Nurs2105sp Ver1 Int 2008

FLINDERS UNIVERSITY
ADELAIDE ● AUSTRALIA
Nursing & Midwifery Faculty of Health Sciences
NURS2105
Nursing 4
Study plan
Semester 2 2008
School of
Ver1
The information in this Study plan was correct at time of printing.
Please refer to https://flo.flinders.edu.au for up-to-date information.
© School of Nursing & Midwifery, Flinders University
2007
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Contents
Week 2: Part 2 - Nursing Management of Musculoskeletal Disorders.............................10

Week 5: Part 1 - Nursing Management of Endocrine Disorders – Type 1 Diabetes Mellitus ...............27
Week 6: Part 2 - Nursing Management of Endocrine Disorders – Type 2 Diabetes Mellitus................35
Week 7: Nursing Management of Renal Disorders – End Stage Renal Failure................41
Week 8: Part 2 - Nursing Management of Urological Disorders –UTI & SPC.................46
Week 9: Nursing Management of Gastrointestinal Disorders – Large Bowel Obstruction51
Week 10: Nursing management of Hepatobilary Disorders.............................................60
Week 11: Nursing Management of Haematological Disorders ............................... .........65
Week 12: Part 1 - Nursing management of Reproductive Disorders – Female Focus.....71
Week 13: Part 2 - Nursing management of Reproductive Disorders – Male Focus..........76
  3
NURS2105: Study plan
Week 1: Part 1 - Nursing Management of Musculoskeletal

Disorders
This week focuses on two problems related to the musculoskeletal system. The tutorial will focus on
osteoarthritis, resulting total knee replacement and nursing management options. The workshop will
involve a number of activities including management of the postoperative patient following total joint
replacement – Total hip replacement.
Learning outcomes for this week

Upon the successful completion of this section you should be able to:
• describe the purpose, significance of results, and nursing responsibilities related to diagnostic
studies of the musculoskeletal system
• describe the aetiology, pathophysiology, clinical manifestations and management of metabolic
bone disorders
• describe the types of reconstructive surgery associated with osteoarthritis and rheumatoid arthritis
• identify the preoperative and postoperative teaching and collaborative care of the patient having
reconstructive joint surgery associated with osteoarthritis and rheumatoid arthritis
• describe the pathophysiology, collaborative care and nursing management of the person with a
total knee replacement and total hip replacement
What you need to do to meet your learning outcomes

1. Before attending your tutorial read this week’s scenario and complete the
readings below
Brown, D & Edwards, H (eds) 2005, Lewis’s medical-surgical nursing: assessment and management
of clinical problems, Elsevier Mosby, Sydney.
Chapters:
60 ‘Nursing assessment: musculoskeletal system’
61 ‘Nursing management: musculoskeletal trauma and orthopaedic surgery’
63 ‘Nursing management: arthritis and connective tissue disease’ (this will be especially useful
for this week’s practical session).
Consult a pharmacology text regarding:
• non-steroidal anti-inflammatory (NSAID), antipyretic and analgesic drugs
  4
2. If you wish to read more widely you may wish to revise these chapters.
Crisp, J & Taylor, C (eds) 2005, Potter & Perry’s fundamentals of nursing, 2nd edn, Elsevier, Sydney.
Chapter:
49 ‘Care of surgical patients’
62 ‘Nursing management: musculoskeletal problems’
Skills:
49-1 Demonstrating postoperative exercises, p. 1556 (also on CD)
39-6 Cardiopulmonary resuscitation, p. 1092
Sample nursing care plan:
Peri operative patient, p. 1552
Client teaching boxes
32-20 Vascular assessment, p. 723
42-17 Preparation for patient controlled analgesia, p. 1211
3. Visit these websites
Access the following websites:

Osteoporosis site: http://www.osteoporosis.org.au/html/index.php
Arthritis Foundation: http://www.arthritisfoundation.com.au/html/index.php
Orthopaedic sites: http://www.worldortho.com/database/etext/ and
http://www.ozarkortho.com/patiented/totaljr.htm#What
4. Attend the tutorial and workshop for this week
The scenario questions will be discussed in the tutorial. Remember the workshops are compulsory.
  5
Consider this scenario for your tutorial
Read through this scenario and consider the questions that follow. Please be ready to discuss your
answers in the tutorial.
Mr Harold Heinrich is an 80 year old and has lived in the Barossa Valley town of Tanunda all of his life.
Before retiring at 65 he worked for Penfolds Winery, managing their back blocks where the very old shiraz
grapes are grown.
At age 20 Harold was thrown from his horse and sustained a fracture to his left tibial plateau. This was
treated at the Nuriootpa hospital where he was immobilised in traction in bed for four weeks and then on
crutches for another four weeks. As a consequence of this injury Harold has gone on to develop
osteoarthritis in his left knee joint. His orthopaedic specialist, who he visits in the city every six months, has
managed him conservatively with medications including NSAIDs and COX inhibitors and physical aids for
three years. Harold has undergone two arthroscopies and joint lavages to his left knee and now reluctantly
uses a walking stick.
As a public patient Mr Heinrich has been waiting to be called up for a total knee replacement ( TKR - total
joint arthroplasty). Finally the letter has arrived which has asked him to attend the pre-admission clinic and
donate a unit of his blood and repeat this in two weeks time—this will be used as an autologous blood
transfusion postoperatively.
At the pre-admission clinic he meets the RN, Greg, from the wards where he will be nursed postoperatively.
Greg goes through all the standard teaching and lets Mr Heinrich borrow a video which explains important
patient information regarding the pre and postoperative care he will require during his stay in hospital and
several weeks after.
Surgery was uneventful and Mr Heinrich is recovering well after the procedure was carried out under a
spinal anaesthetic. To block out the noise in the theatre, Mr Heinrich was able to wear headphones and
listen to music throughout the procedure.
Postoperatively his care is outlined as follows:
• routine post op vital signs

• rest in bed
• wound checks
• wound drain checks
• morphine Patient Controlled Analgesia (PCA) with purges
• keep L) leg in Zimmer knee splint
• anti-emetics ordered
• autologous blood up with orders for second unit to go up
• leg exercises
• C&B exercises.
  6
5. Consider these questions relating to the scenario
Please come to the tutorial prepared to discuss the following questions:
• Prioritise the nursing care for Mr Heinrich in preparation for his return to the ward and then when
he arrives on the ward postoperatively and give reasons for your priority.
• Define a PCA and explain why it is not used on all patients.
• Define osteoarthritis and its pathophysiology. Outline its relation to the resulting total knee
replacement.
  7
• Formulate a nursing care plan for Mr Heinrich for the first 24 hours post op. Include the
following:
– statement of patient need or nursing diagnosis
– outcome statement that is patient-focused
– nursing interventions including rationale
– changes that may need to occur to the nursing care plan during the 24-hr post op period.
• Discuss the complications that may occur in patients who have total joint replacements.
• Outline the discharge planning which is required for Mr Heinrich.
• Primary health care issues relating to the musculoskeletal system are vital for healthy ageing. List
some public health strategies that are currently in place.
• Focus on Mr Heinrich’s elderly Primary Health Care issues.
  8
  9
Week 2: Part 2 - Nursing Management of Musculoskeletal

Disorders
This week focuses on acute infection problems related to the musculoskeletal system. The tutorial will
focus on osteomyelitis and appropriate nursing management options. The workshop will involve a
number of activities including management of the patient with osteomyelitis and rehabilitation options.

• describe the purpose, significance of results, and nursing responsibilities related to diagnostic
studies of the musculoskeletal system
• describe the aetiology, pathophysiology, clinical manifestations and management of metabolic
bone infections
• identify the preoperative and postoperative teaching and collaborative care of the patient
having reconstructive surgery associated with acute musculoskeletal injury and subsequent
metabolic infection
• describe the pathophysiology, collaborative care and nursing management of the person with
osteomyelitis
readings below
Chapter:
62 Nursing management: musculoskeletal problems.
Consult a pharmacology text regarding:

• non-steroidal anti-inflammatory (NSAID), antipyretic, and analgesic medications.
• IV antibiotics.
• Analgesic medications.
  10
Chapters:
60 ‘Nursing assessment: musculoskeletal system’
61 ‘Nursing management: musculoskeletal trauma and orthopaedic surgery’
63 ‘Nursing management: arthritis and connective tissue disease’ (this will be especially useful
for this week’s practical session).
Chapter:
Skills:
49-1 Demonstrating postoperative exercises, p. 1556 (also on CD)
39-6 Cardiopulmonary resuscitation, p. 1092
Client teaching boxes
32-20 Vascular assessment, p. 723
42-17 Preparation for patient controlled analgesia, p. 1211
Access the following websites:

Osteomyelitis site: www.kidshealth.org/teen/diseases_conditions/bones/osteomyelitis.html
Osteomyelitis site: www.nlm.nih.gov/medlineplus/ency/article/000437.htm
Osteoporosis site: http://www.osteoporosis.org.au/html/index.php
Arthritis Foundation: http://www.arthritisfoundation.com.au/html/index.php
Orthopaedic sites: http://www.worldortho.com/database/etext/ and
http://www.ozarkortho.com/patiented/totaljr.htm#What
9. Attend the tutorial and workshop for this week
The scenario questions will be discussed in the tutorial. Remember the workshops are compulsory.
  11
Consider this scenario for your tutorial
answers in the tutorial. The workshop activity involves the same scenario where the learning acquired
in the tutorial can be implemented and consolidated in the nursing interventions undertaken in the
workshop.
Mr Stephen Cartwright is 56 years old living in Adelaide within the eastern suburbs. He is married with three
adolescent children and works in an executive banking position in the city. He enjoys weekend home
maintenance and landscaping as relaxation activities. He is a committed Jehovah Witness and attends
twice weekly services at the local Jehovah’s Witness Kingdom Hall.
His general health is sound for his age. His wife is committed to a healthy eating and physical lifestyle. They
play tennis weekly and walk several kilometres throughout the week. They entertain at their home frequently
and consume large amounts of alcoholic beverages – mainly wine and spirits.
A month ago Stephen was on the roof of his house performing maintenance following discovery of a
cracked roof tile. On descending the ladder whilst carrying the replaced tile he slipped and fell to the ground,
landing on the rough rocky garden edges.
His injuries included a severe compound fracture (open fracture) of his right tibia. Numerous cuts and
scratches of his face and right and left arms were also evident.
Surgery involving debridement of the damaged tissue and reduction of the fracture was performed. A right
leg cast was applied equipped with cast-windows to enable the surgical sight to be visualised. His facial and
body scratches and bruising were treated and some dressed with gauze and hyperfix. He made sound
progress on the orthopaedic ward and was discharged after two weeks.
After one week being home he began feeling unwell accompanied with fever, some night sweats,
restlessness and generally increasing malaise. His surgical sight had become more painful and had
increased swelling and erythema. He is currently admitted with the development of osteomyelitis of his right
lower leg. The organism Staphylococcus aureus has been identified as the infective agent. Bone ischemia
has not yet developed and so vigorous and prolonged IV AB therapy is anticipated, including after discharge
from hospital. PICC line to be inserted into right upper arm prior to discharge for long term IV AB therapy.
His care is outlined as follows:
• 4/24 vital signs

• rest in bed (RIB)
• 4/24 wound checks
• morphine PCA with purges
• R) leg cast insitu – pending possible further surgical intervention
• anti-emetics ordered – Maxalon 10mg 6/24 prn
• IV AB’s – 1g Penicillin 8/24.
• C&B exercises.
• Ward diet and fluids.
• Bowel monitoring and coloxyl and senna when necessary.
  12
• Prioritise the nursing assessment for Mr Cartwright on admission to the orthopaedic ward. Give
reasons for your priority.
• Formulate a nursing care plan for Mr Cartwright for the first 24 hours on the ward. Include the
following:
– statement of patient need or nursing diagnosis
– outcome statement that is patient-focused
– nursing interventions including rationale
– changes that may need to occur to the nursing care plan during the first 24-hrs period.
• Detail the possible clinical symptoms Mr Cartwright would have increasingly experienced at home
and presented to the admitting hospital’s Emergency Department.
  13
• Detail the range of diagnostic studies undertaking to confirm the presence of osteomyelitis.
Include the likely values and possible causative agents involved.
• What medications would be most likely commenced immediately upon hospital admission? List
these under the appropriate drug class e.g. antiemetics and analgesia. Provide a rationale for their
administration.
• Discuss the complications that may occur in patients who have osteomyelitis.
  14
• Outline the discharge planning which is required for Mr Cartwright. Include actions he can
implement at home for infection control. How will IV AB therapy be performed at home?
• Primary health care issues relating to the musculoskeletal system are vital for healthy ageing. List
some public health strategies that are currently in place.
• Focus these Primary health issues on Mr Cartwright’s circumstances.
Week 3: Part 1 Nursing management of Cognitive and

Perceptual Disorders
This week the tutorial will focus on the nursing management required during the acute and
rehabilitative phases for the person who has had a stroke. The workshop will focus on the nursing care
required for the semi-comatose/concussed patient and the patient with seizures.

• describe the incidence and risk factors for stroke in Australia
  15
• describe the acute and rehabilitative nursing management for the stroke patient
• describe the common diagnostic study abnormalities found in patients with a cerebrovascular
(CVA) accident
• describe age-related changes to the nervous system and differences in assessment findings
• describe first aid management of the person who is having a seizure and the nursing
responsibilities

readings below
Chapters:
2 ‘Culturally competent care’
54 ‘Nursing assessment: nervous system’
56 ‘Nursing management: patient with a stroke’
Client teaching box:
32-34 Neurological assessment, p. 759
Sensory/perceptual alterations, p. 1544
Skill:
37-2 Seizure precautions, p. 962
McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults and
children, 4th edn, Mosby, St Louis, Missouri.
Chapter:
16 ‘Alterations in neurologic dysfunction.
Consult a pharmacology text regarding
• thrombolytics—streptokinase, heparin and warfarin
• antihypertensive medications—enalapril (Renitec), amiloride (Moduretic)
• anti-seizure medications—Dexamethasone, Diazepam and Mannitol
  16
13. Visit the following websites
These three sites have been developed specifically for registered nurses as continuing education sites.
The diagnostic test section is particularly interesting. The first site will take you to all the neurological
studies on the site.
http://www.nurseceu.com/nur.htm
http://www.nursingceu.com/NCEU/courses/strokeac/index.htm
http://nsweb.nursingspectrum.com/ce/ce98.htm
Please see the following sites that are linked from the above site:
http://ww1.heartandstroke.ca/Page.asp?PageID=1017&CategoryID=2&Src=stroke
http://www.strokefoundation.com.au/
http://www.strokeresearch.com.au/
This site is interactive with photos, x-rays and video clips:
http://www.umassmed.edu/strokestop/index.html
Epilepsy Australia has an award-winning site. It is worth a visit, especially see the teen section.
http://www.epilepsy.org.au/
The Centre for Neuro Skills has a good article on brain function:
http://www.neuroskills.com/index.shtml?main=/tbi/brain.html
14. Attend the lecture, tutorial and workshop for this week
  17
Consider the following scenario for your tutorial
Angelo is a very proud 70-year-old retired market gardener who now lives with his son and continues to help
in the family business of tomato and onion farming. Today while out tending the tomato vines, Angelo
suddenly realised he was dragging his left leg and his left arm would not hold the rake. He stumbled to the
ground and was found by his son, who called the ambulance because he could not understand what his
father was saying and his father could not get up from the ground.
In emergency the nurses obtain a health history from the son who is quite distressed to see his father this
way.
His health history reveals:
• cigarette smoker for 50 years, about 10 a day
• hypertension managed with
– enalapril (Renitec)
– amiloride (Moduretic)
• having some difficulty passing urine with poor stream and urgency particularly at night
• otherwise healthy
• no history of recent head trauma
• no FFFFTs (no fits, faints, falls, funny turns)
• vital signs
– pulse 70
– resps 20
– BP 160/95
– temp 37˚C
• ECG shows sinus rhythm
• assessed by emergency medical officer who orders a CT scan
• CT confirms Angelo has had a CVA with possible embolism in the right hemispheres of the brain
evidenced by swelling on the CT
• neurological examination found the following clinical features:
– weakness and parathaesia of left limbs

– R sided hemianopia
– expressive dysphasia
– mild dysphagia
– confusion—speaking in Italian with apparent no understanding of English
The decision is made to give him streptokinase, followed by a heparin infusion.
  18
A MO sees Angelo and orders:
• O2 therapy 2L/min through nasal cannulae
• Activated Partial Thrombin test
• IVT 2L in 24 hours—4% dextrose and 1/5 normal saline
• continue with antihypertensive therapy
• IV heparin therapy—1000u every hour
• electrolyte blood levels
• CBP
• Speech therapy consult
Physiotherapy consult
• Nil orally until seen by the speech therapist.

• Outline any further information that you need to know about Angelo
• List the risk factors that Angelo has for developing a CVA
  19
• Discuss the different types of CVAs.
• TIAs are often seen as a precursor to CVAs. Discuss the pathophysiology associated with TIAs.
• Explain the rationale for the MO’s orders, including the streptokinase administered in the ER.
  20
• Prioritise the problems, both physical and psychological, Angelo has.
• Formulate a nursing care plan for Angelo.
• Determine the aims of rehabilitation for Angelo.
Week 4: Part 2 Nursing management of Cognitive and

Perceptual Disorders
This week the tutorial will focus on the nursing management required during the acute and
rehabilitative phases for the person with raised intracranial pressure (ICP). The workshop will focus on
the nursing care required for raised intracranial pressure and other trauma following a motor vehicle
accident (MVA).

• describe the incidence and risk factors for raised intracranial pressure
  21
• describe the acute and rehabilitative nursing management for the raised intracranial pressure
patient
• describe the common diagnostic study abnormalities found in patients with raised intracranial
pressure.
• describe age-related changes to the nervous system and differences in assessment findings
• describe first aid management of the person who is having a seizure and the nursing
responsibilities

readings below
Chapters:
55 ‘Nursing management: intracranial problems’
57 ‘Nursing management: chronic neurological problems’
32-34 Neurological assessment, p. 759
Sensory/perceptual alterations, p. 1544
Skill:
37-2 Seizure precautions, p. 962
McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults and
children, 4th edn, Mosby, St Louis, Missouri.
Chapter:
17 ‘Alterations in neurologic dysfunction.
Consult a pharmacology text regarding
• thrombolytics—streptokinase, heparin and warfarin
• antihypertensive medications—enalapril (Renitec), amiloride (Moduretic)
• anti-seizure medications—Dexamethasone, Diazepam and Mannitol
  22
17. Visit the following websites
These three sites have been developed specifically for registered nurses as continuing education sites.
The diagnostic test section is particularly interesting. The first site will take you to all the neurological
studies on the site.
http://www.nurseceu.com/nur.htm
http://www.nursingceu.com/NCEU/courses/strokeac/index.htm
http://nsweb.nursingspectrum.com/ce/ce98.htm
Please see the following intracranial web sites:

www.nda.ox.ac.uk/wfsa/html/u08/u08_013.htm
www.med.monash.edu.au/paediatrics/resources/icp.html
www.braininjury.com/intracranialpressure.html
Please see the following sites that are linked from the above site:
http://ww1.heartandstroke.ca/Page.asp?PageID=1017&CategoryID=2&Src=stroke
http://www.strokefoundation.com.au/
http://www.strokeresearch.com.au/
This site is interactive with photos, x-rays and video clips:
http://www.umassmed.edu/strokestop/index.html
Epilepsy Australia has an award-winning site. It is worth a visit, especially see the teen section.
http://www.epilepsy.org.au/
The Centre for Neuro Skills has a good article on brain function:
http://www.neuroskills.com/index.shtml?main=/tbi/brain.html

Martin is a 28-year-old physical education instructor working in various high schools. His physical fitness is
very sound as he undertakes numerous physical activities and he incorporates a considered dietary routine.
He is single and spends significant time associating with friends and sporting group clubs. His general
outlook on life is ‘life should always be lived to the fullest’.
  23
Martin is devoted to his motorcycle and spends weekends riding through the Adelaide Hills and sometimes
races at local meetings. Today he was riding through a difficult piece of road in the rain and collided with an
oncoming motor vehicle. He incurred serious head, thoracic, and leg injuries and subsequently had to be
sedated and intubated by ambulance paramedics at the crash scene prior to being transported to the
emergency department.
Medical investigations confirm a closed head injury with an associated fracture of the frontal skull. His right
wrist (with severe soft tissue damage) and left tibia are broken transversely and will be set in plaster. No
internal organ damaged is confirmed and he has numerous cuts and deep lacerations about his torso and
forehead.
In emergency the nurses obtain a health history from his father who is quite distressed to see his son this
way.
At the scene of the accident he was:
• Unresponsive with Glasgow Coma Scale of 3.
• Hypotensive with systolic varying between 55 and 82 mmHg. Diastolic ranged from 35 and 45
mmHg.
• Tachycardic 120 to 130 bpm.
• Respirations rapid and shallow – 30 breaths per minute.
• Pupils 3mm and non-reactive.
• assessed by emergency medical officer who orders a CT scans
In the emergency department:
• CT confirms Martin has a frontal skull fracture with right subdural haematoma, subarachnoid
haemorrhage. Pronounced cerebral oedema confirmed.
• X-Ray show right wrist fracture and left tibial transverse fracture.
• Increased Cranial Pressure confirmed at 3 mmHg.
• Bleeding from numerous lacerations to his leg, torso, and forehead.

• Outline the pathophysiology of a closed head injury and the medical tests required to confirm it.
  24
• What clinical manifestations of Martin’s head injury are presented?
• Outline the pathophysiology of Intracranial Pressure and how increases in it present life
threatening situations.
• Outline the progression of increased intracranial pressure.
• What are the clinical manifestations of intracranial pressure?
• What are the clinical instruments used to monitor intracranial pressure?
  25
• Detail the nursing management for Martin’s increase in intracranial pressure and formulate a
nursing care plan.
• Describe medications that may be implemented in Martin’s care.
• Determine the aims of rehabilitation and discharge planning care for Martin.
  26
Week 5: Part 1 - Nursing Management of Endocrine
Disorders – Type 1 Diabetes Mellitus
The endocrine system is under study this week. The case study focuses on a six year old girl who has
Type 1 Diabetes mellitus and has had a hypoglycaemic episode. The element to be particularly covered
in the tutorial around this case study is primary health care. Relevant clinical nursing skills will be
covered in your workshop related to the patient with such diabetes.

1• apply critical thinking to the case study presented
2• apply primary health principles to the case study presented
3• apply biophysical and pharmacological knowledge to the case study presented
4• develop your application of nursing research to the case study presented
5• extend your knowledge of lifespan development in childhood and the implications for nursing
practice
6• expand on your assessment skills in the area of the endocrine system
7• apply diabetes management principles to type 1 diabetes mellitus
8• develop your knowledge base in the nursing management of a child who has type 1 diabetes
mellitus
9• practise and discuss nursing skills relevant to the area under study including: care of skin, feet and
eyes in a client with diabetes, mixing of insulin medications, oral hypoglycaemic medications, BGLs,
and diabetic diet.
2What you need to do to meet your learning outcomes

Attend your lectures, one tutorial and one workshop session as well as the following activities.
Read the case study, ask the critical questions and then refer to the relevant pages in the following texts
to answer those critical thinking questions. By this stage students should be able to find their own
reference material pertaining to the area of study.
1Complete these activities
Please refer, refresh, read and/or note the relevant pages and chapters in your texts.
Text readings
Brown, D & Edwards, H 2005, Lewis’s medical-surgical nursing assessment and management of
clinical problems, Elsevier Mosby, Sydney.
Chapters
46 ‘Nursing assessment: endocrine system’
47 ‘Nursing management: diabetes mellitus’
Crisp, J & Taylor, C 2005, Potter & Perry’s fundamentals of nursing, 2nd edn, Elsevier, Sydney.
  27
Chapter 4 ‘Nutrition’
19. Extra readings
Please read and refer to the following readings that are available electronically on eReserve in the
library or on hard copy.
Reading 5.1 on eReserve
Meyers, L 2005, ‘Safe at school: treating diabetes in the classroom’, Diabetes Forecast, May, vol. 58,
no. 5, pp. 44-49.
Shilling, F 2003, ‘Foot care in patients with diabetes’, Nursing Standard, vol. 17, no. 23, pp. 61-68.
Cruciani, M, Lipsky, BA, Mengoli, C & de Lalla, F 2005, ‘Are granulocyte colony-stimulating factors
beneficial in treating diabetic foot infections a meta analysis’, Diabetes Care, vol. 28, pp. 454-460.
Storch, EA, Lewin, A, Silverstein, JH, Heidgerken, AD, Strawser, MS, Baumeister A, Geffken, GR
2004, ‘Peer victimization and psychosocial adjustment in children with type 1 diabetes’, Clinical
Paediatric, June, vol. 43, no. 5, pp. 467-471.
Barker, JM, Goehrig, SH, Barriga, K, Hoffman, M, Slover, R, Eisenbarth, GS, Norris, JM,
Klingensmith, GJ & Rewers, M 2004, ‘Clinical characteristics of children diagnosed with type 1
diabetes through intensive screening and follow-up’, Diabetes Care, June, vol. 27, no. 6, pp. 1399-
1404.
20. Further references
Extra text readings (for pertinent information)

McCance, K & Huether, S 2002, ‘Pathophysiology. The biological basis for disease in adults &
children’, 4th edn, Mosby, St. Louis.
Chapter 20 ‘Alterations in hormonal regulation’
21. Consult the additional texts listed in the Topic information/Topic details for
additional information pertinent to the case study—further specific
reference will given to these texts during the semester
There are always more references that can extend your knowledge in any area.
  28
Suggested websites
http://www.realitycheck.org.au/
http://www.diabetes.org/home.jsp
http://www.idf.org/home/
http://www.nlm.nih.gov/medlineplus/diabetes.html
http://www.adea.com.au/
http://www.emedicinehealth.com/articles/17044-1.asp
http://www.idi.org.au/home.htm
www.med.umich.edu/1libr/pa/pa_diabmell_hhg.htm
www.ispad.org
  29
Activity
Research the following medications and complete the pharmacology worksheet before coming to class.
MEDICATION
Trade and MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS
Generic Name
INSULIN (Include
all forms)
GLICLAZIDE
  30
MEDICATION
Trade and MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING IMPLICATIONS
Generic
Name
METFORMIN
ARCABOSE
  31
Read through this scenario and consider the questions that follow. Please be ready to discuss
your answers in the tutorial.
Emily is a six year old little girl. She has Type 1 diabetes. She loves to go to school and being
a very energetic child, and likes to participate in active sport activities with her friends at
lunchtime. Emily is cared for by her conscientious mother and father. Her mother has
informed the teacher about Emily’s condition and what should be done if she should suffer
from a ‘hypo’ event. To maintain glycaemia management, Emily requires an insulin injection
before breakfast, lunch and tea. Her meals consist of a well balanced diabetic diet.
The problem: Emily has her usual injection before lunch but does not eat all her food that day
because the class finishes late and she wants to join in the usual sports activity. Half way
through the sports activity Emily suddenly has a ‘hypo’ and the sports teacher has no idea
how to cope with the situation. Emily rapidly becomes drowsy and then becomes
unconscious.
She is admitted to your ward after she has been stabilised.
Her parents Jane 29 and Graham, 27 are very worried about Emily’s situation and diabetic
status especially as it was diagnosed at five years of age. They have decided to not have any
more children so that they can devote themselves to Emily’s welfare and Jane has reduced her
full time employment to part-time so that she can be more readily available to Emily. Jane
tells you that she had an aunt who had diabetes and she died at 53 from a heart attack, but
before her death she had had one leg amputated, was blind and was in renal failure.
• Outline the purpose and functions of the Endocrine System
• What are the predominant glands of the Endocrine System?
• Outline the communicating functions of the Endocrine System.
  32
• Outline the assessment of the Endocrine System.
• What is Diabetes Mellitus Type 1?
• Discuss the aetiology and pathophysiology of Diabetes Mellitus Type 1.
• What are the main differences between Type 1 and Type 2 Diabetes Mellitus?
  33
• Discuss the major differences in medications used to regulate blood sugar levels in both,
Type 1 & Type 2. Why do they differ?
• Outline the meaning of Emily’s ‘Hypo’ event.
• Detail the nursing and collaborative care plan management for Emily.
• Outline the two types of hypoglycaemic medications. Why can insulin only be
administered either subcutaneously or intravenously?
• Discuss the discharge educational required to alleviate Emily’s parents concerns and
knowledge. Does Emily require further education? What about the sports teacher?
  34
Week 6: Part 2 - Nursing Management of Endocrine
Disorders – Type 2 Diabetes Mellitus
The endocrine system is under study this week. The Tutorial scenario focuses on a 72 year
old man who has Type 2 Diabetes mellitus and relating health conditions. Differences with
Type 1 Diabetes Mellitus will be made clearer as well as the nursing interventions required.
Relevant clinical nursing skills will be covered in your workshop related to the patient with
Type 2 Diabetes mellitus.

6• extend your knowledge of lifespan development for the elderly and the implications for
nursing practice
7• expand on your assessment skills in the area of the endocrine system
8• apply diabetes management principles to Type 2 diabetes mellitus
9• develop your knowledge base in the nursing management of an elderly man who has type
2 diabetes mellitus
10• practise and discuss nursing skills relevant to the area under study including: care of skin,
feet and eyes in a client with diabetes, mixing of insulin, oral hypoglycaemic medications,
BGLs, and diabetic diet.
3What you need to do to meet your learning outcomes

Attend your lectures, one tutorial and one workshop session as well as the following
activities.
Read the case study, ask the critical questions and then refer to the relevant pages in the
following texts to answer those critical thinking questions. By this stage students should be
able to find their own reference material pertaining to the area of study.
1Complete these activities
Text readings
Brown, D & Edwards, H 2005, Lewis’s medical-surgical nursing assessment and

management of clinical problems, Elsevier Mosby, Sydney.
Chapters
46 ‘Nursing assessment: endocrine system’
  35
47 ‘Nursing management: diabetes mellitus’
Crisp, J & Taylor, C 2005, Potter & Perry’s fundamentals of nursing, 2nd edn, Elsevier,
Sydney.
Chapter 4 ‘Nutrition’
22. Extra readings
Please read and refer to the following readings that are available electronically on eReserve in
the library or on hard copy.
Meyers, L 2005, ‘Safe at school: treating diabetes in the classroom’, Diabetes Forecast, May,
vol. 58, no. 5, pp. 44-49.
Shilling, F 2003, ‘Foot care in patients with diabetes’, Nursing Standard, vol. 17, no. 23, pp.
61-68.
Cruciani, M, Lipsky, BA, Mengoli, C & de Lalla, F 2005, ‘Are granulocyte colony-
stimulating factors beneficial in treating diabetic foot infections a meta analysis’,
Diabetes Care, vol. 28, pp. 454-460.
Storch, EA, Lewin, A, Silverstein, JH, Heidgerken, AD, Strawser, MS, Baumeister A,
Geffken, GR 2004, ‘Peer victimization and psychosocial adjustment in children with type
1 diabetes’, Clinical Paediatric, June, vol. 43, no. 5, pp. 467-471.
Barker, JM, Goehrig, SH, Barriga, K, Hoffman, M, Slover, R, Eisenbarth, GS, Norris, JM,
Klingensmith, GJ & Rewers, M 2004, ‘Clinical characteristics of children diagnosed with
type 1 diabetes through intensive screening and follow-up’, Diabetes Care, June, vol. 27,
no. 6, pp. 1399-1404.
23. Further references

McCance, K & Huether, S 2002, ‘Pathophysiology. The biological basis for disease in adults
& children’, 4th edn, Mosby, St. Louis.
Chapter 20 ‘Alterations in hormonal regulation’
  36
24. Consult the additional texts listed in the Topic information/Topic
details for additional information pertinent to the case study—
further specific reference will given to these texts during the
semester
Available under the extra resources for week
0Suggested websites
http://www.realitycheck.org.au/
http://www.diabetes.org/home.jsp
http://www.idf.org/home/
http://www.nlm.nih.gov/medlineplus/diabetes.html
http://www.adea.com.au/
http://www.emedicinehealth.com/articles/17044-1.asp
http://www.idi.org.au/home.htm

Jean Paul is a 75 year old man living on his own in a small apartment in the suburbs. He was
a chief for many years and had a French restaurant for 15 years after immigrating to
Australia. He never married but has a son living nearby with his family.
He was diagnosed with Type 2 Diabetes Mellitus eight years ago after the development of
several foot neurotropic ulcerations and various points of dermopathy around his body. He
has begun to develop early signs of diabetic neuropathy in his right hand. Changes in his
urinary function were also detected and a diagnosis of nephropathy was confirmed. This renal
condition is monitored annually. His father died of diseases related to Diabetes Mellitus Type
2 aged 82 years.
His physical activity is minimal due to lifestyle choices, foot pain, and ‘not having the
willingness to do so’. Consequently he is obese and weights 127kgs at 5ft 9. He smokes
heavily in his apartment and consumes approximately 1 packet daily. His diet is devoted to
his love of homeland French cuisine and he consumes large amounts of it. He does not drink
alcohol as he thinks it diminishes the taste of his cooking.
Despite medical instructions, he takes his BGL reading infrequently and does not incorporate
nutritional modifications to his eating habits. He is determined to remain a smoker.
Jean Paul’s medications include: Enalapril (ACE inhibitor) for his hypertension and kidney
conditions. Metformin, for blood sugar level maintenance, which he often forgets to
administer. He takes regular Panadol for foot and other bodily pain.
  37
His son Michael came to visit him where he found Jean Paul very somnolent and almost
unable to move or coordinate. He was immediately taken to the emergency department. A
diagnosis of Hyperosmolar Hyperglycaemic Non-Ketotic Syndrome (HHNS) is made and
medical treatment is rapidly instigated to manage this life-threatening syndrome.
The findings of the emergency department are:
BP: 85/55
Temp: 37.8
Resps: 28
Pulse: 118
SAO2 91%
BGL: 48 mmol/L
IV Insulin: immediate treatment for high BGL
IV N/S 1000mls 250mls hour – then titrated according to fluid volume status.
IV 5% dextrose administered when BGL is 12-16 mmol/L to prevent hypoglycaemia.
Cardiac irregularity detected by ECG
Pronounced dehydration and serum osmolarity – frequent urination.
Ketoacidosis not present.
Routine blood and urine tests for electrolyte balances.
Oxygen therapy via nasal cannula commenced at 4L.
• Outline the aetiology and pathophysiology of Type 2 Diabetes Mellitus.
• Discuss the meanings of Endogenous and Exogenous insulin.
  38
• Detail Jean Paul’s HHNS diagnosis. What are the main differences with Diabetic
Ketoacidosis?
• Outline the medical treatment of HHNS. What are the most vital interventions at the
beginning of treatment?
• What is the reason underlying advanced dehydration? What is its precise pathological
cause?
• What are the main differences between Type 1 and Type 2 Diabetes Mellitus?
• Discuss the major differences in medications used to regulate blood sugar levels in both
Type 1 & Type 2. Why do they differ?
  39
• Draw a flowchart of the progression of untreated or controllable HHNS.
• Outline the nutritional education that should be emphasised to Jean Paul when
discharged.
• Discuss the discharge educational able to be supplied to patients with Type 2 Diabetes
Mellitus. Focus on Jean Paul’s age and management of his condition.
  40
Week 7: Nursing Management of Renal Disorders –

End Stage Renal Failure
This week will focus on urological/renal diseases culminating in urological/renal failure.
The tutorial focuses on chronic renal disease (CRD) leading to end stage renal disease
(ESRD). The practical workshop will involve a number of activities including fluid and
electrolyte management, blood pressure (BP) management, arterio-venous fistula/graft
(AVF or AVG) care and central venous dialysis catheter (CVDC) care.

• describe the clinical manifestations, complications, collaborative care, and nursing
management of a person with CRD leading to ESRD
• describe the preoperative and postoperative nursing management for a person requiring
AVF or AVG formation prior to haemodialysis
• describe the treatment options of a person with ESRD including haemodialysis, chronic
ambulatory peritoneal dialysis (CAPD), intermittent peritoneal dialysis (IPD) and renal
(kidney) transplantation
• describe the nursing and collaborative management of a person undergoing

haemodialysis

Visit the following websites
The following websites have useful information for health professionals and patients.
Access the sites and note what you found most interesting for the seminar discussion.
The Renal Resource Centre website has many useful fact sheets available to download
www.kidney.org.au/renalresources
Kidney Health Australia is a non-profit organisation with a mission to be the lead
organisation promoting kidney and urinary tract health through research, advocacy,
education and health service excellence in Australia. www.kidney.org.au/
  41
Renal Society of Australasia is an Australasian society of mainly nursing, technical and
allied health professionals, aiming for excellence in the dissemination of knowledge in
Renal Replacement Therapies www.renalsociety.org/
Hypertension, Dialysis and Clinical Nephrology (HDCN) is a useful website with many
links for renal professionals www.hdcn.com
Nephron Information Centre is a very informative website that features basic renal
anatomy, basic renal disease information and "professional" links (for doctors, nurses,
social workers, technicians, dieticians) to jobs and conferences. Dialysis Patient's Health
Guide. www.nephron.com
The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) collects a
wide range of statistics that relate to the outcomes of treatment of those with end stage
renal failure www.anzdata.org.au
Atlas of Diseases of the Kidney www.kidneyatlas.org
Text readings

Chapters
43 ‘Nursing assessment: urinary system’
45 ‘Nursing management: acute renal failure and chronic kidney disease

Lewis, S., Heitkemper, M. & Dirksen, S. 2004, Medical–Surgical Nursing—Assessment and
Management of Clinical Problems, 6th edn, Mosby Inc., Missouri.
Chapter 44. NURSING MANAGEMENT: Renal and Urological Problems
Chapter 45. NURSING MANAGEMENT: Acute Renal Failure and Chronic Kidney Disease
Lehne, R. A. 2001, Pharmacology for Nursing Care, 4th edn, W. B. Saunders Co.,
Philadelphia.
Please read the following research paper:

Lindqvist R. Carlsson M. Sjoden PO. 2000 Perceived consequences of being a renal failure
patient. Nephrology Nursing Journal: Journal of the American Nephrology Nurses'
Association. 27(3):291-7;
Attend the lecture, seminar and practical workshop for this week
  42
Elements covered in the lecture will relate to the scenario below. The scenario questions
will be discussed in the seminar. Remember the practical workshops are compulsory.

Nguyen is a 35 year old female who lives in Fulham Gardens. She is married with two young
children (8 and 6 years old). She has lived in Australia for the past two years and her English is
limited. She was admitted 2 weeks ago with symptoms of increasing lethargy, nausea, weakness,
depression, and recurring gastritis. Following diagnostic tests including blood tests (urea,
creatinine, potassium), renal ultrasound and renal biopsy she was diagnosed with ESRD. Nguyen
had not previously been diagnosed with (chronic renal disease) CRD. On day 2 after admission
Nguyen had a CVDC (often called a Permcath) inserted into her left subclavian vein and
haemodialysis was commenced. After 10 days of intermittent haemodialysis (every alternate day)
she had an (arteriovenous fistula) AVF surgically constructed in her left forearm. She returned
from theatre 8 hours ago.
Current nursing care includes

• post-operative observations (BP not on operated arm)
• post-operative neurovascular observations
• observation of bruit/thrill
• wound observation
• RIB
• IVT
• FBC
• Her medications include:
o Paracetamol or Panadine Forte 1g QID prn
o IV AB (Two Doses) Cephalothin 1gm 8/24.
o Alutab 1 TDS
o Amlodipine 10mg nocte
o Caltrate 3 TDS
o Calcitriol 1 mcg non-dialysis days
o EPO 6000u s/c twice weekly
  43
o Folic Acid 5mg daily
o Loperimide 2 nocte
o Vit C 500mg post dialysis
o Mega B 1 post dialysis
Consider these questions relating to the scenario
Please come to the seminar prepared to discuss the following questions:
• Outline how a patient can progress from CRD to ESRD without previous clinical
manifestations of CRD.
• How have Nguyen’s cultural background and language difficulties contributed to the
above disease state progression?
• Do Nguyen’s presenting clinical manifestations concur with the above disease state
progression?
• Detail the medical tests and related pathophysiology and possible aetiology involved in
Nguyen’s diagnosis of ESRD.
• Detail the nursing management of a patient with CRD – focus on Nguyen’s treatment.
  44
• Why was Nguyen commenced on haemodialysis and what were her likely main test
results indicating such a move?
• Discuss the principles of Haemodialysis and Dialysis. List the medical options available.
• Describe the AVF operative procedure.
• Prioritise Nguyen’s care post operatively and give a rationale for your answer.
• Formulate a nursing care plan for Nguyen including the following:
o need/problem/nursing diagnosis
o outcome statement
o nursing interventions including rationale
o possible changes to the nursing care plan if required
o List the psychosocial needs Nguyen may have in the near future
  45
• Describe why Nguyen is administered each of her medications:
Week 8: Part 2 - Nursing Management of Urological

Disorders –UTI & SPC
This week will focus on permanent urological problems of an elderly man. The tutorial
focuses on chronic UTI development due to the use of a permanent SPC. The practical
workshop will involve the nursing responsibilities for treating a UTI and the assessment
and maintenance of an SPC.

• describe the clinical manifestations, complications, collaborative care, and nursing
management of a person with chronic urological problems – chronic UTI development
• describe the nursing management for a person requiring UTI treatment and SPC
monitoring
• describe the treatment options of a person with urological problems – chronic UTI
• describe the education and public health information able to be give to such patients

Access the sites and note what you found most interesting for the seminar discussion.
The Renal Resource Centre website has many useful fact sheets available to download
www.kidney.org.au/renalresources
  46
Kidney Health Australia is a non-profit organisation with a mission to be the lead
organisation promoting kidney and urinary tract health through research, advocacy,
education and health service excellence in Australia. www.kidney.org.au
Renal Society of Australasia is an Australasian society of mainly nursing, technical and
allied health professionals, aiming for excellence in the dissemination of knowledge in
Renal Replacement Therapies www.renalsociety.org
Hypertension, Dialysis and Clinical Nephrology (HDCN) is a useful website with many
links for renal professionals www.hdcn.com
Nephron Information Centre is a very informative website that features basic renal
anatomy, basic renal disease information and "professional" links (for doctors, nurses,
social workers, technicians, dieticians) to jobs and conferences. Dialysis Patient's Health
Guide www.nephron.com
The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) collects a
wide range of statistics that relate to the outcomes of treatment of those with end stage
renal failure www.anzdata.org.au
Atlas of Diseases of the Kidney www.kidneyatlas.org
Text readings

Chapters
43 ‘Nursing assessment: urinary system’
44 ‘Nursing management: renal and urological problems

Lewis, S., Heitkemper, M. & Dirksen, S. 2004, Medical–Surgical Nursing—Assessment and
Management of Clinical Problems, 6th edn, Mosby Inc., Missouri.
Chapter 44. NURSING MANAGEMENT: Renal and Urological Problems
Lehne, R. A. 2001, Pharmacology for Nursing Care, 4th edn, W. B. Saunders Co.,
Philadelphia.
Attend the lecture, seminar and practical workshop for this week
  47
Elements covered in the lecture will relate to the scenario below. The scenario questions
will be discussed in the seminar. Remember the practical workshops are compulsory.

Peter is a 78 year old nursing home resident. He has been resident in the home for ten years
following the death of his wife from liver cancer. Peter’s daughters rarely visit and he insists
on remaining in his room alone most of each day.
His physical mobility is poor and he remains in his wheelchair rather than walking. He has
significant osteoarthritis in his hips and left knee. He has Type 2 diabetes resulting in lower
leg ulcerations and hypertension. Peripheral neuropathy is also present in his lower legs. Peter
will not take hypoglycaemic medication as he says he doesn’t eat enough nor wants to take
such tablets. The nursing home RN performs BSL monitoring twice weekly.
Two months ago he had a suprapubic catheter (SPC) inserted following numerous incidents
of urinary tract infections. Medical investigations revealed a neurogenic bladder with
associated low bladder wall compliance. His tolerance of having such a urinary catheter has
been low and he refuses to be involved in its care and maintenance. Such low involvement
has contributed to the numerous cases of (urinary tract infections) UTI’s.
Three days ago the nursing home staff noticed an increase in his agitation and confusion; he
frequently refused to have carers attend to his hygienic needs. An increase in flank pain,
discomfort, agitation, and development of a fever led to his emergency department admission
where a severe recurrent upper UTI with related urethritis were diagnosed. Misuse and non-
hygienic maintenance of his SPC in the nursing home are the determined causes. A dipstick
urinalysis confirmed the presence of nitrates and leucocytes.
Peter is on your ward undergoing treatment for his infections and the assessment and
management of his SPC.
You are assigned his care:
• IVT N/S 1000mls 8 hours
• Diabetic diet. Encourage fluids
• IV AB Penicillin 1.2gms 8/24
• BSL – random daily
• Panadol 1gm QID prn
• Metformin 850mg nocte
• Oxybutynin 10 mgs prn.
• Metaprolol 25mgs mane
• Serenace 1.5mg prn
• SPC maintenance and assessment – 2/24
  48
• FBC
• Agitation and confusion management.
• Define a urinary tract infection.
• Detail the aetiology and pathophysiology of UTI development.
• Detail Peter’s recurrent upper UTI tendency, including his presenting clinical
manifestations which suggest this diagnosis.
• How do the nitrates and leucocytes in his urine confirm infection presence?
  49
• Detail the nursing management of a patient with a UTI and SPC insitu – focus on Pete’s
case.
• Formulate a nursing care plan for Peter including the following:
o need/problem/nursing diagnosis
o outcome statement
o nursing interventions including rationale
o possible changes to the nursing care plan if required
o List the psychosocial needs Peter may have in the near future
• Discuss the most probable link with Peter’s reluctance to participate in the management
of his SPC with his recurrent upper UTI states.
• Discuss how nursing staff at the nursing home could attempt to encourage Peter’s
participation in his SPC maintenance.
  50
• Detail why Peter is administered each of his medications:
Week 9: Nursing Management of Gastrointestinal

Disorders – Large Bowel Obstruction
1The gastrointestinal system is under study this week. The scenario focuses on a patient who
develops a large bowel obstruction from cancer and undergoes a resection with a temporary
colostomy. Her consequential clinical nursing care will be covered in the workshop.

5• expand on your GIT nursing assessment skills
  51
6• develop your knowledge base in the nursing management of an elderly person undergoing
major GIT surgery
7• extend your knowledge of nursing management of clients with a diagnosis of cancer, major
surgery, loss of independence, and a chronic illness
8• practise nursing skills relevant to the area under study including: NG tube drainage and
LPS, colostomy/ileostomy care, revision of PEGs, assessment of bowel sounds, faecal
impaction, constipation/diarrhoea, nausea and vomiting.

Attend the lectures, one tutorial and one workshop session as well as the following activities.
Read the case study, ask the critical questions and then refer to the relevant pages in the
following texts to answer those critical thinking questions.
9 Complete these activities
Please refer, refresh, read and/or note the relevant pages in the following chapters and other
relevant areas in your texts.
Text readings

Chapters
38 ‘Nursing assessment: gastrointestinal system’
41 ‘Nursing management: lower gastrointestinal problems’
Crisp, J & Taylor, C 2005, Potter & Perry’s fundamentals of nursing, 2nd edn, Elsevier,
Sydney.
Chapters
45 ‘Bowel elimination’
 Extra readings
Please read and refer to the following readings that are available electronically on eReserve in
the library or on hard copy.
Sargent, C & Murphy, M 2003, ‘What you need to know about colorectal cancer’, Nursing;
Feb, vol. 33, no. 2, pp. 36-42.
Robinson, ES 2002, ‘The truth about colorectal cancer’, Nursing, April, pp. 4-7.
  52
Paula Erwin-Toth, P 2001, ‘Caring for a stoma is more than skin deep’, Nursing, May, vol.
31, no. 5, pp. 36-40.
Weerakoon, P 2001, ‘Sexuality and the patient with a stoma’, Sexuality and Disability, vol.
19, no. 2, Summer.
Pontieri-Lewis, V 2000, ‘Colorectal cancer: prevention and screening’, Medsurg Nursing,

February, vol. 9, no. 1, pp. 9-14.
 Further references
McCance, K & Huether, S 2005, Pathophysiology. The biological basis for disease in adults
& children, 5th edn, Mosby, St. Louis.
Chapters
38 ‘Structure and function of the digestive system’
39 ‘Alterations of digestive function’
 Consult the additional texts listed in the Topic information/Topic details for
additional information pertinent to the case study—further specific reference will
given to these texts during the semester
0Suggested websites
http:////www.beyondblue.org.au/
http://www.depression.com.au
http://www.cancerscreening.gov.au/bowel/
http://www.cssa.org.au/patientarticle.asp?ArticleNo=10
http://www.cancerresearch.org.au/faq.html
http://www.gutdisorders.com/welcome.cfm
http://www.cancercouncil.com.au/editorial.asp?pageid=17
Research the following medications and complete the pharmacology worksheet before
coming to the tutorial.
  53
  54
Trade and Generic
Name MODE OF ACTION PRECAUTIONS SIDE EFFECTS NURSING
IMPLICATIONS
MAXALON
CEPHALOTHIN
  55
Trade and Generic Name PRECAUTIONS N MODE SIDE EFFECTS NURSING IMPLICATIONS
OFACTIO
METRONIDAZOLE
GENTAMICIN
  56
Consider this scenario for the tutorial – Gastrointestinal System
Read through this scenario and consider the questions that follow. Please be ready to
discuss your answers in the tutorial
Mrs Carsons is a an 86 year old woman who was admitted to the ward two days ago with
mild abdominal pain, anorexia, slight nausea and chronic constipation for investigation
via her GP. She has no significant past medical history and is taking no medications. Her
GP had done a Haematest on her stool in the surgery and found it to be positive for occult
blood.
On admission Mrs Carsons seems very anxious. She says she has never been in hospital
before and ‘she is frightened that she’ll never get out’. When you ask her why, she says
‘she’s sure she’s got cancer and she’s going to die’. She also tells you that she lives alone
since her husband died six years ago, but her only daughter, who is 58 and married, visits
her every day and they are very close.
Her admission observations are T 37.5°C, P92 (reg), R22, BP 145/90
On examination, Mrs Carsons’ tissue turgor is poor, her tongue is dry and coated, her lips
are cracked and her skin is dry and frail. Her abdomen is distended and she pulls away
when you try to palpate it. On auscultation you hear no bowel sounds in the left upper and
lower quadrants but hyperactive sounds in the right upper and lower quadrants. Her
admission weight is 50 kgs and she is 160 cm tall. She tells you ‘she used to be quite a
big woman, weighing about 10 stone a year ago’. She has no explanation for this weight
loss, however.
About two hours after her admission Mrs Carsons calls you over urgently and says she
thinks she’s going to be sick. She promptly vomits about 150 mls of green bile into the
bowl you offer her. After making her as comfortable as possible you administer the
injection of IM Maxalon 10 mgs 4-6 hourly that has been ordered. Unfortunately this has
no effect and Mrs Carsons continues to vomit large amounts over the next two hours
culminating in a large brown offensive vomit. The total amount she has vomited is 680
mls. Her observations are T 38°C, P118 (reg), R 26, BP100/55.
You call the RMO, who after examining Mrs Carsons diagnoses a large bowel
obstruction. He inserts a NG tube and asks for it to be on free drainage, inserts a Jelco
with Normal Saline 1000 mls running over four hours and he asks you to prepare Mrs
Carsons for emergency surgery.
During surgery Mrs Carsons is found to have Bowel Ca —Dukes Category C. The
surgeon goes on to perform a Left Hemi-colectomy and creates a temporary colostomy.
During the procedure the bowel was perforated distal to the anastomosis but this was
repaired during the operation. She returns to the ward with a NG tube, an IDC and IV line
in situ. Her midline abdominal wound is clean and dry and covered by combine and
Hyperfix. She is receiving O2 via nasal spectacles and she is drowsy but rousable. When
asked, she states she is experiencing pain at a level of 8 out 10.
Her post-op orders are:
0• routine post-op obs
1• naso-gastric tube on free drainage.
2• oxygen @ 2L/min via nasal specs
3• nil orally
4• measure urine output 2 hourly
5• IVT: 5% Dextrose 1/5 Normal Saline 1000 ml in 8 hours (current bag)
6• normal Saline 1000 mls in 8 hours
7• 5% Dextrose and 1/5 Normal Saline 1000 ml in 8 hours.
2
3Medications:
o Morphine 5-10 mgs S/C 2—4 hourly PRN.

o Maxalon 10mg IV 6-8 hourly PRN.
o • Cephalothin 1 gm TDS IV.
o • Metronidazole 500 mgs TDS IV.
o • Gentamicin 160 mgs IV daily.
o • Panadine 500 mg-1000 mgs 4 hourly PRN.
1

• Define a Large bowel obstruction, Bowel Ca, and Left Hemi-colectomy.
• Discuss and detail Mrs Carson’s presenting clinical manifestations which result in her
large bowel obstruction diagnosis – requiring a Left Hemi-colectomy.
• Discuss the aetiology and pathophysiology of colorectal cancer and resulting large
bowel obstruction.
• Outline the reasoning for the ordered emergency surgery for Left Hemi-colectomy.
  58
• Detail the necessary Left Hemi-colectomy and the need for a temporary colostomy.
• Describe what risks are present following the intra-operative distal bowel perforation.
• Prioritise Mrs Carson’s care postoperatively and give a rationale for your answer.
• Formulate a nursing care plan for Mrs Carson including the following:
− need/problem/nursing diagnosis
− patient aims
− nursing interventions including rationale
− outcome statement
− possible changes to the nursing care plan if required.
  59
• Discuss the issues you need to consider when providing discharge planning for Mrs
Carson.
Week 10: Nursing management of Hepatobilary

Disorders
This week involves the study of the hepatobiliary system. The tutorial focuses on a
woman who develops acute pancreatitis secondary to cholelithiasis; she is admitted for an
open cholecystectomy. The workshop will focus on the nursing skills associated with
caring for patients with such hepatobiliary problems.

• apply critical thinking to the scenario presented
• apply primary health care (PHC) principles to the scenario
• utilise your knowledge of physiology and pharmacology (from 1st & 2nd year) in
your analysis of the scenario
• appreciate the relevance of cultural safety in the nursing context
• plan the nursing management of a patient with pancreatitis secondary to cholelithiasis
• Plan and implement the post operative open cholecystectomy nursing management

29. Before attending your tutorial, read this week’s scenario and
complete the readings below
Brown, D & Edwards, H (eds) 2005, Lewis’s medical-surgical nursing: assessment and
Chapters:
42 ‘nursing management: liver, biliary tract and pancreas problems’
  60
17 ‘Nursing management: preoperative care’
19 ‘Nursing management: postoperative care’
Additional pertinent reading can be found in the following:

Crisp, J & Taylor, C (eds) 2005, Potter & Perry’s fundamentals of nursing, 2nd edn,
Elsevier, Sydney.
Chapters:
47 ‘Skin integrity and wound care’
Skills:
34-9 Adding medications to IV containers, p. 874 (also on CD)
40-2 Regulating intravenous flow rate, p. 1136 (also on CD)
45–4 Inserting and maintaining a nasogastric tube, p. 1360 (also on CD)
47–3 Applying dry and wet-to-dry moist dressings, p. 1482 (also on CD)
49–1 Demonstrating postoperative exercises, p. 1556 (also on CD)
Box 47-19 Dressing application, p. 1485
Sample nursing care plans:
Skin integrity and wound care, p. 1459
McCance, K & Huether, S 2002, Pathophysiology: the biologic basis for disease in adults
and children, 4th edn, Mosby, St Louis, Missouri.
Chapter:
38 ‘Alterations of digestive function’
Consider this scenario for the tutorial

discuss your answers in the tutorial
Mrs Justine Oliver (aged 32 years and single mother of two girls) is seen in Accident &
Emergency with the following clinical findings:
• Acute RUQ pain
• Severe nausea & vomiting
• T – 37.8˚C
• P - 114
• R – 28
• BP – 110
/60
  61
• Mild jaundice
• Some abdominal distension
Her medical history is
• She has been having episodes like this for about a month, but none of them have
been this bad.
• She can’t really say if they have been associated with any particular food intake.
• The only medication that she tales is the “Pill” which is oestrogen based.
• Her alcohol intake is an average of 3 Standard Drinks a week
The MO orders the following tests
• Serology
o CBP
o LFT
o Electrolyte levels
o C-reactive Protein
• CXR
• Abdominal X-ray
• Abdominal Ultrasound
• ERCP
The results show
• Raised White Cell Count
• Raised creatine
• Raised SGOT, LDH & ALT
• Raised BUN
• Enlarged & swollen CBD & Pancreatic Duct with stones in evidence
• Raised CRP
• Raised BGL
The provisional diagnosis is acute pancreatitis due to cholelithiasis and she is to be

admitted for an open cholecystectomy. She arrives in the ward with the following orders
• N/G tube in situ on free drainage
• IVT – 3 Litres in 24 hours alternating Hartmanns with N/Saline
• N/G tube to be aspirated with IV replacement of N/Saline
• IV Antibiotics – Metronidazole 500mg/100mls TDS & Ticacillin 1g 8/24
• Analgesia
o S/C Morphine 2.5-5mg 2/24
  62
o IM Hyoscine butylbrmide 20mg/ml
• Nil Orally
You are assigned to look after her the next day when she has just returned from theatre
after her open cholecystectomy with
• IVT – with 2 lines

o the main IV line is running at 3L/24 hrs, this can be reduced once her naso-
gastric fluids have been reduced & bowel sounds have returned
o the second line is for replacement of her naso-gastric fluids which you will
need to calculate 4/24ly
• IV ABs are to continue
• Wound drain (Haemovac) in situ
• T-tube in situ
• S/C Morphine 2.5-5mg 2/24 for pain relief
• RIB with toilet privileges as tolerated for 1st 24 hours, then mobilise as tolerated
• N/G tube in situ on free drainage

o Aspirate 2/24ly – replace with IV fluids if > 50mL an hour
o To be removed once drainage < 50 mls an hour for 4 hours
• Free fluids once N/G tube is removed
• Light diet once N/G tube removed and bowel sounds are present

• Define pancreatitis, cholelithiasis, and cholecystectomy.
• Detail Mrs Oliver’s presenting clinical manifestations which result in her pancreatitis
diagnosis.
  63
• Discus the aetiology and pathophysiology of pancreatitis and cholelithiasis.
• Outline the reasoning for the ordered medical tests.
• Outline what is involved in an open cholecystectomy.
• Describe the differences between open and laparoscopic cholecystectomy.
• Prioritise Justine’s care postoperatively and give a rationale for your answer.
• Formulate a nursing care plan for Justine including the following:

− patient aims
  64
− possible changes to the nursing care plan if required
• Discuss the issues you need to consider when providing discharge planning for
Justine.
Week 11: Nursing Management of Haematological

Disorders
This week focuses on problems relating to the haematological system. Knowledge of
haematology is useful in clinical environments to assess the patient’s ability to transport
oxygen, carbon dioxide, and other blood-borne considerations. The tutorial will focus on
various haematological problems and their management options. The workshop will involve a
number of activities focussed on the OSCE assessment later in the semester. These will
involve wound management, patient education, pain management, and infection control and
prepare the student for this item of assessment.

• Describe the clinical manifestations, complications, collaborative care, and nursing
management of the patient with haematological problems. Iron-deficiency anaemia,
Neutropenia, and Thrombocytopenia will be discussed
  65
• Describe the preoperative and postoperative nursing management for the patient with
haematological considerations
• Explain the essential functions of the haematological system
• Describe age-related changes in the haematological system and differences in
assessment findings

Chapters:
29 ‘Nursing assessment: haematological system‘
30 ‘Nursing management: haematological problems‘
[Please note that you may use the 5th edition of Lewis, Heitkemper & Dirksen. The
chapter numbers may differ but the chapter titles are the same but it does not have an
Australian focus.]
33. If you wish to read more widely you may wish to revise these
chapters.
Galbraith, A, Bullock, S & Manias, E 2004, Fundamentals of pharmacology, 4th edn,

Pearson Education Australia, Prentice Hall Health, Frenchs Forest, NSW.
Chapters:
46 ‘Anticoagulants, Thrombolytics and Antiplatelet Drugs’, pp. 482-496.
50 ‘Antianaemic Drugs’, pp. 546-552.
51 ‘Drugs used to Maintain Gas Exchange’, pp.553-570.
Access the sites and note what you found most interesting for the tutorial discussion.
Haematological sites: www.uq.edu.au/vdu/HDUIntro.htm
www.imvs.sa.gov.au/haematology/index.htm
Iron deficiency Anaemia site: www.virtualbloodcentre.com/diseases.asp?did=60

Thrombocytopenia site: www.merck.com/mmhe/sec14/ch173/ch173d.html
Neutropenia site: www.virtualbloodcentre.com/diseases.asp?did=704
  66
Elements covered in the lecture, tutorial and workshop will relate to the scenario below.
The scenario questions will be discussed in the tutorial. Remember the workshop and
tutorial sessions are compulsory.
  67
Consider these questions for the tutorial
The tutorial this week examines the haematological system. Please consider the following
questions and be ready to discuss your answers in the tutorial.
Haematological Foundations
• Define the structures and functions of the haematological system
• Discuss the objective data used in the assessment of the haematological system.
• Discus the gerontological considerations in the haematological system
• List and describe the full blood count (FBC) diagnostic studies.
• List and describe the clotting diagnostic studies.
  68
Haematological Problems
• Describe iron-deficiency anaemia and its clinical manifestations.
• Describe the nursing management of this haematological condition.
• Describe Neutropenia and its clinical manifestations.
• Describe Thrombocytopenia and its clinical manifestations.
  69
  70
Week 12: Part 1 - Nursing management of

Reproductive Disorders – Female Focus
This week focuses on two problems relating to the female reproductive system. The
tutorial examines endometriosis and its management options. The workshop will involve
a number of activities related to the post operative management of an abdominal
hysterectomy.

management of the patient with endometriosis
• Describe the preoperative and postoperative nursing management for the patient
requiring major surgery of the female reproductive system
• Explain the functions of the major hormones essential for the structure and function
of the female reproductive system.
• Describe age-related changes in the female reproductive system and differences in
assessment findings.
• Describe the nursing and collaborative management of the patient undergoing an
abdominal hysterectomy.

Chapters:
49 ‘Nursing assessment: reproductive system’
52 ‘Nursing management: female reproductive problems’
Australian focus.]
chapters.
Galbraith, A, Bullock, S & Manias, E 2001, Fundamentals of pharmacology, 3rd edn,

Chapters:
34 ‘Non-steroidal anti-inflammatory, antipyretic and analgesic drugs’, pp. 371-385.
53 ‘Adrenocortical and gonadial pharmacology’, pp. 609-630.
  71
or
Lehne, RA 2001, Pharmacology for nursing care, 4th edn, WB Saunders Co,
Philadelphia.
Chapter:
61 ‘Drug therapy for infertility’, pp. 705-713.
Hysterectomy sites: www.womhealth.org.au/factsheets/hysterectomy.htm
www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Hysterectomy_surgical_proce
dures?open
www.mja.com.au/public/issues/feb17/tsaltas/tsaltas.html
Endometriosis sites: http://www.ecca.com.au/home.html

http://www.endometriosisassn.org/endo.html
  72
discuss your answers in the tutorial.
Tracey is 38 years of age and has been in a stable relationship with her partner David for 11
years. They live in Pasadena and both work full time in the hospitality industry. Tracey has
been living with endometriosis, dysmenorrhoea and dyspareunia. she was first diagnosed
following a diagnostic laparoscopy at 20. She has undergone another two laparoscopies which
involved laser surgery to remove the many ‘chocolate cysts’ found in her peritoneal cavity.
Tracey has also tried a six-month course of danazol but was unable to tolerate the acne side
effects. Tracey and David have been unsuccessful in becoming pregnant after trying for seven
years with IVF. Tracey is now fed-up with the pain and disruption to her life and the lost time
from work. Together they have discussed the options and Tracey has decided to have an
abdominal hysterectomy so that laser oblation of the endometriosis can occur at the same
time. While the nurse is alone with Tracey, she tells the nurse that prior to her relationship with
David she become pregnant and had a termination. She does not want David to know about
this.
Tracey is prepared for theatre and David walks beside her until he reaches the transfer bay.
The ward RN walks David back to Tracey’s room to await her return. Four hours later, Tracey
returns to the ward very sleepy with the following postoperative care orders:
Routine postoperative vital signs and wound/rain checks:
• morphine PCA and purge

• IVT for hydration 4% dextrose and 1/5 normal saline
• IDC
• wound drain
• wound covered and dry
• RIB
• fluids when bowels sounds return and passage of flatus.

• Define endometriosis, dysmenorrhoea and dyspareunia
  73
• List the psychosocial issues for Tracey and David at this time. Discuss how you could
assist them?
• Discuss the ethical issues surrounding patient confidentiality concerning this case.
• Outline how Danazol works in the body & its main side effects.
• Outline what is involved in an abdominal hysterectomy i.e. operative approach and

organ removal
  74
• Describe what laser oblation of the endometrial implants entails.
• Prioritise Tracey’s care postoperatively and give a rationale for your answer.
• Formulate a nursing care plan for Tracey including the following:

− patient aims
− possible changes to the nursing care plan if required.
• Discuss the issues you need to consider when providing discharge planning for
Tracey.
  75
Week 13: Part 2 - Nursing management of

Reproductive Disorders – Male Focus
This week focuses on problems relating to the male reproductive system. The tutorial will
examine Benign Prostatic Hyperplasia (BPH) and its management options. The workshop
involves a number of activities relating to the post-operative management of bladder
irrigation following a transurethral resection of the prostate (TURP) secondary to BPH.

management of the patient BHP
• Describe the preoperative and postoperative nursing management for the patient
requiring major surgery of the male reproductive system
• Explain the functions of the major hormones essential for the structure and function
of the male reproductive system
• Describe age-related changes in the male reproductive system and differences in
assessment findings
• Describe the nursing and collaborative management of the patient undergoing a
transurethral resection of the prostate
  76
Chapters:
49 ‘Nursing assessment: reproductive system’
53 ‘Nursing management: male reproductive problems’
Australian focus.]
chapters.
Galbraith, A, Bullock, S & Manias, E 2001, Fundamentals of pharmacology, 3rd edn,

Chapters:
34 ‘Non-steroidal anti-inflammatory, antipyretic and analgesic drugs’, pp. 371-385.
53 ‘Adrenocortical and gonadial pharmacology’, pp. 609-630.
Prostate cancer site: http://www.prostate.org.au/
TURP sites:
www.health.qld.gov.au/informedconsent/PatientInformationSheets/patient_infosheet_08.pdf
www.barwonhealth.org.au/periop/urology/trans.htm
www.medicalobserver.com.au/patienthandout/displayhandout.asp?ID=198
www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Prostatectomy?OpenDocument
  77
discuss your answers in the tutorial.
Mr Gregory Roller first went to his GP with a 1 year history of decreased force and
volume of his urinary stream, difficulty in starting urination, and dribbling at the end
of urination. He also reported an incomplete feeling on emptying his bladder. He now
has frequency, nocturia, and dysuria and he has had 2 Urinary Tract Infections (UTI)
in the past 2 months. He has had a pre-operative C&S of his urine and is currently
free from infection. He also has the occasional indigestion and dyspepsia which
respond well to antacid medication. Mr. Roller is 65 years of age and weighs 102kgs.
Mr Roller has been admitted to your ward to undergo a Trans-urethral-resection-
prostate gland (TURP) procedure secondary to benign prostatic hypertrophy (BPH).
Pre-operatively Mr. Roller was visited by an anaesthetist and the attending surgeon.
The doctor has ordered that he have the following tests done
• CBP and Cross Match
• CXR
• ECG
• PSA
Nursing assessment on admission revealed that he is quite anxious about surgery, and
his indigestion has been troubling him. His urinalysis: Ph 5.5 NAD
• Post op orders
• Routine post operative care
• Standard triple lumen catheter and continuous bladder irrigation (CBI) with
N/Saline – 2000ml flasks.
• Check patency of catheter and CBI flow 1/24ly & prn
• Change CBI flasks prn to maintain continuous bladder irrigation.
• FBC
• IVT: Hartmanns running at 100 – 120mls/hr
• Pain relief Morphine 10-15mg sc 4/24ly
• Antiemetics as per post-op pathway for nausea & vomiting
• Check wound 1/24ly
• IV ABs
• IV Oxybutin 5mg 8.24ly prn – oral
• Ceftriaxone (Rocephin) 500 mg BD
• Oral stool softeners
• Breathing, coughing and leg exercises
  78
• Frequent changes of position
• Pelvic Floor Exercises

• Define Benign Prostatic Hyperplasis (BPH), nocturia, dysuria, and trans-urethral
resection of the prostate (TURP).
• Discuss the aetiology and pathophysiology of BHP.
• Discuss Mr Roller’s clinical symptoms and their relevance to diagnosis of BHP.
• List the psychosocial issues for Mr Roller at this time. Discuss how you could assist
him?
  79
• Discuss the diagnostic studies employed to confirm BPH.
• Outline the reasoning for the performance of a TURP on Mr Roller.
• Detail what is involved in a TURP.
• Prioritise Mr Roller’s care postoperatively and give a rationale for your answer.
• Formulate a nursing care plan for Mr Roller including the following:

− patient aims
− possible changes to the nursing care plan if required
  80
• Discuss why confusion is frequently experienced post-operatively with TURP
procedures.
• Discuss the issues you need to consider when providing discharge planning for Mr
Roller.
  81

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FLINDERS UNIVERSITY

Nursing & Midwifery Faculty of Health Sciences

Week 2: Part 2 - Nursing Management of Musculoskeletal Disorders.............................10

Week 1: Part 1 - Nursing Management of Musculoskeletal

Learning outcomes for this week

What you need to do to meet your learning outcomes

3. Visit these websites

Access the following websites:

4. Attend the tutorial and workshop for this week

Postoperatively his care is outlined as follows:

• routine post op vital signs

Please come to the tutorial prepared to discuss the following questions:

• Define a PCA and explain why it is not used on all patients.

• Outline the discharge planning which is required for Mr Heinrich.

• Focus on Mr Heinrich’s elderly Primary Health Care issues.

Week 2: Part 2 - Nursing Management of Musculoskeletal

Learning outcomes for this week

What you need to do to meet your learning outcomes

Consult a pharmacology text regarding:

8. Visit these websites

Access the following websites:

9. Attend the tutorial and workshop for this week

His care is outlined as follows:

• 4/24 vital signs

• Ward diet and fluids.

• Bowel monitoring and coloxyl and senna when necessary.

• Focus these Primary health issues on Mr Cartwright’s circumstances.

NURS2105: Study plan

Week 3: Part 1 Nursing management of Cognitive and

Learning outcomes for this week

What you need to do to meet your learning outcomes

His health history reveals:

• cigarette smoker for 50 years, about 10 a day

• hypertension managed with

• no history of recent head trauma

• no FFFFTs (no fits, faints, falls, funny turns)

• ECG shows sinus rhythm

• assessed by emergency medical officer who orders a CT scan

• neurological examination found the following clinical features:

– weakness and parathaesia of left limbs

The decision is made to give him streptokinase, followed by a heparin infusion.

• O2 therapy 2L/min through nasal cannulae

• Activated Partial Thrombin test

• IVT 2L in 24 hours—4% dextrose and 1/5 normal saline

• continue with antihypertensive therapy

• IV heparin therapy—1000u every hour

• electrolyte blood levels

• Speech therapy consult

• Nil orally until seen by the speech therapist.

Please come to the tutorial prepared to discuss the following questions:

• Formulate a nursing care plan for Angelo.

• Determine the aims of rehabilitation for Angelo.

NURS2105: Study plan

Week 4: Part 2 Nursing management of Cognitive and

Learning outcomes for this week

What you need to do to meet your learning outcomes

Please see the following intracranial web sites:

Consider the following scenario for your tutorial

At the scene of the accident he was:

• Unresponsive with Glasgow Coma Scale of 3.

• Tachycardic 120 to 130 bpm.

• Respirations rapid and shallow – 30 breaths per minute.