Case study 4

Josephine has advanced dementia and lives in a care facility. She cannot communicate using words and requires a lot of physical assistance with showering and dressing.

When Josephine is bored, distressed, angry or upset she throws her head back into the chair repeatedly and pulls out her hair. It is not always obvious to the support workers what the triggers are for these behaviours are or how they can best minimise her disruptive and problematic behaviours.

Isaac works at the care facility and seems to be able to minimise Josephine’s problematic behaviours more so than other workers.

The rest of the workers don’t understand why her behaviour varies so much as they are all following the same information in the behaviour plan.

What type of information should Isaac and the other support workers document about Josephine’s behaviours?

6 Learning Activity regarding Nursing: The Scope and Standards of Practice Using your book please answer the following questions.

6 Learning Activity regarding Nursing: The Scope and Standards of Practice Using your book please answer the following questions. You may use the words in the book with references Included, but I belleve you demonstrate understanding by explaining in your own words-this is a learning experlence and It is helpful to know what you think these things mean so we can be sure you do understand what it means! I know you are using your book, but please be sure to include the reference in APA format at the bottom of the page-thanks 1. What is the definition of Nursing? 2. Using the glossary in the book define the following and then describe it in your own words a. Scope of nursing practice b. Standards of practice c. Standards of Professional nursing practice 3. Why do we have the Professional Nursing’s Scope and Standards of Practice? (pp xi, 1, & podcast) Development of Standards: The Nursing Scope and Standards of Practice describe what? a. What does the scope describe? b. What do the standards describe? 4. What is the difference between Scope of Practice and individual state Nurse Practice Acts? The Standards of practice mention the nursing process. How does it describe the Nursing Process? (p 4) 5. 6.

Musculoskeletal Section 7. PREOPERATIVE DIAGNOSIS: Retained hardware, left hip, status post closed reduction and subcutaneous pinning of the subcapital fracture of her left hip.

Musculoskeletal Section 7. PREOPERATIVE DIAGNOSIS: Retained hardware, left hip, status post closed reduction and subcutaneous pinning of the subcapital fracture of her left hip. POSTOPERATIVE DIAGNOSIS: Same 0H0b00 OPERATION PERFORMED: Subcutaneous removal of hardware The patient was taken to the operating room and placed in the supine position. After adequate general anesthesia was administered, the left hip was prepped and draped in usual sterile fashion. The previous incision was used to make a 2.0-cm incision. A guidewire into the screw was used to get easily. All of the screws were then removed. The wound was irrigated out and closed in layers, and the skin was closed with 3-0 Prolene. Xeroform and dry sterile dressing were placed over the wound and covered with foam tape. The patient was extubated and taken to the recovery room in stable condition. Codes: S42.44, 24575-LT 16500 Evaluate the codes and determine if the codes are correct. If the answer is not correct, then explain what the correct answer is with supported step by step details. Correct Codes and determination: Respiratory Section

Evaluate the codes and determine if the codes are correct. If the answer is not correct, then explain what the correct answer is with supported step by step details.

Evaluate the codes and determine if the codes are correct. If the answer is not correct, then explain what the correct answer is with supported step by step details. Correct Codes and determination: 4. Anesthesia Section A 54 year old female with chronic hypertension was admitted as an acute care hospital inpatient for vertigo and headaches. After testing, her cerebrospinal fluid pressure was high due to a subdural hematoma with no loss of consciousness. General anesthesia was administered by an anesthesiologist. The surgeon drilled burr holes to evacuate the hematoma and relieve the pressure. The anesthesiologist inserted a percutaneous arterial line 9catheter) to monitor the patient while providing the anesthesia services during the surgical procedure. Following surgery, the anesthesiologist inserted a Swan-Ganz (flow-directed) cardiac catheter. Caden. An 4. RAF

Chapter 2: Quality Assurance and Legal issues in Case Studies Case Study 2-1:

Chapter 2: Quality Assurance and Legal issues in Case Studies Case Study 2-1: Quality Assurance in a Cow Laboratory Cow Laboratory in a large internal medicine group QUESTIONS actice performed over 50 waived tests a day. The medical assistants and the phlebotomists who performed 1. What are CLIA and CLIACI he waved testing were all trained it was obvious 2. Why is CLA visiting their site from the inconsistent results recorded on the cumulative eart that everyone’s technique differed somewhat 3. What are the GLP’s and what makes them valuable W e notification came from CLIA that they would be in standardizing the waived testing process visiting the site within the next month, the lead physician 4. What are other examples of OC components that decided that a OA process had to be put into place. He could be put in place in this laboratory setting! directed the laboratory staff to the CLIA Web site for Instructions on waved testing standardization in the form of GLP issued by CLIAC Case Study 2-2: Blood Draw Fails Delta Check It was a very busy day in the hospital laboratory since the patient Later that morning the delich two phlebotomists were out for medical reasons. An The second specimen was recollected and the results order came from the fourth floor for a timed draw. showed the specimen that Joe had drawn to be in error Joe, a phlebotomist from a temporary agency, was still there, even though he was supposed to have gotten QUESTIONS off 2 hours earlier. No one was there to collect the specimen except Joe. Knowing how important it was 1. What is a delta check? he decided to go ahead and collect it. When he arrived in the room, the patient was seated in a chair between 2. What do you see that could have caused this the beds. Joe asked the patient his name and in which discrepancy? bed he belonged. When the seated patient answered 3. What should Joe have done differently? with the right last name and pointed to the correct bed, Joe proceeded to collect the specimen from him while 4. What were Joe’s obligations to the laboratory after he sat in the chair. Joe labeled the specimen tubes at his regular shift? the nursing station while noting the draw on the desk 5. Who is ultimately responsible for Joe’s actions clipboard. When a second specimen was drawn from while he is at work? in the area of the draw. The phlebotomist quickly wraps a pressure bandage around the arm and tells her she is free to go. The patient is later diagnosed with permanent nerve injury and sues the clinic. Case Study 2-3: Nerve Injury A phlebotomist prepares to draw three tubes of blood from an outpatient. The only vein that is visible is the basilic vein on the right arm. He was taught that the basilic vein is the last choice for venipuncture because it is hard to anchor and a major nerve lies close to it, but it is so large he decides that he can draw it without a problem. When he inserts the needle, sure enough, the vein rolls and the needle slips beside the vein. The patient cries out in pain, and jerks her arm. The needle goes even deeper, but blood begins to flow into the tube, so he continues the draw. The patient tells him it is hurting and to pull the needle out, but the tubes are filling quickly, so he continues to fill all three before ending the draw. The woman is still in pain and her arm begins to swell QUESTIONS 1. Can the phlebotomist be held liable for the woman’s injury? 2. What tort might be involved in this casel 3. Do you think the standard of care was breached? Why or why not?

Cases 1 Modified Allen Test and ABG Specime Case Study 14-1: Mod A hlebotomist has an Specimen onun specimen the night the same arm, and sin modified Allen lesti t and ABG Specimen Collection QUESTIONS

Cases 1 Modified Allen Test and ABG Specime Case Study 14-1: Mod A hlebotomist has an Specimen onun specimen the night the same arm, and sin modified Allen lesti t and ABG Specimen Collection QUESTIONS 1. What error did the phlebotomist make? 2. How could the error have been avoided? 3. What could have caused the change in collateral ist has a request to collect a STAT ARC an a patient. He had collected an ABG he night before from the same patient on m. and since the patient had a positive llen test then, he skips the Allen test now to As he is preparing to insert the needle, the t’s nurse enters the room and tells him to stop. alls him that the patient does not have adequate ollateral circulation in that arm and he must not circulation? save time. As he is pren putient’s nurse enter She tells him that the patient does collect the specimen there. check the arm, a large hematoma had formed at the collection site. When he checked the patient’s pulse below the collection site, it was so weak he could Study 14-2: ABG Hazards and Complications A phlebotomist had an order to collect STAT ABC and electrolyte specimens from a patient in the ICU. The patient was having difficulty breathing when the phlebotomist arrived. There was an IV in the patient’s barely feel it right arm, so the phlebotomist performed the Allen test on the left arm. The test result was positive, so QUESTIONS the phlebotomist proceeded to collect the specimen from the radial artery of that arm. He had to redirect 1. What could have caused the weak pulse and what the needle several times before dark bluish-red blood should the phlebotomist do about it? finally pulsed into the syringe. When the syringe was 2. What error did the phlebotomist make that contrib- filled to the proper level, he withdrew the needle and uted to hematoma formation? held pressure over the site. As he was attempting to cap the syringe, the cap dropped into the patient’s bed 3. What would cause the specimen to be bluish red? covers, so the phlebotomist asked the patient to hold 4. How can the phlebotomist be certain that the pressure while he retrieved it. Later, when he went to specimen is arterial blood? Case Study 14-3: Brachial Artery Puncture Problem A phlebotomist is sent to collect an ABG specimen the phlebotomist completes the draw. The phlebotomist from a patient in the cardiac care unit (CCU). The holds pressure and then applies a pressure bandage. patient has an IV in the right arm near the wrist and finishes the paperwork, and returns to the laboratory the left wrist has a rash. The phlebotomist has been with the specimen. trained to do brachial artery punctures, so he decides to use the brachial artery of the left arm. The physician QUESTIONS has specifically requested that the specimen be drawn without the use of lidocaine. The phlebotomist verifies that all other patient conditions have been met and proceeds with specimen collection. As he inserts the needle the patient winces in apparent great pain and moves his arm. No blood flows so the phlebotomist cautions the patient to keep still and redirects the needle. The syringe then rapidly fills with blood and potomist verifies 1. Why might the physician have purposely requested that the specimen be drawn without lidocaine? 2. What should the phlebotomist have done when the patient felt great pain? 3. What nerve lies near the brachial artery and may have caused the pain response!

lens and Tests 263 Case Studies A murse delivered phlebotomist se Study 13-1: CSF Specimen Handling ce delivered three vials of CSF to the lab. A

lens and Tests 263 Case Studies A murse delivered phlebotomist se Study 13-1: CSF Specimen Handling ce delivered three vials of CSF to the lab. A comist newly trained in specimen processing cented the specimens from the nurse. The Whatomist had never received CSF specimens before phlebotomist was not sure what to do with them. She wae mely busy and her supervisor was at lunch so she set the vials a set the vials aside, intending to ask her supervisor hat to do with them upon her return from lunch The supervisor got called to an emergency meeting and did not return for several hours. The phlebotomist was husy she completely forgot about the CSF specimens until the physician called for the results on them. When he found out the specimens had not been tested he was furious. The specimens had to be recollected and the phlebotomist almost lost her job. and was not sure what extremely busy and her su QUESTIONS 1. How could this incident have been prevented? 2. Why did the specimens have to be recollected? 3. How is a CSF specimen collected Case Study 13-2: Urine C&S Specimen Collection Luann recently received on-the-job phlebotomy training. Today was the first day she had been allowed woman came out of the rest room, set the specimen on the counter as she had been told and left. Later to work alone. It was a busy day and patients were that day when things quieted down, Luann discovered starting to stack up in the waiting area. One elderly that the patient had placed the antiseptic wipes in the woman needed a blood test and a urine C&S. Luann urine container with the specimen. She was mad that was good at drawing blood and liked doing it. She the woman could be so foolish and also that she would hated to instruct patients in urine collection, however. have to call her and request that the woman return to She drew the blood specimen, quickly bandaged the the lab and submit a new specimen. patient and handed her a labeled urine collection container and several antiseptic wipes. She asked the QUESTIONS patient if she had ever given a urine specimen for a culture before and when the patient said “Yes,” she 1. Why would the patient make such a mistake if she showed her where the restroom was, and told her had submitted a urine specimen before? that she should put the specimen on the counter when 2. What should Luann have done that would have she was finished and then she could leave. She then prevented the problem with the specimen? called another patient in for a blood draw. The elderly the tech in the micro laboratory. He was relieved and quickly left the floor. Case Study 13-3: AFB Culture It was Friday morning in the small rural hospital, Gerry, the phlebotomist, had just finished his usual morning draws when the nurse handed him an order for an AFB culture and directed him to the patient who was in isolation. The phlebotomist had not seen this order before and asked the nurse if someone else could do it. The nurse said it needed to be done that morning and because they were short staffed he needed to advise the patient on how to collect the specimen. Before dressing to enter the room, he called his supervisor and was told to bring the request to QUESTIONS 1. What does AFB mean? 2. What disease do they think the patient has? 3. What type of specimen would be collected and how should it be done?

Chapter 12: Computers and Specimen Handling and Processing 245 Case Study 12-3: Specimen Processing Issues Janine, a phlebotomist has been newly trained to do specimen processing in the hospital laboratory.

Chapter 12: Computers and Specimen Handling and Processing 245 Case Study 12-3: Specimen Processing Issues Janine, a phlebotomist has been newly trained to do specimen processing in the hospital laboratory. She is QUESTIONS normally expected to work alongside an experienced 1. Should Janine have rejected any of the specimens? processor except when that person is on break or at Why or why not? lunch. Today, while the other processor was on his 2. What could have caused the gel to form at a slant lunch break, multiple specimens arrived from a new in the SSTs, and why do you think Janine exam- off-site drawing station. All of the specimens had ined them so closely? proper identification and paperwork. One of them, an ACTH specimen was in a cooling rack. There were 3. What can cause clotted blood to stick to tube stop- several serum separator tubes (SSTs) that had already pers? How can this be prevented? been centrifuged. The gel had formed at a slant in 4. One specimen was handled incorrectly. Which one all of them. She examined each of them very closely. was it and how should it have been handled? In addition, there were several other SSTs that had 5. What do you think caused the centrifuge to vibrate not been centrifuged. The clot was stuck to the tube loudly and shut itself off. What should Janine do stopper in every one of these tubes. Janine eventually about that? accessioned all of the specimens, loaded the unspun SSTs and the ACTH into the centrifuge, started it up, and began preparing to aliquot the SSTs that had already been spun. Just then the centrifuge began vibrating loudly and turned itself off.

242 Unit IV Special Procedures Case Studies Case Study 12-1:

242 Unit IV Special Procedures Case Studies Case Study 12-1: Specimen Handling and Collection Verification he had already been drawn, and refused to be de Chad is the lone phlebotomist on the night shift at a again. Chad remembers the glucose specimen in hospital. Al 03:00 he collects a timed glucose using a mack. He quickly verifies collection of and the St PST per laboratory policy. On return to the laboratory and personally delivers them to the proper labor he attempts to verify collection of the specimen. dements. The chemistry tech refuses to a The LIS is down for scheduled updates but will be the glucose specimen. When the STAT CBC is te back on-line soon. He sets the tube in a rack of extra microclots are detected, and it has to be recollected Tubes collected during ER draws. He intends to verify collection in a few minutes but starts sorting morning draw requisitions and forgets about it. After that QUESTIONS he goes on break and loses track of time reading a newspaper until he is puged by an ER nurse to collect 1. Why do you think the glucose specimen was a STAT CEC. He tries but is unable to collect it, so an rejected for testing? ER tech collects it while starting an IV. It is past time 2. What could Chad have done differently, so the for Chad’s shift to be over, so he quickly grabs the specimen would not have been forgotten! tube Labeling it on the way back to the laboratory. The 07:00 shift is already there. One of them has just 3. What do you think caused the microclots in the returned from trying to collect a glucose specimen СВсі because the patient’s nurse had called for results and 4. How should Chad have handled the CBC? there was no record of the draw. The patient insisted Case Study 12-2: Specimen Rejection and Centrifuge Operation Melinda, a recent phlebotomy graduate, works with an She quickly grabs the tubes. As she puts them in a experienced phlebotomist in a clinic. Her job involves transport bag, she notices the serum in one SST looks drawing specimens, centrifuging them if required, and gelled. She wonders why but puts it in the bug anywa sending them by courier to an off-site laboratory. Today The courier takes the bag and leaves. The elderly her coworker is ill, and Melinda is by herself. Quite a man’s BMP specimen, the difficult draw specimen, few patients arrived shortly after the clinic opened at and the homocysteine specimen are all rejected by the 08:00, but most were easy draws and by 09:15 only laboratory and must be recollected. three are left. The first one, an elderly man, needs a PT and BMP. She draws a light blue top and SST. The QUESTIONS next one needs a liver profile. He is a difficult draw and her first attempt is unsuccessful. On the second 1. Why do you think the centrifuge made the noise? try blood flows slowly, but she is able to collect a few Why did moving tubes fix the problem? milliliters in an SST before it stops. The last patient 2. What do you think the gel-like substance in the needs a homocysteine level. She easily draws the elderly man’s BMP specimen was? What may have specimen. The waiting room is empty. She looks at the clock. It is 09:40. The courier arrives in 20 minutes caused it, and would that be why it was rejected and she has not centrifuged any of the specimens. She for testing? quickly loads the centrifuge and turns it on. It makes 3. What do you think was most likely wrong with the a terrible noise, so she turns it off. She moves a few difficult draw specimen tubes around and starts it again. This time it sounds OK and finishes spinning just as the courier arrives. 4. Why do you think the homocysteine specimen was rejected?

226 Unit IV: Special Procedures Case Study 11-3:

226 Unit IV: Special Procedures Case Study 11-3: Forensic Blood Alcohol Collection and asks for the specimen in the gray-top tube an In his first week on the job, a new graduate the accompanying paperwork. The phlebotomist phlebotomist is called to the ER for a stat blood draw. relieved and returns to the laboratory. When he arrives he is told to collect an ETOH. The 10 patient smells heavily of alcohol and the phlebotomist is pretty certain that this is going to be an elevated der QUESTIONS ETOH with a legal investigation involved. The phlebotomist studied forensic blood alcohol collection 1. Was the phlebotomist correct in deciding that the in his training program, but this is the first real one he ETOH was going to involve an investigation, and has collected and he is a little unsure of what to do. what does a forensic collection involve? He remembers that a certain strict protocol is involved 2. What is the strict protocol that the phlebotomist and that the site must not be cleaned with alcohol. remembered from his training and what does it All he has on his tray other than alcohol preps are a few benzalkonium chloride preps. He decides to use involve? those. Laboratory protocol says to use an SST for an 3. Was benzalkonium chloride an acceptable antiseptic ETOH level, but he remembers something from his to use to collect the specimen? training about drawing a forensic ETOH in a gray top. He decides to draw one of each tube, collecting the 4. Was it acceptable to draw both an SST and a gray SST first. A police officer arrives just as he is finishing top?