With reference to appropriate guidelines and evidence, critically analyse the issues raised by Peter’s decision.

Essay question 1: Diabetes and renal failure

Meera Gupta is a 78 year old lady who lives at home with her husband. Before her acute admission to hospital with a myocardial infarction (MI) Meera had experienced a decline in her mobility and had noticed she was slightly more breathless than usual, resulting in a decline in her ability to conduct daily activities. Meera suffered a myocardial infarction (MI) at home, requiring Primary Percutaneous Coronary Intervention and stent insertion. Due to problems achieving radial access, the PPCI was conducted through a femoral artery approach. As a result Meera suffered a haematoma covering roughly half the front surface of her upper leg stemming from the entry site in the groin. The access site had been managed with manual compression post sheath removal.
As the haematoma was so large, she was referred to a vascular surgeon for advice about its management. The surgeon chose to aseptically remove the haematoma under local anaesthetic which left a very large open wound that needed to be dressed daily. The wound was very large and wasn’t healing well, the tissue viability nurse was asked for advice about wound management. Meera also began to get embarrassed about the wound and became withdrawn often refusing to see her visitors.

Alongside Meera’s acute problem of an MI she also had haemodialysis (HD) three times a week for end stage renal failure, she’d been has having this treatment for approximately 18 months. Meera was also diagnosed 8 years ago with type two diabetes, which was believed to have contributed to her renal problems and MI.

During her time on the cardiac ward following the angioplasty and stent insertion Meera was reluctant to eat as she said that she had been told many years ago that she needed to follow a low protein diet to “protect her kidneys”. Meera was slightly built and MUST screening demonstrated a poor score. Nursing staff tried to explain that a low protein diet was ill advised and encouraged her to select higher protein/calorie choices from the menu card. The dietitian reiterated the importance of a good diet and the dangers of restricting her protein intake. Nutritional supplements were prescribed for Meera to help boost her protein/calorie intake.

After 5 days Meera was deemed to have made a good recovery from her MI and was transferred to a vascular ward for ongoing management of her wound.

Assignment: Write a 4000-word essay in which you:

Explore the significance of type II diabetes in relation to Meera’s myocardial infarction, renal failure and wound healing;

Discuss the multidisciplinary management of patients with end-stage renal failure, with reference to the scenario, clinical evidence and national guidelines;

With reference to Meera’s individual needs, analyse the nutritional assessment and advice described in the scenario.

Essay question 2: End of Life Care

Laura Ford is 34 years old, and was diagnosed with a lung adenocarcinoma (T3 N2 M0) eighteen months ago. She has completed several cycles of palliative treatment including chemotherapy and radiotherapy. Sadly, despite some initial response, a recent CT scan has shown extensive disease progression.

Laura woke up in the early hours of the morning struggling to breathe. She was frightened and so was Paul who called an ambulance. On admission to the ED Laura presents with severe dyspnoea, a tachycardia of 130bpm and she seems disorientated.

Laura and her husband Paul are aware of the stage of her disease and have talked openly about their wishes for Laura’s’ future care. Their three children, aged 3, 6 & 10 years are being cared for by Paul’s parents whilst they attend hospital.

Assignment: Write a 4000-word essay in which you:
With reference to the scenario where appropriate, explore the pathophysiology of lung cancer;

Analyse the current management of lung cancer using the published literature and policy guidance to support your discussion;

Discuss the wider holistic needs of Laura, Paul and their three children as she approaches end of life, and explore how a multidisciplinary approach can help meet these needs.

Essay question 3: Hip fracture

Joyce Brown is 87 years of age. She is a widow and lives alone in an ‘assisted living’ flat in the centre of town. She has a daughter who lives about 15 miles way who pops in most days after work to check on her and bring shopping. She also has a cleaner who come for 2 hours a week. Otherwise, she usually manages fairly well on her own with her personal care and cooking.

Joyce has been diagnosed with stable angina for which she uses a Glyceryl Trinitrate (GTN) Spray. She also has what she describes as a ‘bit of high blood pressure’ for which she takes Nifedipine. Over the last few weeks, however, Joyce has had a few falls at home. She isn’t sure what has caused them but she hasn’t told anyone as she is worried her daughter will think she can’t cope on her own at home and she doesn’t want to go into residential care. Otherwise she is fit and well for her age.

Joyce fell in the hallway of her flat on her way back to her sitting room after going to the toilet at about 13.30 hours. She was unable to get up and had to wait until her daughter arrived at about 17.20 to get help. She was complaining of pain in her left hip. Her daughter called an ambulance and she was taken to the local emergency department. An x-ray of her hip showed that she had a hip fracture – specifically, an intertrochanteric fracture. About 36 hours after she was admitted to hospital she underwent surgery to ‘fix’ the fracture with a ‘dynamic hip screw’ (at 10.30 hrs that morning).

It is now 19.00 hrs on the day of Joyce’s surgery and she returned to the ward at approximately 12.20 hrs. Joyce seems restless, agitated and aggressive and appears to be frightened of the staff which, according to her family and the staff who cared for her pre-operatively, is out of character for her. Joyce doesn’t have a history of memory problems and her family say there have never been any signs of dementia. Joyce’s observations are within her own normal limits and stable: BP=146/94mmhg, Pulse=68/min, Respiratory rate=17/min, SpO2 =95%.

When asked about her pain Joyce has some difficulty answering questions about her pain levels using the VAS (Visual Analogue Score), but she is wincing when the staff attempt to move her and this seems to make her agitation worse. It is standard practice to get patients out of bed on the evening of the day of surgery if they have their surgery in the morning, but the nursing staff do not feel it is safe to do this with Joyce at present. Joyce has a surgical wound vertically across her left hip and a vacuum drain in situ as well as an IV infusion as well as a urinary catheter.

Assignment: Write a 4000-word essay in which you:

Examine the prevalence, pathophysiology and potential complications of hip fracture, with reference to the clinical evidence base ;

With reference to clinical evidence, national policy and guidelines, analyse the inpatient care and multidisciplinary management of Joyce’s hip fracture

Essay question 4: Venous Leg Ulcer

Ben Johnson is 26 years old. He is has just been sent to prison from the magistrates court in Hull to serve a 3 year sentence for aggravated burglary. The prison is a category B local prison.

Ben has a history of intravenous drug use since he was 16 years old. Prior to being sent to prison he worked as a labourer on a buildings site. He lived with his girlfriend and 2 year-old son. Since being in prison Ben has suffered with depression and has told the DARS (Drug and Alcohol Recovery Service) team that he doesn’t feel he has much of a future. He presents with a ‘larger than life’ personality which may mask his true feelings. He engages well with staff when he attends to collect his medication daily but lives a solitary existence in prison.

Ben has had a chronic venous leg ulcer on his right shin for the past 18 months. Previously his GP and practice nurse have been providing wound care but because of Ben’s chaotic lifestyle and his job, he has not complied well with any of the treatments offered, including compression bandaging or stockings. He often fails to attend health care appointments saying he can’t get there in time. The wound has gradually got larger and on many occasions it leaks fluid and smells.

Ben is currently prescribed 60ml of methadone solution which he has administered (supervised) each morning. The prison Doctor refuses to prescribe the pregabalin that he was used to receiving in the community due to the potential interaction between the two medications. On questioning Ben, effective pain management has not been achieved and he reports being awake for long periods at night due to extreme pain.

Assignment: Write a 4000-word essay in which you:

Explore the healthcare issues faced by prisoners, particularly in relation to substance misuse;

Demonstrate an understanding of the prevalence, pathophysiology and impact of venous leg ulcers;

With reference to clinical evidence and guidelines (and in relation to Ben where appropriate) explore the management of venous leg ulcers.

Essay question 5: Respiratory Failure

Peter Jones a long term heavy smoker has long standing chronic obstructive pulmonary disease (COPD). He has been admitted to hospital with this condition with increasing frequency over the past 18 months. Peter has been unwell at home for a number of days with an acute exacerbation of his condition. On admission to a medical ward he is severely hypoxic, noticeably cyanosed and in obvious respiratory distress.

Peter Jones required treatment with NIV and had a protracted stay in hospital before eventually recovering. He found the treatment arduous and given his many similar recent admissions Peter has decided he doesn’t want to be so aggressively treated in the future should his condition deteriorate again.

Assignment: Write a 4000-word essay in which you:

Explore the pathophysiological changes which have resulted in Peter Jones’ respiratory distress;

Analyse and evaluate the assessment and management required by Peter Jones. Support your discussions with appropriate guidance and evidence;

With reference to appropriate guidelines and evidence, critically analyse the issues raised by Peter’s decision.

Essay question 6: Atrial fibrillation and dementia

Elsie Smith is an 82-year-old who lives alone since her husband died 8 years ago. She has one daughter, who visits twice a week to help out where she can with shopping and cleaning.

Elsie was diagnosed with Alzheimer’s disease 6 years ago. Though initially she only demonstrated mild cognitive dysfunction, she has been becoming increasingly forgetful and – on occasions – confused over the past few months.
In addition to hypercholesteroleamia and hypertension, Elsie also has permanent atrial fibrillation. Her medication consists of Warfarin, Atorvastatin and ACE inhibitors. She also has a variety of analgesics in her home to help with pain from arthritic knees.

Elsie has been falling at home recently. Most recently, she was found at home by her daughter after about 12 hours on the floor. She has been admitted to the elderly assessment unit – though she has no fractures, she is badly bruised. Mrs Smith’s daughter is worried about her Mum’s safety at home, particularly in relation to mum’s falls and her ability to take medication correctly.

Assignment: Write a 4000-word essay in which you:

Examine the pathophysiology of atrial fibrillation and the risks that this condition presents to Elsie;

Explore the prevalence, pathophysiology and impact of dementia, with specific reference to Elsie where appropriate;

With reference to relevant policies, guidelines and evidence, analyse how the multidisciplinary team can work in partnership to enhance Elsie’s safety in the home following discharge.

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