Posted: June 7th, 2015

Assignment 2 Exploration of A&P and Pathophysiology relating to a Case

Assignment 2 Exploration of A&P and Pathophysiology relating to a Case

Order Description

Assignment 2 Exploration of A&P and Pathophysiology relating to a Case

Please pay attention to the marking rubric and ensure your essay covers all areas.

Case Study – Greta Balodis
One of Greta’s close friends from the Latvian club has a daughter who is a second year student nurse. Greta has asked if you can explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system to her friend’s daughter, as she doesn’t understand and has an exam approaching. Greta has given her permission for you to use her as an example. Please explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system using the correct medical and nursing terminology.

INTRODUCTION
Mrs Greta Balodis is a 75 year-old widow who until recently lived alone in her single-storey house. She has recently returned home from rehabilitation post a R) CVA. Her daughter Anne has relocated to the city with her family to become Greta’s full-time live-in carer. However, Anne’s family have psychosocial and psychological complexities that impact on the wider family dynamics. Greta is regularly subjected to her grandson and son-in-law’s problematic alcohol and drug use. Also, because of Anne and John’s relationship issues and Dylan’s erratic behaviour, Greta no longer feels safe in her own home. For some time, Anne manages to care for her mother in the home; however after Greta trips over the cat, she deteriorates post-fall and eventually needs to be placed in high level care.

Meet Greta
Patient
information    MRN:
78012499    Surname:
BALODIS    Given names:
Greta Ainija    DOB:
22/4/1938    Gender:
F
•
Personal details
Patient: Greta Ainija Balodis
DOB: 22/4/1938
Age: 75
Address: 36 Main Street, Elizabeth North SA 5113
Weight: 84 kg
Height: 155 cm
MRN: 78012499
Migrated: Latvia to UK (age 20) and UK to Australia (age 35) under the ‘Skilled Workforce’ program
Family/Significant others
Daughter: Anne, 42yrs old
Son-in-law: John, 45yrs old
Grandchildren: Dylan 11yrs old, Jessica 5yrs old
No other family living in Australia
Background
Greta has been living independently for 38 years in a single-storey house with a garden in the northern suburbs of Adelaide. Over the past two years, Greta’s health has declined making it harder for her to carry out her activities of daily living as independently as she would like. She has been paying for Domiciliary Care to visit once per week and assist her with cleaning and shopping. Greta’s daughter Anne and her family have decided to move back to Adelaide and share Greta’s home in order to assist caring for her. Socially, Greta enjoys attending her local Latvian club for their monthly activities.
Past medical history
? Trans-ischemic attack (TIA) – 2/12 ago (refer year 1 lecturer notes, 1)
Hypertension (refer year 1 lecturer notes, 2)
3 falls in last 6/12
Past surgical history
Appendectomy 40 years ago
Current medication
Atenolol PO 50mg daily
Panadol PO 500mg prn
///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Physiotherapy notes (Jill Garner PT): Day 2 Admission post CVA
Patient is in ICU, check with nursing staff and medical staff re status and read medical notes. Subjective assessment: diagnosis, noting area of stroke and interventions until this date, PMH, SH: living arrangements, steps inside and access to her home, services provided, falls history, note 3 falls in last 6 months, previous level of mobility including use of aids. Some of this information may be in the notes and some may not be able to be gained from the patient due to her state of alertness/orientation, so the assessment may continue over the next few days  until a fuller picture of the patients SH is uncovered.

Objective assessment:
•    state of alertness
•    orientation
•    ability to communicate
•    Body awareness and awareness of midline,
•    Chest assessment, auscultation regarding flow of air in the lungs and any added sounds such as creps or atelectasis.
•    Assessment will be limited with communication issues due to dysphasia.
•    All limbs: ROM, motor control and sensation, JPS, tone, special note re left shoulder possible pain and risk of subluxation.
Treatment at this stage:
•    positioning of Greta’s limbs in normal alignment, especially left side
•    active exercises on right side and active assisted exercises on left
•    chest care
•    In consultation with medical staff bring Greta up against gravity into sitting with Greta trying to manage as much of the task as possible with help of therapist and nursing staff as needed. Sitting assists orientation, head and eye control and use of trunk muscles

Physiotherapy notes (Jill Garner PT): Day 3 Admission post CVA
Treatment:
•    Continue to monitor shoulder. If low tone and inactivity persists, possible use of supportive device to protect left shoulder from subluxation and pain.
•    encouraging correct alignment of left side
•    active exercises especially left side.
•    Functional activities of lying to sit,
•    sitting balance, including reaching out of her base of support.
•    orientation to her environment
•    sit to stand practice, standing balance and stepping practice with 1-2 assist.
•    discussion and advice to nursing staff re: manual handling of Greta, sitting and how to transfer her on the ward.

Physiotherapy notes (Jill Garner PT): Day 4 Admission post CVA
Day 4 transferred to Inpatient rehabilitation:

Initial physiotherapy assessment focuses on functional abilities to assist with Greta’s management on the ward. This will be documented in the medical notes and clearly discussed with the nursing staff.
There is further assessment by the treating physiotherapist as per Day 2. Review and check for vestibular symptoms that may have led to previous falls at home.
Rehabilitation outcome measure is the FIM (Functional Independence measure).This measures level of dependence and is completed by the team. It is completed on admission and discharge. All FIM information is collated by AROC (Australian Rehabilitation Outcome Centre).
Physiotherapy outcome measures include Ritchie articular index to measure shoulder pain, 6 min walk test, and standing balance. These are assessed on admission and discharge.
Assessment for hydrotherapy: check list for contraindications and risks, especially continence post stroke/ seizure and cognitive/behavioural problems.
If Greta is continent she will have daily hydrotherapy as well as Individual therapy. There may be group interaction as her condition improves.
Patient centred goals identified on admission for first week: Lie to sit independently. Sit to stand with standby, stand transfer to the right with x 1 assist.
Whilst on rehabilitation the rehabilitation team (medical, nursing, physiotherapy, occupational therapy, speech pathology, social worker, possible: dietician and psychologist) will have weekly case conferences to review goals made and achieved and discuss discharge plans.
Many of the goals will involve a few team members, ie. Stand transfer to the right will involve nursing/physiotherapy and maybe occupational therapy.

Physiotherapy notes (Jill Garner PT): Day 3 Triage nurses
Triage Nurses
Assess for rehabilitation in consultation with doctors, nurses and therapists. When medically stable, triage nurses discuss with patient and family:
•    patient centred goals
•     discharge destination
•    Proposed length of stay.

Physiotherapy notes (Jill Garner PT): Weeks 2-3 of rehabilitation
Weeks 2-3 of rehabilitation
As Greta becomes more mobile her falls risk on the ward increases. Often patients have decreased insight into their abilities and feel they can perform functional activities by themselves when they are not safe to do so.
Patient centred goals identified for week 3: get in and out of her bed independently. Walk to bathroom with rollator frame and 1 assist.
Greta attends physiotherapy as per her  timetable: 9am hydrotherapy,1pm  land based physiotherapy in the gym including: functional exercises, exercises in standing , stepping, walking , exercises to encourage active use of her left without right side being over active. Greta is now walking with a rollator frame with x 1 assist to the bathroom.

Physiotherapy notes (Jill Garner PT): Week 4 of rehabilitation
Week 4
Goals for week 4: walk to bathroom and dining room independently with rollator frame, car transfers with one assist, on and off the floor with use of furniture, falls prevention strategies
Treatment: balance exercise in standing and walking, walking in therapy with nil aids, on and off the floor, car transfers, stair practice. Outside mobility with rollator frame.
Pre –discharge: family meeting, to give an overview of Greta’s patient journey and discuss discharge plans

On discharge: Falls risk assessment, discharge summary/ equipment/RITHOM referral.

RITHOM physiotherapy assessment: patient centred goals, full assessment in the home. Rehabilitation outcome measure used in RITHOM setting: Lawton’s outcome measure

RITHOM physiotherapy goals:
•    Independent mobility inside her home and in the garden without walking aid.
•     Increase strength in left upper and lower limb,
•    increase co-ordination left side and accuracy of task.
There is a weekly case conference where great’s progress is discussed

/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////

CVA and rehabilitation
Patient
information    MRN:
78012499    Surname:
BALODIS    Given names:
Greta Ainija    DOB:
22/4/1938    Gender:
F
•    Greta was gardening when she started to feel a headache coming on; she felt dizzy and nauseous. She went inside the house to have a rest and while washing her hands noticed her mouth and eye was drooping on the left side of her face.
Greta was diagnosed with a R) cerebral vascular accident (CVA) and atrial fibrillation. She spent 14 days in an acute care hospital until she was medically stable. Greta then spent six weeks at the Specialist Stroke Rehabilitation Unit in a rehabilitation facility. Greta has mild residual L) sided hemiplegia and resolving dysphagia.
Greta is very glad to be home and especially pleased that her daughter and her children have moved down from the country to live with her. Greta is not overly happy about Anne’s husband John living with her as she has never seen eye to eye with him. Greta is receiving regular in-home physiotherapy and a nurse comes to visit her once a week as a part of the home rehabilitation program.
Greta is currently mobilising short distances with a three-pronged stick. She is enjoying being more mobile, sitting outside and being in her garden.
Greta has been discharged home from hospital on the following medications:
Aspirin PO 50mg daily
Clopidogrel PO 300mg daily
Atenolol 50mg daily – has been ceased
Digoxin 125mg PO daily

Case mentor
________________________________________
Greta has returned home following rehabilitation and has been living with her daughter Anne, her husband, and two children for the past 6 weeks. Greta has lived alone for 38 years and is a little worried about the noise and having to share her space with others especially her daughter’s husband, John.
Greta is concerned about her grandson as he seems so much more distant than when she last saw him. She often thinks he smells like cigarettes – a smell she remembers from her late husband.
Jessica, Greta’s granddaughter has been unwell too. The weather changes have upset her Asthma and she had to be rushed to hospital last week. Greta did not like being in the house with just her son-in-law and Dylan and was very glad to see her daughter Anne home earlier the next morning.
Since arriving home Greta is finding is difficult to adjust to “… not having her L) arm and leg totally on board”. Greta feels a sense of loss and has periods of feeling over whelming sadness. With these emotions also comes a great amount of fear as Greta “… is fearful she may have another stroke and may not make it next time …”.
Although Greta strongly believes it is her daughter’s duty to care for her now she does feel guilty that her daughter has so much pressure on her.

Patient notes and results

Physiotherapy notes (Jill Garner PT): Day 3 Admission post CVA
Treatment:
•    Continue to monitor shoulder. If low tone and inactivity persists, possible use of supportive device to protect left shoulder from subluxation and pain.
•    encouraging correct alignment of left side
•    active exercises especially left side.
•    Functional activities of lying to sit,
•    sitting balance, including reaching out of her base of support.
•    orientation to her environment
•    sit to stand practice, standing balance and stepping practice with 1-2 assist.
•    discussion and advice to nursing staff re: manual handling of Greta, sitting and how to transfer her on the ward

Physiotherapy notes (Jill Garner PT): Day 2 Admission post CVA
Patient is in ICU, check with nursing staff and medical staff re status and read medical notes. Subjective assessment: diagnosis, noting area of stroke and interventions until this date, PMH, SH: living arrangements, steps inside and access to her home, services provided, falls history, note 3 falls in last 6 months, previous level of mobility including use of aids. Some of this information may be in the notes and some may not be able to be gained from the patient due to her state of alertness/orientation, so the assessment may continue over the next few days  until a fuller picture of the patients SH is uncovered.

Objective assessment:
•    state of alertness
•    orientation
•    ability to communicate
•    Body awareness and awareness of midline,
•    Chest assessment, auscultation regarding flow of air in the lungs and any added sounds such as creps or atelectasis.
•    Assessment will be limited with communication issues due to dysphasia.
•    All limbs: ROM, motor control and sensation, JPS, tone, special note re left shoulder possible pain and risk of subluxation.
Treatment at this stage:
•    positioning of Greta’s limbs in normal alignment, especially left side
•    active exercises on right side and active assisted exercises on left
•    chest care
•    In consultation with medical staff bring Greta up against gravity into sitting with Greta trying to manage as much of the task as possible with help of therapist and nursing staff as needed. Sitting assists orientation, head and eye control and use of trunk muscles

Physiotherapy notes (Jill Garner PT): Day 3 Triage nurses
Triage Nurses
Assess for rehabilitation in consultation with doctors, nurses and therapists. When medically stable, triage nurses discuss with patient and family:
•    patient centred goals
•     discharge destination
•    Proposed length of stay.

Physiotherapy notes (Jill Garner PT): Day 4 Admission post CVA
Day 4 transferred to Inpatient rehabilitation:

Initial physiotherapy assessment focuses on functional abilities to assist with Greta’s management on the ward. This will be documented in the medical notes and clearly discussed with the nursing staff.
There is further assessment by the treating physiotherapist as per Day 2. Review and check for vestibular symptoms that may have led to previous falls at home.
Rehabilitation outcome measure is the FIM (Functional Independence measure).This measures level of dependence and is completed by the team. It is completed on admission and discharge. All FIM information is collated by AROC (Australian Rehabilitation Outcome Centre).
Physiotherapy outcome measures include Ritchie articular index to measure shoulder pain, 6 min walk test, and standing balance. These are assessed on admission and discharge.
Assessment for hydrotherapy: check list for contraindications and risks, especially continence post stroke/ seizure and cognitive/behavioural problems.
If Greta is continent she will have daily hydrotherapy as well as Individual therapy. There may be group interaction as her condition improves.
Patient centred goals identified on admission for first week: Lie to sit independently. Sit to stand with standby, stand transfer to the right with x 1 assist.
Whilst on rehabilitation the rehabilitation team (medical, nursing, physiotherapy, occupational therapy, speech pathology, social worker, possible: dietician and psychologist) will have weekly case conferences to review goals made and achieved and discuss discharge plans.
Many of the goals will involve a few team members, ie. Stand transfer to the right will involve nursing/physiotherapy and maybe occupational therapy.

Physiotherapy notes (Jill Garner PT): Weeks 2-3 of rehabilitation
Weeks 2-3 of rehabilitation
As Greta becomes more mobile her falls risk on the ward increases. Often patients have decreased insight into their abilities and feel they can perform functional activities by themselves when they are not safe to do so.
Patient centred goals identified for week 3: get in and out of her bed independently. Walk to bathroom with rollator frame and 1 assist.
Greta attends physiotherapy as per her  timetable: 9am hydrotherapy,1pm  land based physiotherapy in the gym including: functional exercises, exercises in standing , stepping, walking , exercises to encourage active use of her left without right side being over active. Greta is now walking with a rollator frame with x 1 assist to the bathroo

Physiotherapy notes (Jill Garner PT): Week 4 of rehabilitation
Week 4
Goals for week 4: walk to bathroom and dining room independently with rollator frame, car transfers with one assist, on and off the floor with use of furniture, falls prevention strategies
Treatment: balance exercise in standing and walking, walking in therapy with nil aids, on and off the floor, car transfers, stair practice. Outside mobility with rollator frame.
Pre –discharge: family meeting, to give an overview of Greta’s patient journey and discuss discharge plans

On discharge: Falls risk assessment, discharge summary/ equipment/RITHOM referral.

RITHOM physiotherapy assessment: patient centred goals, full assessment in the home. Rehabilitation outcome measure used in RITHOM setting: Lawton’s outcome measure

RITHOM physiotherapy goals:
•    Independent mobility inside her home and in the garden without walking aid.
•     Increase strength in left upper and lower limb,
•    increase co-ordination left side and accuracy of task.
There is a weekly case conference where great’s progress is discussed.

Assignment 2 Exploration of A&P and Pathophysiology relating to a Case

Case Study 2 – Greta Balodis
One of Greta’s close friends from the Latvian club has a daughter who is a second year student nurse. Greta has asked if you can explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system to her friend’s daughter, as she doesn’t understand and has an exam approaching. Greta has given her permission for you to use her as an example. Please explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system using the correct medical and nursing terminology.

MARKING RUBRIC   Assignment 2 – Exploration of A&P and pathophysiology

Student Name: Performance standard
Assessment criteria     Weighting     Exceeds standard     Meets standard     Below standard
Detailed explanation of the pathophysiology /pathogenesis of the illness/disease of the patient in the scenario     40     Outstanding understanding of the A&P and pathophysiology presented in the case demonstrated by accurate, highly relevant information provided with clear, succinct explanation of illness/disease pathogenesis.
(33.5-40) ?     Clear explanation of the A&P and illness/disease pathogenesis. Generalised demonstration of pathophysiology knowledge. Info mostly relevant, some details absent or incorrect. Generalised linkage to the related case study demonstrated
(20-33) ?     Poor explanation of illness/ disease pathogenesis. Poor understanding of pathophysiology and inadequate knowledge demonstrated as related to the specific case-study
(0-19.5) ?
The explanation of two (2) signs and symptoms that the patient has presented with and why they manifested as part of the illness/disease.     30     Accurate, highly relevant explanation of signs/ symptoms with a very clear, succinct understanding of signs/symptoms demonstrated by the case study patient.
(25.5-30) ?     Generalised linking of signs /symptoms to the specific case study. Information has adequate relevance, but some details absent, or incorrect. Generalised understanding of signs /symptoms demonstrated. (15-25) ??    Student unable to clearly and succinctly link signs/symptoms to the specific case study. Poor knowledge demonstrated of why signs /symptoms relevant to case study patient. Information missing or irrelevant
(0-14.5) ?
Critical thinking and rationale     20     Clarity of thought and linking of ideas clearly demonstrated. Detailed, concise description of the pathophysiology and the signs and symptoms therefore seen in the case world patient. Links A&P, pathophysiology, context, and theory together
(17-20) ?     Reasonable description as to why the medication is being given to the case world patient. Linking to multiple parts of practice (pharmacology, infection control, safety, cultural awareness, nursing considerations)
Links medication, context, and theory together (10-16.5) ??    Poor description/ rationale as to why the medication is being given to the case world patient. Linking to multiple parts of practice (pharmacology, infection control, safety, cultural awareness, nursing considerations) missing or not in enough depth
Does not link medication, context, and theory together (0-9.5) ??
Writing style     10     The essay flows well, it is easy to read and follow the sequence of ideas. Introduction, body of essay, conclusion, and referencing is all correctly formatted.
No spelling or grammatical errors throughout essay (8-10) ??    No more than 5 spelling or grammatical errors through essay. Clear introduction, body of essay and conclusion.
(5-7.5) ?     Multiple spelling and or grammatical errors throughout essay. Students unclear in the introduction what will be described in the body of the essay.
(0-4.5) ?

MARKING RUBRIC Assignment 2 – Exploration of A&P and pathophysiology