Long question

Jenny, a 72-year-old lady, has complained of an increase of leg pain while walking and performing exercise in the past two months. She is a
chronic smoker living with her husband. Furthermore, she has histories of cataract, hypertension, and diabetes mellitus with regular follow-up.
Her blood picture reveals hypercholesterolemia. On physical examination, the skin of her left leg is cool and appearing pale, and pulses are weak
once the affected leg is elevated. Jenny informs you that she can only manage to walk about a block because of pain over her left calf. As a
result, she becomes more home bounded in the recent two months. Haemodynamically, Jenny’s systolic blood pressure in her leg is an average
of 82 mmHg lower than her arms. The doctor makes the diagnosis of peripheral arterial disease (PAD) on her left leg.

a) Identify FIVE possible risk factors of developing peripheral arterial disease (PAD) in the case of Jenny. (5 marks)

Aging- Walls of arteries and arterioles become thicker (lumens of arteries reduced) and elasticity of the arteries are loss. It increases the
formation of blood clot. Together with narrowed blood vessels, it reduced the amount of blood flow to peripheral arteries.

Smoking- Nicotine cause constriction of blood vessels, making the blood vessel less elastic.

Hypertension- Increase the formation of blood clot inside the arteries, causing the lumen of the blood vessel becomes narrowed.

Diabetes mellitus- Excessive blood sugar decreases elasticity of blood vessels and cause them to narrow, reducing the blood flow to peripheral
arteries.

Hypercholesterolemia- Plaques accumulate in the vessel wall, causing vessel lumen to be narrowed.
Long question (Cont’d)

Jenny, a 72-year-old lady, has complained of an increase of leg pain while walking and performing exercise in the past two months. She is a
chronic smoker living with her husband. Furthermore, she has histories of cataract, hypertension, and diabetes mellitus with regular follow-up.
Her blood picture reveals hypercholesterolemia. On physical examination, the skin of her left leg is cool and appearing pale, and pulses are weak
once the affected leg is elevated. Jenny informs you that she can only manage to walk about a block because of pain over her left calf. As a
result, she becomes more home bounded in the recent two months. Haemodynamically, Jenny’s systolic blood pressure in her leg is an average
of 82 mmHg lower than her arms. The doctor makes the diagnosis of peripheral arterial disease (PAD) on her left leg.

b) As a nurse, how should you assess the condition on the affected leg of Jenny in FIVE different ways? Provide the related rationales. (5 marks)

Recommend for magnetic resonance angiography (MRA) scan and interpret the result.

R: MRA uses radio waves to create images of blood vessels. It can help detect narrowing of arteries.

Measure the blood flow of the legs using doppler and duplex ultrasound.

R: Duplex and doppler ultrasound involves the use of high frequency sound waves to look at the speed of blood flow in the veins. The lower the
speed of blood flow, the higher the chance is for peripheral artery disease to occur.
Assess for decreased sensation of patient’s legs.

R: With reduced blood flow to the legs, it reduces oxygen supply to patient’s legs and decrease patient’s sensation of the legs.

Assess the skin colour of the affected leg, such as pale and cold skin.

R: With insufficient blood flow, it causes loss of warmness to the peripheral areas.

Elevate the affected leg slightly to see whether the patient complains pain.

R: Elevate the affected leg slightly cause more blood return to the heart and less blood flow to the peripheral circulation. With little reduction of
blood flow, it causes little more pain to the patient.

Measure the ankle brachial index for the patient.

R: By measuring the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the arm, it can reflect the amount of blood flow
in the legs. As artery narrows in the distal area (ankle), it should have a lower blood pressure.
Long question (Cont’d)

Jenny, a 72-year-old lady, has complained of an increase of leg pain while walking and performing exercise in the past two months. She is a
chronic smoker living with her husband. Furthermore, she has histories of cataract, hypertension, and diabetes mellitus with regular follow-up.
Her blood picture reveals hypercholesterolemia. On physical examination, the skin of her left leg is cool and appearing pale, and pulses are weak
once the affected leg is elevated. Jenny informs you that she can only manage to walk about a block because of pain over her left calf. As a
result, she becomes more home bounded in the recent two months. Haemodynamically, Jenny’s systolic blood pressure in her leg is an average
of 82 mmHg lower than her arms. The doctor makes the diagnosis of peripheral arterial disease (PAD) on her left leg.

c) Formulate a care plan to address ONE nursing problem regarding Jenny’s ability of activities (1 mark). The plan should include TWO
expected outcomes (1 mark), SEVEN interventions with respective rationales (7 marks), and ONE indicator for evaluation. (1 mark)

Problem: Reduced mobility due to peripheral arterial disease.

Expected outcomes: Ankle brachial index increases to the normal range.

Skin colour returns of Jenny’s left leg returns to normal.

Interventions and rationales

I: Continue to assess for signs of peripheral artery disease regularly. e.g. ankle brachial index, skin colour and texture.

R: Cold and pale skin reflect a lack of supply of blood to the peripheral circulation; measuring the ankle brachial index can reflect the severity of
arterial occlusion and ischaemia.

I: Encourage bed rest.

R: To reduce numbness and painfulness to Jenny due to insufficient blood flow to the peripheral arteries.

I: Use a foot cradle and lightweight blankets, socks and slippers to keep extremities warm.

R: Keeping extremities warm can conserve heat, prevent vasospasm and promote arterial flow.

I: Instruct to avoid crossing legs or using a pillow under the knees.

R: Leg crossing can compress partially obstructed arteries and impair blood flow to the distal tissues.

I: Encourage frequent position changes.

R: To promote blood flow and reduced damage caused by pressure, improving capillary circulation and reduce ischaemia.
I: Advise Jenny to quit smoking.

R: Smoking promotes platelet aggregation. Nicotine causes constriction of blood vessel. It reduces lumen of the arteries and reduces blood flow
to the peripheral circulation.

I: Keep extremities warm.

R: Warming the extremities promote vasodilation and improve arterial flow of blood. Hence, it reduces the numbness to the extremities.

I: Avoid electric heating pads or hot water bottles.

R: To reduce the risk of burns in as Jenny is with impaired sensation on her legs.

I: Encourage the patient to reduce stress.

R: Stress leads to vasoconstriction and increases pain to the peripheral circulation.

I: Encourage gradual increase in intensity of exercise.

R: Exercise promotes development of collateral circulation to ischaemic tissues.

Indicator: Ankle brachial index of Jenny increases to reach the normal range (1.0-1.4)
2. Rafael, a 40 year-old man complains of fever, running nose and coughing with yellowish sputum

for more than a week. He has developed tachypnea, used accessory muscles to breathe and appeared drowsy since yesterday. He was sent to the
Accident & Emergency Department. His vital signs showed body temperature: 40.2o, SpO2: 87% on room air, and respiration rate 36 bpm.

Arterial Blood Gas (ABG) results are shown as below. Physical examination and chest X-ray show

signs of pneumonia. He is diagnosed with pneumonia and acute respiratory failure. The physician

ordered noninvasive mechanical ventilation to support his compromised ventilation.

Arterial blood Reference range

pH 7.23 7.35-7.45

PaCO2 70 35-45 mmHg

PaO2 55 80-100 mmHg

HCO3 25 22-26 mmHg

Base excess 0 -2.0 to +2.0 mmol/L

Oxygen saturation 88% 95-100%

a. Which type of respiratory failure does Rafael have? Explain with the information provided. (2 marks)

Type II respiratory failure. The patient has PaO2 <60mmHg and PaCO2 >50mmHg

b. Formulate a care plan to address ONE of his breathing problems. The plan should include his nursing problem (1 mark), immediate goal (0.5
mark), FIVE prioritized interventions with rationales (10 marks), and THREE expected outcomes. (1.5 marks)

Problem: Respiratory acidosis related to prolonged sputum production.

Immediate goal: No sputum produced by the patient.

Interventions and rationales:

I: Continue to assess vital signs, such as BP, pulse, SpO2, RR, HR, GCS level.

R: Vital signs serve as an indicator for respiratory function. For example, if patient has high respiratory rate, it means that the patient experience
difficulties in breathing.

I: Obtain sputum culture from the patient for laboratory testing.

R: To know which type of bacterial infection does the patient suffer from.
I: Encourage the patient to drink more water.

R: To maintain the moisture of the respiratory tract so that the patient can cough out the sputum more easily.

I: Perform percussion, vibration and postural exchange on the patient.

R: Percussion helps dislodge mucus; vibration helps loosen thickened secretions while postural drainage helps remove mucus out of patient’s
body by gravity.

I: Encourage the patient to perform deep breathing and coughing exercise, such as diaphragmatic breathing and pursed-lip breathing.

R: Diaphragmatic breathing reduces respiration rate and increases alveolar ventilation; pursed-lip breathing helps slow down expiration and
prevents collapse of small airways.

I: Have the patient sit in semi-Fowler’s position.

R: To stimulate maximum expansion of chest that helps the patient breath.

I: Continue to evaluate data of the patient in the ABG report regularly.

R: As indicator for whether patient has improvement in respiratory function. For example, increase in PaO2 means that the patient can breathe in
oxygen into the body more effectively, showing an improvement the condition.
Expected outcomes:

pH of the patient blood increases.

No yellowish sputum produced by the patient.

PaO2 of patient blood increases and PaCO2 of the patient decreases.

Mr. Wen is a 50-year-old man who is a taxi-driver. He was admitted to coronary care unit due to sudden onset of chest pain. He presents chest
pain with radiation to left arm and neck but he denies breathing difficulty. The blood test for Troponin I has been done in the Accident and
Emergency Department (AED) and the result is 1.81 ng/mL (reference range e <0.03 ng/mL). Based on the 12-lead electrocardiogram (ECG),
Mr. Wen is diagnosed with ST elevation MI and thrombolytic therapy is prescribed.

a) What is the major complication of thrombolytic therapy? (1 mark) and give TWO questions you will ask Mr. Wen to check for eligibility for
this treatment. (1 mark)

Excessive bleeding.

Questions: Do you have any prior intracranial haemorrhage?

Do you have any past history of ischaemic stroke?

Have you done any aortic dissection before?

Do you have any past history of active bleeding?

Do you have any known structural cerebral vascular lesion?

a. Sinus tachycardia
b. Normalize heartbeat by slowing the electrical conduction of the heart

c. I: Ensure IV access available.

R: For earlier administration of medication through IV immediately.

I: Continuous ECG monitoring.

R: To see whether patient’s heart rhythm returns to the normal.

I: Monitor 12 lead ECG results.

R: To see whether there is dysfunction of the patient’s heart rhythm.

I:

I: Monitor side effect of the adenosine administration regularly, such as headache, flushing and dizziness.
R: For earlier treatment possible.

I: Fall prevention should be done.

R: To prevent disconnection of IV line to the patient’s body.