NURS801

Graduate Practice for Registered

Nurses
Assessment 2: Case Study
Word Count: 4126 words

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Introduction

A 62yr old Samoan gentleman, Mr Sefa Faletolu (pseudonym) presented to

the preoperative area for a parathyroidectomy procedure, the removal of the
parathyroid glands in the neck. Mr Faletolu spoke no English and was hard of
hearing in his left ear. Since parting ways with his wife 18 months prior Mr
Faletolu lived alone, renting a small flat with the landlord living in front who
kept an eye on him. Mr Faletolu's sister and nephew were in attendance. On
his left forearm was a radiocephalic fistula at the wrist for vascular access for
dialysis. Mr Faletolu had been on haemodialysis 3 times a week since 2012
due to end-stage renal failure (ESRF). Due to Mr Faletolu's longstanding
hypertension he had developed hypertensive nephrosclerosis, the hardening
and narrowing of the small blood vessels in the nephrons where over time the
increasing reduction in lumen diameter and wrinkling of blood vessel walls has
lead to tubular injury and ischemia causing renal failure.

It was indicative that Mr Faletolu's parathyroid be removed due to

hyperparathyroidism; the production of excess parathyroid hormone (PTH)
from the gland resulting in hypercalcemia. The parathyroid gland releases
PTH when triggered by a negative feedback response to low calcium in the
blood. It actions the release of calcium from the bones to the blood and
causes the kidneys and intestines to reabsorb calcium therefore increasing
serum calcium levels. His hyperparathyroidism was classified as tertiary
where the parathyroid gland loses regulation and releases PTH unprompted.
This would likely have occurred due to previous chronic hypocalcemia when
his kidneys began to fail, losing calcium from the body due to ineffective
calcium reabsorption in the kidney tubules (Craft, Gordon & Tiziani, 2013).

The proposed surgery was planned to not only alleviate his symptoms of
hypercalcemia such as excessive thirst, muscle weakness and bone pain
(Craft et al., 2013) but also to help initiate placement on the renal transplant
list. Following surgery a multi-disciplinary team meeting was planned followed
by a scoring assessment for probability of transplant where better controlled
blood calcium levels would be desirable.

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In light of this it was particularly important that Mr Faletolu and his family had a
good understanding of the proposed procedure and progression in plan of
care. In my communications with Mr Faletolu and family it quickly became
apparent that they had little understanding of the peri-operative process. This
combined with minimal English spoken posed a challenge for me to ensure
patient and family would understand and articulate plans and to make fully
informed decisions about Mr Faletolu's care. Other nursing priorities also
became apparent where Mr Faletolu began to complain of chest pain.

Preoperative Assessment

My role in the preoperative room was to ensure all patients coming from the
hospital wards were appropriately prepared for surgery. I reviewed the
preoperative checklist using family members to translate as no interpreter had
been organised by the ward. According to Waitemata District Health Board
(WDHB) policy (WDHB, 2013) the checklist is to act as an essential record
and communicative tool to ensure patient safety in readiness for surgery and
to relay important information about the patient to the other sectors involved in
the patient's care. A physical 'head-to-toe' assessment is provided and can
influence decisions made about the patient's care and practice carried out in
theatre. Mr Faletolu had not eaten in the last six hours nor drank fluids in the
last two hours as instructed as per WDHB policy (WDHB, 2013) therefore his
risk of aspirating stomach contents into his lungs while under anaesthetic and
causing aspiration pneumonitis was low. He had no areas of broken skin to
increase risk of infection and had been tested for health-care associated
infections. He had tested positive for colonisation of Extended-Spectrum Beta-
Lactamase (ESBL). Standard contact precautions such as doning a gown and
gloves were required of all staff where they come into physical contact with Mr
Faletolu. Mr Faletolu's hardness of hearing in the left ear was noted in order
for staff to speak with him from his right side to enhance adequate
communication. I documented placement of Mr Faletolu's fistula and checked
that it was sufficiently bandaged with a green guard and labelled so as to
ensure staff did not use the area for phlebotomy or blood pressure monitoring.

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Informed Consent and Cultural Safety

Once my priority to assess Mr Faletolu's readiness for surgery was complete I

worked on urgently organising an interpreter, liaising with the WDHB
interpreting service. An interpreter is required to be present where necessary
and practicable for the Anaesthetist and Surgeon to discuss the plan for
surgery and ensure adequate understanding before seeking signed consent
from the patient in order to proceed (WDHB, 2014). Untrained interpreters
such as family members can be used at the discretion of the responsible
health professional, which was granted by the Anaesthetist on the proviso that
an interpreter be organised as soon as practicable (WDHB, 2013a).

Informed consent in a surgical setting is defined as a patient's acceptance of a

healthcare plan or procedure in accordance with their needs after they have
been provided with all accurate and necessary information to which they must
have the capacity and competence to understand the benefits and risks of the
planned procedure (WDHB, 2014).

The Code of Health and Disability Services (The Health and Disability
Commissioner, 2009) stipulates that a health consumer must be fully
informed to be able to make informed choices in regards to their care
including the right to a full explanation of treatment, the risks involved, honest
answers to their questions and the consequences that could incur if the
treatment is not undertaken.

To ensure all information is provided and to obtain consent is the ultimate

responsibility of the health professional who is to carry out the procedure
(WDHB, 2014). In general conversation with Mr Faletolu and his family it
became apparent to me a lack in understanding of the plan of care. For
example, Mr Faletolu and family seemed to be unaware of the long-term
consequences of the removal of the parathyroid gland particularly in relation
to lifelong calcium supplementation. They were not able to recall the risks
associated with the surgery that were discussed with the Surgeon the
previous day. Probing further I discovered Mr Faletolu had been provided with
an information booklet about the procedure but in the English language.

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Different family members who also had limited English were present at the
time of surgical consent discussion the previous day and it seemed not all
information had been relayed or understood collectively amongst the family
unit.

WDHB policy states anyone involved in the care of a patient who believes that
patient is not adequately informed must relay their concerns to the health
professional responsible for the consent (WDHB, 2014). Therefore I requested
urgently that the surgeon return to repeat discussion with Mr Faletolu and
family.

In accordance with the Nursing Council of New Zealand (NCNZ) Code of

Conduct Principle 3 (NCNZ, 2012) as a Registered Nurse I must work in
partnership with my patients to ensure I promote their health and wellbeing by
including them in decision-making about their care. In doing so I needed to
ensure information was provided to Mr Faletolu and family in a way that would
be best understood in accordance with their cultural needs.

In appreciation of cultural difference to that of my own culture, I set out to

acknowledge Pacific customs in my practice as is my professional
responsibility outlined by NCNZ 's 'Competencies for Registered Nurses'
(NCNZ, 2007) in respecting patient beliefs and values. I knew that an oral
rather than written tradition dominated Samoan culture and significant
importance is placed on legitimising relationships with others. The Surgical
Registrar appeared to discuss the surgery process, risks and benefits again
with Mr Faletolu and family, a different surgeon to whom they had met the day
before. I introduced the Surgeon to Mr Faletolu and family and explained his
role and credentials in order to establish trust. Samoan culture reveres
leadership, they need to be provided with the information that allows them to
recognise those individuals with status and offer their respect and
acknowledgement. What followed was general conversation about the nature
of our work at the hospital and where we are from. In Pacific culture members
want to know who you are before what you know. Respectful engagement
with Pacific patients and their families before carrying out more intended
discussion builds a rapport and creates a connection. A 'va' is created which
in Samoan means 'space' or a safe environment for the Samoan patient and
family to choose whether to engage with another and in this instance ask

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questions and take on new information (Tiatia, 2008). Once these ideals have
been demonstrated they are reassured of the respect and cultural
competence of staff deemed in their care (Faasalele, 2010).

Pacific culture is collective in nature where decisions are made as a family or

community to benefit the collective good. WDHB's 'Informed Consent' policy
(WDHB, 2014) stipulates that cultural differences in decision-making should
be respected and a safe and open environment created for collective
processes to occur. I ensured family members were part of all discussions
and in my focus of conversation made certain to address all members of the
family as well as the patient. A system of eldership predominates this
collective culture with males as protectors and leaders to be revered and
respected by other family members (Tiatia, 2008). With an absent elder
spokesman present that day, Mr Faletolu's nephew would be representative of
the wider family ensuring appropriate decisions would be made as the 'right-
hand man' of the father. I needed to ensure I addressed him appropriately and
therefore asked him how he would like to be addressed.

Pacific culture is holistic in approach to health and wellbeing where physical,

mental, emotional and spiritual aspects of a person need to be in harmony in
order to sustain a healthy balance for the collective group. I ensured Mr
Faletolu was provided with time for prayer if appropriate according to the
family's cultural practice. I explained that an elder or minister known to the
family would be welcome to visit or I could arrange for a hospital chaplain or
minister through the hospital Pacific Cultural Support Service: Tautai
Fakataha. The family declined but appreciated the thought and offer.

Providing health care in a manner that is culturally appropriate is imperative

where New Zealand's Pacific population suffer poorer health outcomes and
reduced access to health care services than other populations (Ministry of
Health [MOH], 2014). Acknowledgement of Pacific cultural practices and
preferences in my health care delivery contributes towards creating a health
care environment that Pacific people can value and trust and in turn move
them toward better health outcomes (Tiatia, 2008).

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Chest Pain Assessment and Clinical Decision-Making

Following completion of surgical consent a family member approached me to

mention that Mr Faletolu was complaining of chest pain. I immediately went to
the bedside to assess the characteristics of his chest pain to determine if it is
of cardiac origin. Cardiac chest pain can be indicative of acute coronary
syndrome. Acute coronary syndrome occurs where the build up of fatty
deposits or plaque against the arteries causes arteries to harden and narrow.
This plaque build-up can rupture and a thrombus may form causing a
blockage of blood flow to the myocardium. Such pathophysiology needs
prompt diagnosis and intervention to prevent myocardial infarction or
development of cardiac arrhythmia (O'Donovan, 2013). I followed the
assessment pathway outlined in WDHB 'Chest Pain/Angina' policy (WDHB,
2010) and used the OLDCART pain assessment tool as it provides for a
targeted pain assessment that works to confirm or rule out pain of cardiac
cause when used alongside a comprehensive haemodynamic examination
(O'Donovan, 2013).

I asked Mr Faletolu through his family interpreting when the pain started (O =
onset) as a rapid onset of chest pain can indicate a sudden critical reduction
in blood flow to the myocardium (O'Donovan, 2013). Mr Faletolu replied the
pain has been coming and going for the last two days while in hospital on the
ward. I asked whereabouts he felt the pain (L = location) to which he said in
his chest and down his legs and sometimes the abdomen. Acute chest pain is
typically located in the central chest and can often radiate through the arms,
neck or jaw (WDHB, 2010). I asked Mr Faletolu how long the pain lasts, does
it fade and return? Is the pain always present? (D = duration). He responded
that it comes and goes, the pain is present for several minutes in his chest
and leaves but the same pain in the abdomen always remains. Acute cardiac
pain is usually persistent and builds in intensity over a few minutes
(O'Donovan, 2013). I then asked Mr Faletolu to describe what the pain feels
like (C = pain characteristics) to which he replied 'heavy' and 'sore'. I then
provided him with common words used to describe cardiac pain such as
'crushing', 'stabbing', 'indigestion pain' or 'dull ache'. He mentioned a 'dull
ache' that was 6/10 in severity where 1/10 represents mild pain and 10/10 is
most severe pain. I asked Mr Faletolu if he was experiencing any other

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symptoms other than pain (A = associated symptoms) such as nausea,
weakness, fatigue, breathlessness, feeling faint and clammy. If these
symptoms were present along with chest pain there is higher probability of an
acute cardiac episode occurring (O'Donovan, 2013). He mentioned a feeling
of tightness and heaviness in the abdomen along with generalised weakness
and fatigue. I asked more specifically if he was feeling short of breath or
struggling to breath to which he declined. Shortness of breath can occur
where there is reduced blood flow to the myocardium therefore poor oxygen
supply. He was not experiencing nausea or faintness. Nausea and vomiting
can be experienced due to the vomiting centre in the brain being stimulated by
a reflex response from the pain (Brown & Edwards, 2009). Mr Faletolu did not
appear cool to the touch with no indication of diaphoresis which can occur due
to vasovagal stimulation from the ischemic area of the heart (Brown &
Edwards, 2009). Mr Faletolu declined if the pain eased or stopped by moving
or changing position in the bed (R = relieving factors). Typical chest pain is
likely to remain unrelieved unless medical intervention is provided (T =
treatment) (O'Donovan, 2013). Mr Faletolu had not taken any medications to
relieve the pain and declined analgesia as he stated to family that his pain
was tolerable.

Throughout this questioning I continued an observational and clinical

haemodynamic assessment of Mr Faletolu's status. Assessing Mr Faletolu's
respirations was another priority. He did not appear in respiratory distress, his
breathing was non-laboured bilateral and spontaneous. Respirations were
deep and long with 18 respirations per minute (normal range 16-20
respirations per minute). His haemoglobin oxygen saturation was 96 per cent
on air (ideal oxygenation 95%+). Mr Faletolu was warm to the touch, well-
perfused with a capillary refill of under 3 seconds and a strong pulse of 90
beats per minute (bpm) (normal range 60-100bpm). This indicated adequate
blood flow therefore sufficient cardiac output. Mr Faletolu was alert,
cooperative and orientated indicating adequate cerebral perfusion. His
temperature was 36.6°C (normal range 36.5-37.2°C). A temperature of 38-
39°C can be indicative of the inflammatory process associated with death of
cells in the myocardium (Brown & Edwards, 2009). Although Mr Faletolu's
blood pressure was high at 180/85 millimeters of mercury (mmHg) his normal
range was 165/70 - 190/90mmHg due to sustained systemic and renal

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hypertension. Greater circulatory volume occurs in ESRF as kidneys tend to
reabsorb sodium and water due to their reduced ability to excrete electrolytes.

In consideration of both objective and subjective data I did not believe Mr

Faletolu was in immediate danger requiring an emergency response. His pain
was not of sudden onset and not of the intensity and nature of acute cardiac
distress. Vital signs were stable and he had no associated symptoms. If Mr
Faletolu was presenting with signs of cardiac distress I would administer 6
litres of oxygen immediately as per chest pain guideline (WDHB, 2010) to
increase oxygen available to the myocardium to help prevent worsening tissue
ischemia. I would also call for emergency assistance. Mr Faletolu still required
a medical review to determine treatment and cause of symptoms so I called
the operating theatre to request the Anaesthetist to see him.

I carried out a 12-lead electrocardiogram (ECG) as per chest pain guideline

where leads are placed on the patient's skin to detect electrical activity of the
heart producing an electrocardiogram that depicts waves of each heartbeat.
Upon the arrival of the Anaesthetist I gave an account of what had occurred
and the details of the assessment I carried out. We reviewed the ECG which
depicted a small ST elevation in V2 - V4 deemed insignificant to be
representative of cardiac distress. A normal ST wave should be flat where the
heart muscle is without charge in a period between ventricular depolarisation
and repolarisation. I knew that a significant ST elevation is often
representative of cardiac ischemia or infarction. I searched through the notes
to find another ECG to compare these results too and found an ECG from the
previous day which depicted the same result. This ECG had been scrutinised
by the renal team that day and Mr Faletolu was cleared for surgery.

I anticipated that Mr Faletolu would need a blood test to check his troponin
level. Troponin is a protein released to the blood when damage to the
myocardium occurs. The Anaesthetist confirmed such a test would be
appropriate so I paged the Phlebotomist for an urgent blood test. I asked if the
Anaesthetist would like me to contact the hospital renal team to also review Mr
Faletolu since they are familiar with the patient's condition and medical history
and may shed some light on the atypical chest pain Mr Faletolu was
continuing to experience.

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Mr Faletolu's blood troponin was 52 nanograms per millilitre (range 0 - 40ng/l)
not out of range significantly enough to represent significant cardiac distress.
The renal team arrived and determined the slight elevation in troponin level to
be related to the haemodialysis session Mr Faletolu had the previous day.
Troponin proteins are commonly elevated in patients with chronic kidney
disease without evidence of acute cardiac disease (Freda, B., Tang, W., van
Lente, D., Peacock, W & Francis, G, 2002). Troponin proteins are not dialysed
therefore continue to accumulate in the bloodstream. Continued elevation in
troponin levels can be reflective however of ongoing subclinical myocardial
damage or 'micro-infarctions'; gradual and small myocardial cell death (Freda
et al., 2002). This progression of cell death will increase risk of morbidity and
mortality regardless of suggestive symptoms, according to a review of clinical
trials by Freda et al. (2002) in looking at serum levels of troponin proteins in
predicting cardiac events. Due to Mr Faletolu's longstanding renal disease
and associated renal and systemic hypertension the process of
atherosclerosis is likely to have been accelerated therefore he may be at
heighted risk of acute myocardial infarction from acute coronary syndrome
(ACS).

Mr Faletolu's atypical chest pain would require further investigation to

determine the cause. The team decided to cancel Mr Faletolu's surgery in
light of further investigation including a Computed Tomography (CT) Coronary
Angiography, an imaging test using combined CT and x-ray technology to
create imagery to identify plaque build-up in the coronary arteries and
therefore diagnosis of ACS (Brown & Edwards, 2009).

The team requested a meeting with the patient, family, Surgeon, Anaesthetist
and renal team with an interpreter present. I was able to organise an
interpreter to come in within the hour. I reassured Mr Faletolu and family there
was no immediate concern for his pain and explained that I would return to re-
assess his condition frequently. I spent time listening to family members
explain his disappointment that his complaint has caused the cancellation of
his surgery. I reiterated that it is vital the team ensure his condition is stable
for reasons of safety while under general anaesthetic. I encouraged Mr
Faletolu and family to discuss concerns and questions at the family meeting.
Reflection

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I believe my practice strived to be culturally safe in advocating for the cultural
and health needs of Mr Faletolu and family I worked to provide expert
interpreting services for patient and family, offered Pacific health services
representation while also ensuring adequate relationship development and
explanation of health care plans from each member of the health care team
involved in Mr Faletolu's care. The feedback I received from the patient, family
and team members was positive and I felt I supported them to the best of my
knowledge and skills as a Registered Nurse at that time.

I feel it is important to continue to seek expert knowledge and evidence-based

research on relevant conditions and treatments in the area in which I work.
This is to not only inform my practice but to be able to pass on to patients
relevant information about their condition and how to prevent complications in
order to best improve their future health and wellbeing. If I had knowledge
about the cardiac investigations Mr Faletolu was about to embark on such as
the coronary angiogram, I could have talked him through what he can expect
to experience, easing any anxiety and planting a seed of knowledge that
would be further added to where future discussion with cardiology medical
staff and specialist nurses occurs.

Further knowledge and understanding around the relationship between renal

impairment and cardiac function would allow me to develop comprehensive
clinical assessment in future practice and facilitate helpful discussion with
medical team members in the sharing of symptom detail. Further
understanding would also benefit patients where I am able to answer
questions and provide explanation for causes.

In considering Mr Faletolu's understanding of health information, although

there was a cultural element to the lack of understanding of the care plan, I
believe there may have been a deficiency in health literacy that may likely
have influenced comprehension of health plans. Health literacy relates to a
health consumer's skill, knowledge and competency to access, understand
and evaluate health information and services in order to best make informed
decisions in regards to their health (World Health Organisation, 2013). Health
literacy includes communication, critical thinking and problem solving skills
and also encompasses the health consumer's ability to direct their way
through the health system. Health consumers' health literacy is also

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dependent on their capability to self-manage their health and the awareness
of the health care available to them. Where health literacy is poor a health
consumer is less likely to adequately participate in their health care, uptake
advice and are more likely to suffer poorer health outcomes (Reid & White,
2012). According to the Ministry of Health (Ministry of Health, 2010), 50% of
New Zealanders have poor health literacy skills. Significant determinants of
poor health literacy include low socioeconomic status and English as a second
language. An issue of contention arises where on one hand health consumers
are to be provided with all information in regards to their health care plan in
order to be appropriately informed to make informed choices and are deemed
competent to do so but may lack the capacity to suitably process and
comprehend the information due to poor health literacy.

Following the discussion with the surgeon in regards to the plan for surgery
and consequences for the future I could have made an assessment of Mr
Faletolu's knowledge and understanding of the plan. I could have asked
questions about the information discussed and asked him to repeat back the
information in his own words. I would determine understanding by looking for
whether he was able to articulate the key messages that were provided in that
discussion. I could have asked if there were any words he did not understand
or concepts that were unfamiliar or confusing that required further explanation,
all the while ensuring I used clear simple language in my conversation.
Workbase Health Literacy suggests health services have a high expectation of
literacy amongst patients and information should be provided at a level that a
12 year-old could be expected to understand (Workbase, 2013).

Also, it would have been helpful to assess Mr Faletolu's level of English. His
responses to questions involved nods and shakes of the head to indicate yes
and no. It seemed he was used to his family members communicating on his
behalf. Although it was documented that he spoke no English I could have
prompted him to speak by asking open-ended questions that may elicit basic
word answers he may well articulate in English such as 'toilet' and 'food'.
Also, considering Mr Faletolu's hearing impairment I would need to make a
judgement as to whether an appropriate response or lack there-of would be
related to his inability to hear correctly or understand English. In applying
these findings to my practice I could have further included Mr Faletolu in the
decisions around his health care plan.

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NCNZ's Code of Conduct Principle 3.4 provides that Registered Nurses,
where reasonably practicable meet patient's communication and language
needs (NCNZ, 2012). In the future I could access translated health information
to aid conversation and consultation but also ask about the patient and
family's preferred means of learning and communication such as through
reading, listening or through visual materials and provide appropriate
resources where possible to aid in their collective discussion. I could have
also sought feedback from the interpreter on their opinion of Mr Faletolu's
understanding and interpretation of information, any culture-bound messages
or non-verbal cues relayed that may have been missed by the team due to
cultural unawareness.

Mr Faletolu had presented to the emergency department following arrival to

Auckland asking for dialysis treatment. In working towards greater health
literacy in the wider sense of patient ability to navigate the health system I
could have facilitated a discussion around the New Zealand health care
system, its spheres of primary, secondary and tertiary health care and the
points of access for each provision. In living with ESRF Mr Faletolu would
most likely be exposed to all 3 facets therefore knowledge of the services
available and means of access would be beneficial. For example the
Waitemata Regional Renal Service offers outpatient and outreach services
including satellite dialysis units and home-based programmes for patients who
require regular haemodialysis (WDHB, 2016).

Conclusion

In the future, prepared with recent and relevant evidence and research, every
interaction between a patient, family and myself as a Registered Nurse,
should include an opportunity to enhance a patient's knowledge of their
condition and the treatment involved. The chance to assess a patient's level of
health literacy is vital to ensure patients are able to access the health services
available to them to best manage their own health outcomes. Ensuring
cultural awareness and sensitivity in my practice allows me to work in
partnership with patients and their families providing health care that is in
accordance with their health and cultural needs.

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References

Brown, D., & Edwards, H.(2009). Lewis's medical-surgical nursing (2nd ed.).
Chatswood, Australia: Elsevier Australia

Craft, J., Gordon, C., & Tiziani. (2013). Understanding pathophysiology.

Chatswood, Australia: Elsevier Australia

Faasalele, H. Building on Pacific values to achieve health outcomes. Kai

Tiaki, 16(7), 2

Freda, B.J., Tang, W., Van Lente, F., Peacock, W.H., & Francis, G.S. (2002).
Cardiac troponins in renal insufficiency: Review and clinical implications.
Journal of the American College of Cardiology 40(12) 2065-2071

Ministry of Health. (2010). Ko¯ rero Ma¯ rama: Health literacy and Ma¯ ori
results from the 2006 adult literacy and life skills survey. Wellington, New
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Ministry of Health. (2014). Factors affecting Pacific people's health. Retrieved

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O'Donovan, K. (2013). Nursing assessment of the causes of chest pain.

British Journal of Cardiac Nursing, 8(10), 483-488

Reid, S., & White, C. (2012). Understanding health literacy. Best Practice
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The Health and Disability Commissioner. (2009). Code of Health and

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Waitemata District Health Board. (2013a). Interpreting and Document
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Waitemata District Health Board. (2014). Informed consent. Legal Counsel

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