Professional Documents
Culture Documents
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
Situation
Background
Patients diagnosis,
relevant history,
investigations, what has
been done so far.
Assessment
Request/
recommendation
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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
2. Collect cues/ information
(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
3. Process information
(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
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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.
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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.
7. Evaluate
1.
2. d
Scenario 3.2
2. Collect cues/ information
(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
3. Process information
(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
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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
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Pleural effusion
Empyema
Productive cough
Lung abscess
Secondary infection due to
medication
Bacteraemia or septicaemia
Dyspnoea
Fatigue
Malaise
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3. Process information
(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.
Check cognitive status 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.
Anxiety and restlessness may indicate
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
615 litres per minute
1015 litres per minute
FiO2
0.24-0.36
0.4-0.6
0.6-0.9
7. Evaluate
1. a
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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.
3. b, c, d
Scenario 4.2
1. Consider the patient situation 1. c; 2. a, b, e, k; 3. a, c, e, g
2. Collect cues/ information
(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
3. Process information
(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.
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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
Condition
if his myocardial demand can be
reduced through oxygen supply,
medication and bed rest
if he experiences no further
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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
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
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Respirations
Temperature
Oxygen saturations
Level of consciousness
Pain level
Urine output
Scenario 5.2
1. Consider the patient situation (Quick quiz) 1. b; 2. a; 3. a; 4. b; 5. c; 6. a, c, f
2. Collect cues / information
(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
3. Process information
(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.
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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.
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Cognitive status
GCS
Pulse
Urine output
Pupil size
Pupil reaction
BP
Speech
Oxygen saturation level
Scenario 6.2
2. Collect cues/ information
(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
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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
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Rehabilitation nurse
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.
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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.
2. Collect cues / information
(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
9. a F, b T, c T, d T, e F, f T
3. Process information
(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
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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
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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.
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Unchanged
Improving
X
X
X
Deteriorating
X
X
Scenario 8.2
2. Collect cues/ information
(b) Gather new information
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
3. Process information
(b) Discriminate, and (c) Relate Q. c, e, h, k, l
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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.
3. Process information
(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)
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(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
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.
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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.
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
7. Evaluate
Fluctuating
Language ability
Not speaking
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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
2. Collect cues / information
3. Process information
(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
(a)
(b)
(c)
(d)
(e)
(f)
(g)
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(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
Explanation for incorrect responses:
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
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3. Process information
(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
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
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Duration
Temporary
(few days or
weeks)
Pain
descriptors
Sharp,
stabbing
Persists for
indefinite
period > 3
months
Aching,
burning,
sometimes
sharp
3. Process information
(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
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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
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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.
2. Collect cues / information
(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
3. Process information
(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
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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
2. Collect cues/ information
(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
3. Process information
(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
1. Greatest importance
(h) Hb
3. Not of concern at this time
(i) pH
1. Greatest importance
(j) CO2
2. Important
(k) Na+
3. Not of concern at this time
(l) pO2
3. Not of concern at this time
(m) BGL
1. Greatest importance
(n) Ketones
1. Greatest importance
(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
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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
Document all nursing observations and
actions accurately and
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 ensure adequate oxygen delivery
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 adequate oxygen delivery
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
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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
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(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
Document all nursing observations and
actions accurately and
contemporaneously.
Rationale
To ensure clear, accurate and
timely communication between all
health professionals caring for Mrs
Ayman
Check cognitive status regularly.
Anxiety and restlessness may indicate
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
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Improving
Improving
Shivering
Temperature
Scenario 12.2
2. Collect cues / information
(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
3. Process information
(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
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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
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(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
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
2. Collect cues/ information
(a) Review current information Q. f
(b) Gather new information 1. b; 2. b
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3. Process information
(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
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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.
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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.
3. Process information
(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.
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