Kelly J Wilson

4140880602 Vocational placement assignment case study

Edia Ovie is a morbidly obese, quadriplegic she is 62 years of age, recently widowed
African-American female from a small rural town in central Darling Downs, and she
is being seen by a local physician for enduring chronic physical and emotional
conditions.

Mrs Edia Ovie has three sons and one daughter living in the same shire, one son lives
at home with Edia Ovie whom provides care and administers her medication and
provides her with her meals.

A nursing assistant cooks the meals for Mrs Edia Ovie when she is there, the other
two sons and daughter pre-fills the medication planner and administers her insulin
injections.

In July 2nd 1999 Mrs Edia Ovie was admitted to the local hospital for complaints of
sporadic chest pain, back pain and pain in the left knee. Edia spent three days in acute
ward before being transferred to medical ward.

Prior to her discharge, Edia had a consult with the local mental health centre for
medication consultation after episodes of aggressive behaviour.

September 2nd 1999 Mrs Edia Ovie was admitted to the local hospital for
hypoglycaemia there she was being treated by another physician and referred the local
mental health centre for confusion and medication consultation. Edia’s medication
and diet were changed upon discharged.

The leading contributing illness that is affecting Mrs Edia Ovie’s health is that she
had experienced Cerebrovascular accident on three separate occasions leaving her
with the left side weak in muscle movement, dysphasia and quadriplegic.

The common name for Cerebrovascular accident is a stroke, this can only occur when
the blood vessels in the brain is block or erupt. Without a blood supply with oxygen
it carries, a part of the brain starves from lack of oxygen and starts to die.

The results can vary depending on where in the brain the damage had occur, some
parts of the body that are related to that specific area may not function fully or not at
all. Damage to the brain can begin in minutes, only quick treatment can help limit the
damaging affects on the brain and increase the chances of a full recovery.

When the neurons and the glia die due to not receiving any oxygen and nutrients from
the blood supply or they are damaged by a haemorrhage into or around the brain, the
cells can hang around in a via media state for several hours after the incident; with
timely treatment they can be saved.

However when these cells suffer the ischemia free zinc ions begin to enter the cells
which are released from their own proteins even the metallothionein, as this can
release seven (7) zinc ions per molecule. The zinc released is the major contestant in
assuring the death of the brain cells, there are drugs that can buffer the zinc and
reduce the level of free zinc that is already being tested to reduce the brain cell death
after the Cerebrovascular accident.
Kelly J Wilson
4140880602 Vocational placement assignment case study
As the neurons in the surrounding ischemic or infracted areas go through some
changes that interrupts the plasma membranes as cellular edema results thus causing
further compression of the capillaries.

Symptoms that are related to the intracranial haemorrhage from an erupted or leaking
aneuryusm could include one of the following three sets of symptoms: (1)
excruciating headache with immediate lapse into a non-responsive state, (2) headache
but still in conscious state and (3) sudden lapse into unconsciousness.

If there is haemorrhaging constricted to the subarachnoid space local symptoms may

not appear, however if the bleeding moves and spreads into the brain tissue
hemiparesis/paralysis, dysphagia or homonymous hemianopia could be present.

Impending eneurysm rupture may show symptoms of headache, transient one-sided

weakness, transient numbness and tingling, and transient speech disruption. However
many signs can differ from person to person and in some cases there may not be any
at all.

Mrs Edia Ovie lives in a small old house with one of her sons and she also has a
nursing assistant comes in and assist with daily activities and help cook meals for Mrs
Edia Ovie when possible.

Other 2 son and a daughter come in also to assist in medication daily and ensure that
the house is tidy and clean for their mother.

Edia doesn’t go out after her last stroke, spends all of her time either in bed, lounge
room or out in her back yard in amongst the gardens. Only visitors Edia has is her
family that provides care and the nursing assistant that comes daily for a few hours.

Mrs Edia Ovie is pleasant, alert and oriented to person, place and general time. She is
very talkative although her speech is slow but it is understandable to what she is
saying. Edia has occurrences of depression and aggressive behaviour from time to
time; her depression could be a link with her recent loss of her husband Lorey.

In Mrs Edia Ovie’s is able to mobilise herself around in a wheel char but is unable to
move from side to side without assistance, Edia is able to hold on one with the aide of
a bed rail on the bed when turned on the side with assistance.

Assistance is required to go from inside to outside and vice versa as the ramp is too
steep for her to push herself up and she feels uncomfortable going down as Edia is
afraid of failing of the ramp.

There is a potential problem for aspiration as there is a diminished gag reflex and
impaired swallowing ability with some associated weakness on the left hand side.

Dysphasia is apparent as there is impairment of the power of expression by speech

and some impairment of comprehension of spoken words.

Impaired physical mobility related to disuse secondary to cerebrovascular attack.

Kelly J Wilson
4140880602 Vocational placement assignment case study
The cerebrovascular accident can have a big impact on Mrs Edia Ovie’s activities of
daily living especially when she has developed dysphasia, weakness on one side (left)
and quadriplegic as well of having type 1 diabetes.

The way that these illnesses can impact on Mrs Edia Ovie’s ADL’s;
o Unable to perform hygiene needs
o Unable to complete house hold duties
o Unable to complete the need of self nutrition.
o Difficulty in completing self dressing tasks.
o Difficulty mobilising independently
o Loss of sensation
o Loss of bowel and or bladder control
o Loss of independence
o Experience loss in self-image, sense of self-worth, self esteem, and
sexuality

The nurse can assist with the problems that may inhibit the activities of daily living in
Mrs Edia Ovie’s life by helping her to set simple short term goals and provide her
with interventions or ways for her to reach her set goals.

To assist Mrs Edia Ovie with her mobility and to make her feel a little more
comfortable the nurse can follow the steps below;

Goal: full passive and active ROM to all extremities.

Nursing Rx:
1a. Apply warm moist compresses to all of the joints for 20 mins before performing
passive and active ROM to all extremities.
SR: The heat promotes muscle relaxation and mobility, decrease pain and relieves
morning stiffness. (Doenges, 878)

1b. Perform passive and active ROM once a day for 5 mins at a time to all
extremities.
SR: This help in the prevention of join contractions and muscular atrophy. (Sparks,
178)

1c. Perform comfort measures to help encourage relaxation; for example, bathing,
massage, repositioning. This needs to be done between 10 to 20 minutes after the
passive and active ROM were performed.
SR: These measures help reduce the tension or spasm and redistribute the pressure on
the body and help the client focus on non-pain related activities that they might be
interested in doing. (Sparks, 204)

Goal: using positional techniques (eg; Fowlers position, extended leg joints
and foot board)

Nursing Rx:
2a. Assist the client to develop a sitting balance by raising the head of the bed to a 60
degree angle for 10 to 20 minutes when possible throughout the day.
Kelly J Wilson
4140880602 Vocational placement assignment case study
SR: Increase the sitting time, aids in retraining neuronal pathways. (Doenges, 296)

To assist Mrs Edia Ovie’s to eat and help prevent any episodes of choking as she is a
candidate for aspirating which relates to diminished gag reflex and impaired
swallowing ability, the nurse can perform the following;

Goal: Prevent client from aspirating at any time.

Nursing Rx:
1a. Elevate the head of the bed to a high Fowler’s position (60º) before, during and 5
minutes after the meal.
SR: the client should be sitting up straight in bed or in a chair (what ever is the aid
client uses to sit out of bed during the day time) while eating meals to prevent
aspiration. (Medical-Surgical, 890)

1b. Place food on the unaffected area/side of the mouth.

SR: This provides a sensory stimulation which may trigger swallowing action and
enhance the intake. (Medical-Surgical, 891)

Goal: encourage the client to eat 80% to 100% of each meal.

Nursing Rx:
2a. Refer to the dietician to modify the client’s diet and calorie count, as needed.
SR: This is to establish a adequate nutritional needs. (Medical-Surgical, 896)

Goal: demonstrate correct eating techniques to maximize the swallowing such

as placing the bed head in a high Fowler’s position and eating slowly.

Nursing Rx:
3a. Tipping the head forward to help to decrease the risk of aspiration.
SR: The client’s head and neck are slightly forward this allows the esophageus to be
straightened thus allowing for ease of swallowing. (Medical-Surgical, 890)

Mrs Edia Ovie communication is impaired to secondary to CVA; to assist maximum

communication ability the nurse can perform the following;

Goal: Encourage the client to express their needs.

Nursing Rx:
1a. Ask short questions to be answered with a “Yes”, “No” or a nod and giving the
client plenty of time to respond.
SR: this allows the client to express their needs by only answering with simple yes or
no answer.

1b. Make use of picture flash cards to indicate needs.

SR: this allows the client to show the nurse their need.

1c. Stand within the client’s line of vision makes use of simple gestures as an added
cue.
SR: Be supportive and accepting as the client deals with the frustration of finding the
right words.
Kelly J Wilson
4140880602 Vocational placement assignment case study

1d. Divide any task into small units, working with the client to accomplish those tasks
and give praise along the way.
SR: This reinforces the client’s self-esteem and helps them to keep trying and not to
give up on the task and slowly building their independence.

Two factors of Watson’s cartive factors can be of help here by involving the
interpersonal care which consists of a moment of caring for which the client and the
nurse are coming together within the circumstance of the personhood of each
individual.

The carative factors are: 1. Development of helping, trusting, human caring

relationship, and 2. Assistance with gratification of human needs. These factors relate
to Mrs Edia Ovie as they help the nurse to return to the most basic of the human
needs, caring and healing.

The nursing interventions that are in place for Mrs Edia Ovie will be evaluated based
on the patients progress towards each outcome criteria, this can be done by
observation whilst performing the task in place to achieve the client’s goal.

For such interventions as “feed the client liquids which have been thickened, as thin
fluids is more likely to cause aspiration.” And the evaluation outcome for this
intervention might look “client did not have any problems with choking throughout
the shift/day” other things that may need to look at is after evaluating the client with
the intervention you can then also look at, was the nursing Dx appropriate for this
client.

Before discharging the client there is a checklist that must be completed by the
hospital staff before the client is able to leave, as this done along side with the
admission.

Things that are on a discharge checklist are:

Administrative:
o Have you recorded your name and the time you saw the patient?
o Have you identified the contact details of the patients LMO of
specialist?
o Recorded the patients best contact details?

Diagnostic:
o What is the diagnosis?
o What is the differential diagnosis?
o Have you documented investigation results?
o Have a follow up of results been organised?

Management:
o Discharged plan recorded
o Explained to the patient
o Discharged medications dispensed and
Kelly J Wilson
4140880602 Vocational placement assignment case study
o Explained
o Communication with the patients regular practitioner
o Copy included in the medical record
o Is there a follow-up required?
o Explained to the patient (including symptoms requiring return)
o Medical certificate (including TAC, Workcover)

Social
o Social support needed?
o New disabilities or limitations in activity documented?
o Have the next of kin or carers been notified?
o How is the patient retuning home?

Mrs Edia Ovie is able to perform some self care routines such as grooming, wash
face, brush teeth and clean her glasses. The client can mobilize herself around in a
wheelchair by propelling herself using her strong arm or by pulling herself along
using the rails alongside the wall but for only short distances at a time.

Mrs Edia Ovie has trouble with meeting her personal hygiene needs as she is unable
to stand and is weak on the left side secondary to the CVA; to help her overcome this
problem the client needs full assistance by one person, needs two people to assist in
all transfers, lifting and to utilize aides and machines where ever possible.

Assistance is required by one person to help the client to meet her nutritional needs;
although the client is able to feed herself in small intervals supervision is required as
there is a tendency of aspirating.

To help Mrs Edia Ovie to meet her needs, a carer is needed who drops by a certain
particular time/s of the day each week is advisable to able the family (main care
givers) a break from time to time. Respite may be an option as this enables Mrs Edia
Ovie to meet her social needs as well as any other.

To ensure that client’s needs are fully met, array of services may be needed. For the
individual herself a service such as a respite service one a week may be the thing this
gets her out of the house into the community talking with others and making new
friends, this is helpful to her psychological, social and emotional needs.

A carer can be utilized once a day by coming in and fulfilling some of the client’s
needs such as personal hygiene, nutrition needs and at the same time giving time to
the main care givers time to themselves.

Entry written in the client’s record:

25/5/2008, 0800hrs.
-------------------------------------------------------------------------------
Mrs Edia Ovie had a big breakfast this morning she had ate all of her cereal (porridge
puréed), main (purée baked beans) and fruit (soft fruit Banana). I asked Edia would
she like some more and Edia replied yes I would love some more please, I returned
with some more soft fruit (Banana). Edia ate it all with no problems. --------------------
Kelly J Wilson
4140880602 Vocational placement assignment case study
EN Kelly j Wilson kjw ---------------------------------------------------------------------------

Appendix I
Kelly J Wilson
4140880602 Vocational placement assignment case study

Appendix II.I
Kelly J Wilson
4140880602 Vocational placement assignment case study

Appendix II.II
Kelly J Wilson
4140880602 Vocational placement assignment case study
 Kelly J Wilson
4140880602 Vocational placement assignment case study
Appendix III U.R. No. LMO
Appendix III SURNAME
GIVEN NAMES ADDRESS
PHONE
Clinical Pathway Discharge Plan SEX AGE D.O.B.
Disclaimer: This tool is only a guide and does not (Or attach Client I.D. Label)
replace clinical judgement.

Commence discharge plan on admission and complete prior to discharge of a veteran from the community
nursing service. Items on the discharge plan should be dated and ticked when achieved.
Expected date of discharge / /
Date Education
The veteran and/or carer have been provided with verbal and written information and
education, in the appropriate language, relating to
 Ongoing health management
 Medications
 Use of equipment aids & appliances
 Possible complications & warning signs
Comments______________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________

Date Contacts
The veteran and /or carer have been provided with
 An appropriate post-discharge contact to answer queries and address concerns
 Any relevant follow-up appointments
 Contact details for relevant follow-up services
Comments______________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________

Date Discharge information

Relevant discharge information has been provided to
 Veteran &/or carer or authorised representative  LMO  Community providers
 Hospital  Hospice  Residential Aged Care Facility
 Other (specify)_____________________________________________________________
Comments__________________________________________________________________

Date Equipment aids & appliances

Veteran and/or carer are aware of
 Where to return any borrowed equipment
 Where to obtain other aids & equipment they may need
Comments__________________________________________________________________

To acknowledge the involvement of the veteran and/or carer or authorised representative (as referred to in the
Assessment and Clinical Pathway Entry Point, ‘Legal’ page 7) both the nurse and the veteran
and/or carer or authorised representative should sign below.

Date / / Signature of nurse_________________________________________

Signature of veteran or authorised representative___________________________________________

Kelly J Wilson
4140880602 Vocational placement assignment case study
References:

Chapey, R. (1994). Assessment of language disorders in adults. In R. Chapey (Ed.), Language

intervention strategies in adult aphasia (pp. 80-120). Baltimore: Williams & Wilkins.

Chapman, S.B. & Ulatowska, H.K. (1991). Aphasia and aging. In D.N. Ripich (Ed.), Handbook
of geriatric communication disorders (pp. 241-254). Austin, TX: Pro-Ed.

Cole, B., Finch, E., Gowland, C., & Mayo, N. (1994). Physical rehabilitation outcome measures.
Toronto: Canadian Physiotherapy Association.

State University of New York, University at Buffalo, Archive Search: CVA. Sighted
18/06/2008 from http://listserv.buffalo.edu/cgi-bin/wa?S2=CAREPL-
L&q=cva&s=&f=&a=&b=

Powell, Leigh CCNS. (7/12/1995). Swallowing impairment r/t muscle weakness in throat
secondary to CVA. Message posted to listserv, archived at http://listserv.buffalo.edu/cgi-
bin/wa?A2=ind9512&L=CAREPL-L&P=R497

Baker, Trudy. CCNS. (10/4/1996). Impaired physical mobility related to disuse secondary
to CVA. Message Posted at listserv, Archived at http://listserv.buffalo.edu/cgi-bin/wa?
A2=ind9604&L=CAREPL-L&P=R366

Lewis, Heitkemper, Dirksen, Textbook of Medical Surgical Nursing 6th ed, pp 1525 –
1546.

Indiana Sate University, Nursing, Bennett, Nanda. Suggested Nursing Diagnosis. Cited
18/6/2008 from http://web.indstate.edu/mary/nanda.html

Indiana Sate University, Nursing, Bennett, Nanda. Example Nursing Diagnosis

(aspiration). Cited 18/6/2008 from http://www-isu.indistate.edu/mary.carep.html

Larson, Kiser. DR ( 2007). Integration of Watson’s Theory within Nursing Practice. North
Dakota State University. Sighted 19/6/2008

Watson, J. (2006). Jean Watson and the theory of human caring. Retrieved 19/6/2008
from http://www2.uschsc.edu/son/caring/content/tranpersonal.asp

Probst, Katherine, RN, BSN (19/10/1999). East Carolina University, Interdisciplinary

Case Conference, Diabetes Mellitus / Hypertension. Retrieved 19/6/2008 from
http://www.ecu.edu/irhtp/Curriculum_Comp/case_examp.htm#Patient%20Profile:

Australian federal Government, Department of Veterans Affairs. Discharge Plan retrieved

19/06/2008 from
http://www.dva.gov.au/health/provider/community_nursing/pathways/pathindex.htm
Kelly J Wilson
4140880602 Vocational placement assignment case study
Victorian Managed Insurance Authority, Monash Medical Centre (ED) Discharge
checklist. Retrieved 19/6/3008, from
www.vmia.vic.gov.au/skillsEDIT/clientuploads/48/EmergencyDepartmentdischargechecklistproject_1.pdf

Funnel, R. Koutoukidis, G. Lawrence, K. Tabbners Nursing Care 4th Ed. 2005 Elsevier
Australia pg 756.

Sorensen, K. C. Luckmann, J. (1986) Basic Nursing, A Psychophysiologic Approach. W.

B. Saunders Company Sydney Australia. Pg 96,776.
Kelly J Wilson
4140880602 Vocational placement assignment case study

Vocational Placement Assignment

Case Study
Mrs Edia Ovie

May 2007

Kelly J Wilson
15