Ms Singh (Sangeeta) is a 69 year old retired secretary who lives ‘down the road’ from her daughter and grandchild. Her husband passed away 6 months ago and since then she has become socially withdrawn; choosing to spend most of her time at home in the garden, or reading books. She wears bilateral hearing aids and reading glasses. Other than a permanent colostomy (resulting from a large bowel infarction in 2005) she has had nil significant medical history to report. Ms Singh immigrated to Australia 20 years ago from India. English is her second language and she practices the Hinduism religion.

Last night Ms Singh was brought in by ambulance (BIBA) to the emergency department after her daughter found her on her bathroom floor. Ambulance staff report that she was found naked and unable to call for assistance for almost 18 hours. She was diagnosed as having had a cerebrovascular accident (CVA) with residual right (R) sided hemiplegia, dysphagia and dysphasia.
She is soon transferred to the acute medical ward where you work and is accompanied by her daughter (Nita) who is obviously quite distressed. Ms Singh appears quiet and drowsy. She is currently Nil by Mouth (NBM) whilst awaiting a speech therapist review.
Her vital signs on arrival are: T 36.9 degrees C; P 115; R 26; SpO2 94% and BP 170/95.

Answer the following:

1. A deficit refers to ‘a lack or impairment in mental or physical functioning’. Using the information from the case study, identify and define four (4) deficits that Ms Singh presented with (200 words).

2. After review by the speech pathologist, Ms Singh is no longer Nil by Mouth (NBM) and has been placed on a special (modified) diet.
A) Identify and give an example of each of the 3 (three) levels of modified foods and fluids that are recommended to clients with dysphagia (100 words).
B) Identify five (5) strategies used to assist the feeding of patients with hemiplegia and dysphagia (100 words – bullet points acceptable).

3. Assessing Mobilisation:
A) Identify six (6) factors that the nurse needs to consider before mobilising Ms Singh (100 words – bullet points acceptable).
B) What is the most suitable risk assessment tool used in this situation (and why)? (50 words)
4. As a result of the (R) sided hemiplegia, Ms Singh requires assistance to empty and change her colostomy bag. Outline the steps involved (for the nurse) to change her colostomy bag (100 words – bullet points acceptable).

After 5 weeks on your ward Ms Singh’s condition has shown no improvement. She requires full assistance with all aspects of her ADLs and still has dysphagia and dysphasia. Her daughter approaches you in tears stating “What’s going to happen to mum now? I work full-time and cannot look after her. Surely she can’t go home?”
Answer the following:

5. What is the nurse’s role in the discharge planning of Ms Singh? In your answer include when the discharge planning process should commence and the members of the multidisciplinary team involved (150 words)

6. The Australian Nursing and Midwifery Council (ANMC) have a guide of standards that all nurses must uphold in order to ensure the ‘good standing’ of the nursing profession – it is known as the ‘Code of Professional Conduct for Nurses in Australia’. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx . From this document, identify the most applicable conduct statement(s) relating to cultural awareness that apply to the case study (50 words).

Ms Singh is soon transferred to ‘Serenity Nursing Home’. Over the next several months her condition continues to decline. She has now developed aspiration pneumonia and her condition has deteriorated rapidly. She has been transferred back to your ward for intravenous antibiotics. Upon arrival to the ward you notice Ms Singh has a reddened area on her left hip that has not gone away with relief of pressure. Her daughter Nita explains that her mother has not been sleeping lately and is concerned for her level of rest and comfort. She also mentions that her mother has an Advanced Health Directive and she has expressed her wish that no active interventions are to be taken in the event of cardiac or respiratory arrest (Not For Resuscitation – NFR). Supportive measures for comfort only, will be implemented.
Answer the following:

7. Pressure Area and Decubitus Ulcers:
A) What are the extrinsic and intrinsic factors that cause (or contribute) to the formation of pressure areas/decubitus ulcers? (50 words)
B) Define what a decubitus ulcer is and identify six (6) of the most common sites where these can occur? (50 words)
C) Identify five (5) strategies you could implement to prevent Ms Singh’s pressure area from worsening and to promote healing? (100 words – bullet points acceptable).
D) What is the most suitable risk assessment tool used in this situation (and why)? (50 words)

8. Comfort, Sleep & Rest:
A) Identify four (4) factors that you can discuss with the daughter that would help her understand what may be contributing to her mother’s poor sleep? (100 words – bullet points acceptable).

B) Identify four (4) factors that the nurse can implement to promote sleep? (100 words – bullet points acceptable).

9. What is an Advanced Health Directive? (50 words)

10. Identify three (3) ways you could demonstrate respect for Ms Singh’s decision to not actively be resuscitated? (50 words).
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