmother doesnt?
There are two types of diabetes. Both result in patients having too much glucose in the blood.
Type 1 is caused when the pancreas doesnt make any insulin. Insulin is a special messenger
that lets the glucose through to give energy to the working parts of your body. Because you dont
make any insulin you need to have it replaced and the only way we can do that is by injection.
Nanna also has diabetes and high glucose in her blood but the reason is different. Although her
body makes some of the special messenger insulin, it isnt always enough and the target tissues
are not always receiving the message. So, she needs a tablet that will wake up the pancreas to
make more insulin and wake up the cells so they pick up the message from the insulin.
How could you help Haley openly discuss her fears and frustrations?
Children and adults react differently to illness. Children may regress slightly and be less articulate
then they are at home and often find a new diagnosis confusing and annoying. The development
of a therapeutic relationship requires the nurse to provide individualised attention to the child.
Elements of a therapeutic relationship include development of trust, demonstrating
nonjudgmental communication, and being open to discussing concerns. Eye contact, getting
down to the level of the child and speaking in simple terms that the child can understand are all
important strategies. A key element in gaining cooperation is the use of positive language, where
the goal of working towards helping the child feel better is stated clearly. Its also vital that no
false promises are made. Using puppets or dolls is an effective way to distract the child during
30
uncomfortable procedures and also to teach the child in a relaxed and fun way. Practical
initiatives to promote understanding and diminish isolation include introducing Haley and her
mother to a support network for children and parents with diabetes and initiating the use of social
media support groups to decrease the risk of Haley being isolated from support when she returns
home. Ensuring that Haley and her mother develop a sound understanding of the disease and its
management will establish confidence and independence. Simple strategies such as the
provision of suitable reading material and connection with members of the interprofessional team
are all part of achieving this goal.
Haley asks you why she has two different types of insulin in the morning and evening but
only one injection prior to meals. What explanation will you give Haley for this?
Explain that Haley is being given two sorts of insulin that have different jobs. One of them is
intermediate insulin and acts over a longer period of time. Its job is to manage the amount of
glucose that is released from the liver into the body so that glucose levels stay at a constant or
good level. The liver releases extra glucose when you are stressed or when the levels of insulin
get too low. So having a steady release of insulin stops the blood glucose going up and down
throughout the day. The insulin you receive each morning and evening does this job. The other is
short-acting insulin. Haleys body needs basal insulin to help maintain a steady blood glucose
level that is not too high or too low, but it also needs additional doses of insulin through the day.
When she eats carbohydrate foods her body converts the carbohydrate into glucose and absorbs
it into the bloodstream. Haley needs extra insulin to process this additional blood glucose when
she eats. To process the glucose, the insulin either moves it into the cell to be used now or stores
it away to be used when you are exercising. The insulin Haley receives before each meal does
this job.
(b) Gather new information Q. Full set of vital signs including pain assessment, BGL, AVPU to
check conscious state
(c) Recall knowledge (Quick quiz) 1. a; 2. b; 3. a; 4. c; 5. b; 6. a; 7. b; 8. T, T, T, T, F
(a) Interpret Q. Normal: f, h, k; all others are abnormal (respiratory rate marginally raised)
(b) Discriminate Q. f
(c) Relate, and (d) Infer Q. F, T, F, T, T, F, T, T, F, F
(e) Predict Q. b, d, e
4. Identify the problem/ issue Q. e, g
5. Establish goals Q. d
6. Take action Q. e, h
7. Evaluate 1. b, e; 2. outdated test strips, poor skin preparation (i.e. dirt, sugar,
alcohol or other substances on skin), lack of calibration of device to test strips, insufficient
31
blood, battery problems; 3. Ascertainment bias and fundamental attribution error; 4. Haley and
her family have demonstrated that they have a strong commitment to understanding her illness
and to ensuring that Haley receives the best care possible. There is no evidence to substantiate
such a statement. This type of comment can impact on the objectivity of other staff and so
diminish the quality of health delivery to the client. This type of comment is therefore a breach of
the professional codes of conduct and code of ethics.
Scenario 11.2
(b) Gather new information Q. a, b, g, m
(c) Recall knowledge (Quick quiz) 1. a; 2. b; 3. a; 4. b; 5. b; 6. b and d; 7. d; 8. d; 9. a; 10. b;
11. b
(a) Interpret 1. f; 2. a, d, g, h, i
(b) Discriminate
(a) Temperature
2. Important
(b) Pulse rate
2. Important
(c) BP
1. Greatest importance
(d) Respiratory rate and depth 1. Greatest importance
(e) Smell of sweet breath
2. Important
3. Not of concern at this time
(f) SpO2
(g) Capillary refill
(h) Hb
(i) pH
(j) CO2
2. Important
(k) Na+
(l) pO2
(m) BGL
(n) Ketones
(o) K+
2. Important
(p) Urea
2. Important
(q) Condition of oral mucosa 1. Greatest importance
(r) WBC
2. Important
(s) Sleepy, requiring loud stimuli to wake her 1. Greatest importance
(c) Relate, and (d) Infer Q. F, F, T, T, F, F, T, F, F, T, F, T, T, F
(e) Predict Q. a, b, d
4. Identify the problem/ issue 1. a; 2. infection or illness, omitted or inadequate insulin;
poor understanding of carbohydrate intake; failure of insulin administration device
32
5. Establish goals Q. Establish rehydration within 24 hours; stabilisation of serum glucose within
6 hours; stabilisation of electrolytes within 6 hours; resolution of ketosis and acidosis within 12 hours
6. Take action 1. b, d, e, g, h, i
2.
Medical order / Nursing action
contemporaneously.
Check neurological status hourly.
Monitor fluid status closely.
ECG and cardiac monitoring.
Maintain patent IV access and monitor IV
site regularly.
Maintain oxygen therapy via Hudson mask
and hourly oxygen saturations.
Reassure Haley and her family.
Set up an insulin infusion to be
commenced once K+ improves, then
titrate with Se.Glucose and Se.Ketone
levels according to doctors orders.
Hourly capillary BGL and ketones.
Commence IV with N/Saline 0.9% with 20
mmol/KCL as per written fluid orders.
Repeat ABGs in 2 hours.
Check glycosylated haemoglobin (HbA1c).
Prepare IV of 5% dextrose but do not
commence unless ordered.
Ensure patent airway at all times.
Transfer Hayley to ICU.
Hourly vital signs.
Repeat U & Es in 2 hours.
Rationale
To provide effective communication between the health
team and facilitate the delivery of appropriate
individualised care; to provide an accurate and
contemporaneous documentation of Haleys condition
and progress
To identify improvement or deterioration in Hayleys
cognitive state
To determine hydration status and enable
administration of appropriate IV fluids
Hyperkalaemia may cause peaked T waves and cardiac
dysrhythmias
To ensure cannula remains patent
To promote a therapeutic relationship and maintain
psychosocial wellbeing
To provide adequate insulin to clear ketones and
correct acidosis
To monitor response to insulin treatment and to identify
appropriate management strategies
To correct fluid and electrolyte imbalances
To monitor respiratory and acidbase balance and
adjust management appropriately
To determine the average plasma glucose
concentration over a period of time and so gain insight
into how well controlled the disease is
To enable the titration of intravenous dextrose so that
BGL is maintained between 5 and 10 mmols/L (within
acceptable parameters)
To ensure appropriate expertise and resources are
allocated to Haley
To identify improvement or deterioration in Haleys
condition
To identify electrolyte imbalances so that an ongoing
titration of treatment to Haleys condition can occur
33
7. Evaluate
1. Improved cognition: Haley becomes more alert and aware.
BGLs and Se Ketones return to normal parameters.
Skin turgor improves.
Capillary refill returns to < 2 secs.
Vital signs are within normal parameters: afebrile, pulse rate < 100 bpm, respiratory rate < 20,
normotensive.
Respiratory pattern becomes less deep.
Acetone on breath no longer detectable.
2. Hypoglycaemia, hyperglycaemia, hypokalaemia, fluid overload, cerebral oedema
Chapter 12: Caring for a person receiving blood component

therapies
Scenario 12.1
1. Consider the patient situation (Quick quiz) 1. b; 2. a; 3. c; 4. a
1. (a) bedside, (b) compatibility label (in an emergency group O transfusion of PRBCs, will only
be able to identify that the donor group is O and this is compatible as the universal donor), (c)
patient, (d) patient identification, (e) full name and DOB, (f) special requirements, (g) expiry date
2. (a) leaks, (b) turbidity or haemolysis, (c) colour difference
3. documentation, signatures, printed names
(b) Gather new information 1. a, e, f, g
2. Check skin for a rash or hives which may indicate anaphylaxis; check for back pain and colour
of urine to rule out ABO incompatibility; check that the right pack has been given to the right
patient to rule out ABO incompatibility.
(c) Recall knowledge (Quick quiz) 1. d; 2. b; 3. a, b; 4. d; 5. b; 6. e
(a) Interpret
1. Blood pressure and oxygen saturation. A normal oxygen saturation level for Mrs Ayman would
be 95100%; a normal blood pressure for Mrs Ayman would be 100/60 with NO postural drop.
2. This is not of concern with regard to ABO compatibility. During an emergency, O-ve blood is
chosen as this is the universal PRBCs donor and there are no RhD antigens present. However,
as this is un-crossmatched blood, there is the possibility of a reaction to other antigens outside
the ABO grouping system.
(b) Discriminate Q. b, d, g
(c) Relate, and (d) Infer Q. F, F, F, T, F, F
34
(e) Predict Q. a
4. Identify the problem/ issue Q. a, d (as a febrile episode may be the first sign of a
possible antibody/antigen reaction or a possible bacterial contamination)
5. Establish goals Q. b (Immediate resolution of Mrs Aymans symptoms is the desired
goal; however, bacterial contamination may become evident days after the transfusion has been
completed.)
6. Take action 1. a, b, d, f, I (j and k are correct, but these are not immediate actions.)
Explanations for incorrect responses are:
(c) The IV cannula from the transfusion should not be flushed but a new IV line should be
commenced.
(e) Raise the foot of Mrs Aymans bed [Not indicated at this time as her blood pressure has
stabilised]
(g) Monitor Mrs Aymans level of consciousness [The cues provide no evidence of cognitive
impairment (at this stage)]
(h) Monitor Mrs Aymans pain score [Important, but not an immediate action]
2.
Nursing action
contemporaneously.
Rationale
To ensure clear, accurate and
timely communication between all
health professionals caring for Mrs
Ayman
worsening antigen/antibody reaction
Monitor haemodynamic status closely.
To identify improvement or deterioration in
Mrs Aymans condition
Regular skin examination.
To immediately identify an urticarial rash or
any unexplained bleeding
Maintain patent IV access and monitor IV To ensure cannula is patent and as pain
site regularly.
along the IV line may indicate haemolysis
Maintain oxygen therapy via nasal prongs To ensure adequate oxygen delivery as
and hourly oxygen saturation.
deterioration may indicate laryngeal oedema,
bronchospasm or TRALI
Reassure patient.
To maintain psychosocial wellbeing
Check colour in each specimen of urine. Dark-coloured urine may indicate haemolysis
7. Evaluate
Unchanged
Improving
Deteriorating
Deteriorating
Unchanged
Unchanged
Cognitive status
Pulse rate
Blood pressure
Respiratory rate
Oxygen saturation level
Skin condition
35
Improving
Improving
Shivering
Temperature
Scenario 12.2
(b) Gather new information 1. b, f; 2. d
(c) Recall knowledge (Quick quiz) 1. e; 2. b; 3. a; 4. c; 5. g; 6. c; 7. b; 8. d; 9. d; 10. b; 11. a;
12. g
(a) Interpret Q. e
(b) Discriminate, and (c) Relate Q. a, d
(d) Infer Q. restlessness, scratching, dyspnoea, headache
(e) Predict Q. a
Warning signs of adverse reaction
Allergenic reaction
Febrile non-haemolytic reaction
antibodies to proteins
possible contamination with pyrogens
including IgA
and/or bacteria
puritis
flushing
urticaria
rigors
palpitations
fever
mild dyspnoea
headache
Both
restlessness
anxiety
tremor
tachycardia
3 (f) Match
Q. In Scenario 12.1 Mrs Ayman experienced a febrile non-haemolytic transfusion reaction
(FNHTR). This is the most frequent adverse event following transfusion and is typified by a rise in
temperature greater than or equal to 1C above the pre-transfusion baseline that cannot be
explained by the patients condition. The pathogenesis of this type of reaction is multifactorial but
in most cases fever is the only clinical finding. It is thought to occur as a result of an antibody
reacting with a white cell antigen in the patients blood, or a white cell fragment in the blood
product, or to cytokines accumulated in the blood product during storage. Typically this type of
reaction is not life-threatening; there are no specific tests to confirm an FNHTR, so diagnosis
involves a process of exclusion.
In Scenario 12.2 Mrs Ayman is experiencing an urticarial (allergic) reaction. Mild allergic/urticarial
reactions are more frequently encountered than severe allergic (anaphylactic) reactions, which
are extremely rare. It is thought that the contributory factors in mild allergic reactions are cytokine
release or an immune reaction causing complement activation. Urticarial reactions with no other
signs and symptoms may not require investigation. In the more severe reactions, development of
an immunoglobulin E (IgE) antibody to a previously encountered allergen results in the release of
36
leukotriene and cytokine. This may result in stridor, dyspnoea and bronchospasm together with
hypotension, with the bronchospasm leading to chest tightness.
4. Identifying the problem/ issue Q. c. Hypersensitivity (allergic) reactions may result
when antibodies in the patients blood react against proteins (e.g. immunoglobulin A) in the
donors blood.
5. Establish goals Q. b. If Mrs Aymans symptoms can be controlled and her vital signs
improve, continuing her transfusion may be possible.
6. Take action Q. a, b, e, g, h, I, k, m, p, q
7. Evaluate
Sign or symptom
e.g. BP
Pulse
Temperature
Respiratory rate
Skin
Pain
Urine
Desired observation
stable with no postural drop
no evidence of tachycardia from compensatory mechanisms or as a result of
anxiety
normal
normal with no signs of dyspnoea
normal with no evidence of urticarial rash
absent with no pain along IV line, back or chest
normal in colour and amount with no evidence of blood due to DIC
Chapter 13: Caring for a person requiring palliative care

Scenario 13.1
1. Pain assessment
2. Assessment of nausea/vomiting
3. Medication history
4. Assessment of abdo distention and bowel (elimination) assessment
5. Assessment of fatigue
6. Respirations
7. Family/carer/social supports
8. Mobility assessment
9. Falls assessment
10. Vital signs
(c) Recall knowledge (Quick quiz) 1. f, 2. True; 3. Morphine; 4. Metabolites, 5. T, F, F, T, F, T;
6. b; 7. b, d, h, I, k; 8. e; 9. a; 10. b
(a) Interpret 1. b; 2. a; 3. c
(b) Discriminate Q. g, h, j, k, l
37
(c) Relate Q. T, F, T, F, T, T, T, F, T
(d) Infer Q. b
(e) Predict 1. a, b, c, e; 2. b, e, f, g
4. Identify the problem/ issue Q. c, e, g
5. Establish goals 1. a, c; 2. d, f
6. Take action
1. Administer two glycerine suppositories to soften hard rectal stools.
2. Ensure the glycerine suppositories are against the wall of the bowel.
3. Contact Sallys doctor to discuss her condition and for an order for an enema as
well as oral aperients or laxatives.
4. Administer an enema to clear the faecal impaction.
5. Educate Sally about the importance of adequate fluids, mobility and use of
aperients.
6. Negotiate an action plan in case of further episodes of constipation.
7. Evaluate
1.
Cognitive status
Pulse
Bowels
Oral mucosa
Oral intake
BP
Colour
Pain
Nausea
Vomiting
Patient restless and anxious

90
Good result but sticky stools
Mouth is dry and tongue furrowed
Tolerating sips of water
110/70
Pale
On scale of 10, Sally reports 2
Slight nausea
Nil
Unchanged
Improved
Improved
Unchanged
Improved
Improved
Unchanged
Improved
Improved
Improved
2. c
Scenario 13.2
1. Consider the patient (Quick quiz) 1. T; 2. e; 3. c; 4. subcutaneous; 5. terminal
restlessness
(a) Review current information Q. f
(b) Gather new information 1. b; 2. b
38
(c) Recall knowledge 1. e; 2. False Advance Care Planning is best implemented

early in a patients illness when they are able to clearly state what they would like to be
done in regards to healthcare when they are no longer able to speak for themselves.
(a) Interpret (Quick quiz) 1. e; 2. F; 3. T; 4. T; 5. F; 6. T; 7. F; 8. T; 9. T; 10. T
(b) Discriminate Q. d, h, k, m
(c) Relate Q. a T, b F, c T, d T, e T
(d) Infer Q. a
(e) Predict 1. b, c, d, e; 2. b, c, d
4. Identify the problem/ issue Q. b. The provision of medically administered nutrition
and hydration (MN&H) for the end-of-life patient is a controversial issue and there has been much
debate in the literature concerning it.
5. Establish goals Q. a
6. Take action Q. b, c, f
Chapter 14: Ethical and legal dimensions

Responses to questions for consideration
Question 1
Your response to this will very likely depend on your skills and experience, and a number of other factors.
There is a subtle but significant difference between actually making a no-CPR decision and being involved
in the decision-making process. It is important not to conflate the two. Some of the research (Palmer 2007)
that has been conducted on this question has shown a disparity between the degree of involvement in the
process that nurses feel they should have and that which they actually do have (the latter being much
lower). On the other hand, Kerridge, Pearson, Rolfe & Lowe (1998) point out that in some cases patients
will not want to be involved themselves, or not want nurses to be involved either. The ideal is a skilful,
collegial, multidisciplinary approach which fully includes the patient (if that is their preference) and family
(if that is the patients preference) that is sufficiently able to respond to situations in which the patients
views about who should be making the decision may not reflect those of the health professionals.
Question 2
A reluctance to discuss death and dying is not limited to hospital contexts. A 2011 survey commissioned
by Palliative Care Australia found that the majority of Australians had not discussed dying with their loved
ones, and despite the fact that most would prefer to die at home the opposite is the reality most will die
in a hospital. Acute hospitals are in the business of treatment and cure, and death can be seen as an
admission of failure. It is only relatively recently that health professionals education has included skills
such as how to communicate appropriately when discussing difficult and sensitive issues with patients.
Research has consistently shown over decades that healthcare practitioners are not well trained in
discussing advance care planning and do not feel well prepared to do so (Wilkinson, Wenger &
Shugarman 2007). Unless a patient raises the issue, the health professional will have to broach it first; and
39
this is not by any means an easy thing to do. The difficulties with this conversation arent just about
needing to know the right things to ask; they are also about when and how best to do the asking. In
Georges case there wasnt a private, quiet place for this to happen, or indeed much time. For a more
detailed discussion of the Palliative Care Australia survey, and the issues arising from it, see the MJA
insight website <http://www.mjainsight.com.au/view?post=scott-blackwell-let%25e2%2580%2599s-talkabout-death&post_id=6731&cat=comment>. The ACP review by Wilkinson et al. (2007) is a thorough and
comprehensive analysis of all the major issues and difficulties associated with making the process of
advance care planning actually work in practice. A review of ACP processes in Australia is also available
(Street & Ottman 2006). Their first two recommendations are for values-directed discussions among health
professionals, patients and families to begin early in the patients illness and be embedded in clinical
routines; and for there to be a transformation of attitudes and processes in healthcare organisations. Both
of these would have been of great help to George and given guidance to Greg and Dr Jones about best
practice in situations such as these.
Question 3
The barriers identified in this document are time, discomfort in talking about death, patients not wanting to
make these kinds of decisions, fears (such as not being able to change ones mind), lack of knowledge
about the process and the implications of particular decisions, and lack of knowledge about the legal
standing of an advance care directive.
Question 4
This document identifies such things as having detailed, ongoing, timely, focused discussions, in a
relaxed, unhurried environment. It advocates having a multi-disciplinary approach, involving someone who
really knows and cares about the person, discussing the persons values and goals as well as prognostic
information. It also details standards for documentation, including the fact that a witness, while
recommended, is not required.
Question 5
This is a complex question that on the face of it looks straightforward. After all, the informed part of a
valid consent is regarded as crucial. But it is not always as clear that a refusal must also be informed and,
if so, to what standard? The Victorian Medical Treatment Act (2008) stipulates that the patient must have
been informed about the nature of their condition to an extent which is reasonably sufficient to enable
them to make a decision. This accords with a judgment in 2009 in the case Brightwater Care Group (inc) v
Rossiter in Western Australia, where the judge placed a great deal of emphasis on the need for Mr
Rossiters refusal of treatment to have been demonstrably and thoroughly informed. However, in another
2009 case in New South Wales, Hunter and New England Area Health Service v A, Justice McDougall
found that it is not necessary, for there to be a valid advance directive, that the person giving it should
have been informed of the consequences of deciding, in advance to refuse [treatment]. In other words,
some jurisdictions in Australia require that refusal of treatment be informed, presumably to a standard that
the healthcarers are satisfied with, and in New South Wales it appears that patients have the right to be
uninformed if they so wish, and a specific refusal by a competent adult overrides the common law duty to
inform. The common law in New South Wales appears then to support George in saying that healthcarers
cannot override his refusal of CPR on the grounds that he has not yet been sufficiently informed of the
consequences of doing so.
(c) Recall knowledge

Question 6
The answer to this is yes but. The yes arises from legislation in states that have it, or the common law
in states that do not. The but arises from the complexity of the process and the lack of clarity and
organisational support for it. How to first get the decision made (involving everyone who should be
involved) then have it communicated to everyone who needs to know, then to have it followed through,
and also to be able to change or reverse it if needed you can see the difficulty. It becomes even more
40
so when the person concerned may not or does not have the legal capacity to decide. For a case involving
just such a dilemma, read the incredibly involved case of Mrs AB in Kerridge, Lowe & Mitchell (1995).
Question 7
This is another complex question. The doctrine of necessity (allowing treatment without consent in an
emergency) theoretically applies only when the persons wishes about treatment are unknown. However,
when a patient has a cardiac arrest, the nurse has only seconds to decide what to do and the
consequences of not doing CPR are irrevocable. So it is difficult to see how this doctrine could not be
invoked in situations where the persons wishes were still in the process of being determined. There is
also a theoretical conflict between the common law duty of health carers to adhere to the ordinary
reasonable standard, and their duty not to commit a battery. The practical reality is that it would be
extremely difficult for a patient to sue for battery or negligence arising from surviving unwanted CPR.
There have been no wrongful resuscitation law cases thus far in Australia, and only one in the United
States (where a nurse instigated CPR on a patient who had a formal no-CPR order) and in that case the
judge found in favour of the hospital (Anderson v St. FrancisSt. George Hospital). This was on the
grounds that the patient had suffered no physical damage from the battery. Therefore, while not
impossible, it is highly unlikely that legal consequences would ensue from either performing or withholding
CPR in a situation such as this. The question of how clinicians fears and perceptions about the possible
legal consequences of their actions affect their decisions is quite a different one, however.
The epidemiology of in-hospital cardiac arrest

Question 8
This issue is essentially about futility and the balance of potential risks and benefits. Futility can be
conceptualised in terms of mathematical probabilities, but applying these to individual cases is subjective.
Two things are needed: first, a good understanding of the statistical risks and benefits related to CPR,
and, second, the ability to assess how these might apply to the unique situation at hand. Not everyones
concept of what is futile will be the same, no matter what the statistics are. It is also important not to
conflate instigating or withholding CPR with other treatments. No-CPR does not mean all treatment can or
should be withheld. In this situation, it might be perfectly reasonable for George to have continued
treatments for a range of conditions, including prostate cancer, but not have CPR. What the CPR
epidemiology does indicate, though, considering his risk factors and co-morbidities, is that George is at the
low end of probability of survival to discharge should he have a cardiac arrest, and this should be taken
into account when considering his request not to have CPR.
(a) Interpret
Question 9
They are likely to be highly influential. Exactly how is difficult to determine specifically without gaining
direct and honest insight into each persons thought processes. This is something that we rarely do, even
for ourselves, let alone with others. Rather, we espouse the principle that personal values should not
unduly influence decisions, and presume that they do not, and that only professional values do. However,
there is considerable evidence from the work of Haidt and others that values, culture, strong emotions
(and innate intuitions) do have a considerable, but unacknowledged, impact on moral reasoning and
decision making.
Question 10
This question is for you to consider.
41

Clinical Reasoing Cycle Textbook Answers Tracy-Levett Jones

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Answers to Clinical Reasoning questions

Self: name, position,

Can I talk to you about Giuseppe Esposito in room 14B,

Briefly explain the reason

I am concerned about his condition. He is feeling dizzy. I

Summarise the patients

State your request.

He is not drinking a lot and his mouth is dry. His fluid

4. Identify the problem/ issue 1. e

Anxiety and restlessness may indicate

Cognitive status unchanged

4. Identifying the problem/ issue 1. b, e, f; 2. d

Hello .. This is .I am .........., an RN working on .... ward.

Chapter 4: Caring for a person experiencing respiratory

SpO2 increases from 94% to 97%.

To reduce the work of breathing and increase

Administer nebuliser/spacer treatments as

Chapter 5: Caring for a person with a cardiac condition

Mr Parkers vital signs may

continue within normal

4. Identify the problem/ issue 1. b; 2. e

< 20 on exertion and < 16 at rest.

For Mr Parker to participate in education

Commence an education program to provide

For Mr Parker to be free from anxiety by

using stress-reduction techniques

how to recognise and manage stress through

7. Evaluate Q. Outcomes should focus on managing stress, maintaining fluids through

Chapter 6: Caring for a person with an acquired brain injury

(b) Discriminate 1. a, b, d, h, I; 2. d, e, m; 3. Assess patient for any underlying conditions

Emotional distress can raise ICP.

Check that the IV cannula is not kinked or

To ensure patency and delivery of IV fluids.

Raise the head of Mr Apulus bed to 30

Facilitates venous drainage, and prevents

Maintain a quiet environment.

This osmotic diuretic draws fluid out of the

Monitor Mr Apulus pain score.

Severe headache can indicate worsening

Monitor Mr Apulus vital signs, oxygen

Establish baseline observations; sudden

Monitor Mr Apulus ABGs and electrolytes.

4. Identify the problem / issue Q. a, b, c, e, f, h, I, j

Role and responsibilities

Help patients to relearn to carry out activities of daily living and

Chapter 7: Caring for a challenging patient

c. Alcohol, benzodiazepines, opiates

(f) high likelihood

Chapter 8: Caring for a person with an autoimmune condition

Coexisting Sjgrens syndrome had not been diagnosed.

5. Establish goals Q. a, c, f (subject to time available, or schedule follow-up appointment)

(d) Infer, and (e) Match Q. b, d, g

Chapter 9: Caring for an older person with impaired cognition

1. Consider the patient situation (Quick quiz) 1. c; 2. a; 3. c; 4. b

(a) Review current information

4. Identify the problem/ issue Q. b, c, f, g, h, i, j, k

Notify Mr Tiens doctor of his condition. 1

Explanation for incorrect responses:

Transfer Mr Tien to a residential aged-care facility until he recovers.

Encourage gentle ambulation and

To ensure adequate fluid intake and

Monitor oxygen saturation levels.

To ensure adequate oxygen delivery

Encourage family to stay with Mr