Consolidating Clinical Reflective Practice: Assessment Answer

Ysabel Green is a 33 year old woman who prior to giving birth to her 3rd daughter Ruby, at 37 weeks gestation was diagnosed with Cholelithiasis. Post the birth of Ruby, Ysabel’s LFT results and and bilirubin levels had stabilised and a medical decision was made not to remove the gall stones and/or gall bladder.

About 6 weeks after Ruby’s birth, Ysabel started experiencing some episodes of right upper quadrant pain and nausea. Over a period of 5 weeks, her symptoms intensified and became more frequent. She presented to a hospital Emergency Department on a Tuesday evening experiencing acute right upper quadrant pain which was radiating to her right shoulder. She was nauseous and had vomited twice over the last 24 hours. Ysabel was examined by the medical officer on duty and administered Morphine 2.5mg IV 1-2 hourly prn. Following administration of 5mg of Morphine her pain score decreased from a 9/10 to a 2/10. No further investigations were conducted and 8 hours after admission to ED Ysabel was discharged. She was advised by the discharging medical officer to make an appointment to see her own local doctor over the next week.

• Medical History

  Asthma

• Cholelithiasis pre birth of her 3rd child

• Gestational Diabetes

Ysabel lives with her husband and 3 daughters aged 5 years old, 14 months and 3 months. The family recently moved from a rural setting to the city. They currently live in a 2 bed room unit whilst they await the purchase of their own home.

Reason for admission Day 1 (Thursday)

Assessment on Admission to Emergency Department (ED):

Ysabel had presented to Hospital A’s ED on a Tuesday evening and been discharged the following morning. On return home from Hospital A, the pain and antiemetic medications had worn off, and Ysabel continued to experience severe pain and vomiting for 24 hours. Ysabel’s husband (Tom) had to drive her back to ED, however, he chose to take her to a different hospital this time as he was quite upset that she had been discharged from ED the previous day when she was still so obviously ill. On presentation to Hospital B’s ED Ysabel was examined by the medical officer on duty, she was ordered and administered Morphine 2.5 mg IV 1-2 hourly prn and Ondansetron 4 mg IV to relieve her nausea and vomiting. Nursing staff continued to assess her and administer pain medication.

Further investigations included:

FBE, U&E, LFTs, and an abdominal ultrasound scheduled as soon as possible.

Results of Investigations

Blood Tests

: Hb – 125 g/l (115 - 165 g/L) WCC – 11.5 x109/L (4.0 - 11.0 x109/L) ALP 119 (25-225 U/l Bilirubin 2.0 (0.2 – 1.5 mg/dl

Abdominal Ultrasound:

http://lluultrasound.org/home/ebook/original-abdominal/

Ysabel was diagnosed with Cholecystitis secondary to Cholelithiasis. She was referred to the surgical team for review. At 11 am Ysabel was reviewed and advised that she was scheduled for laparoscopic cholycystectomy surgery to take place either later that evening or the following morning. Ysabel remained nil orally awaiting surgery. She had an IVC in situ with 1L of N/Saline 8 hourly and further orders as required. At 3 pm, Ysabel was transferred to the surgical ward to await surgery. Later that evening she was advised that her surgery had been postponed due to the large number of surgical cases scheduled on the day. At 9 pm she was offered a light diet of toast and a cup of tea, and fasted again from midnight

in preparation for surgery the following day.

Day 2 (Friday)

The next day Ysabel waited all day for her surgery but was advised at 6 pm that her surgery had once again been postponed due to more urgent cases and once again given a light diet.

Assessment on the Ward

CNS: Pain increased 3-4/10 – relieved by 2.5mg Morphine, IV

CVS: Vital signs HR – 90, BP – 110/70, T – 37.4°C

RESP: No wheeze, equal air entry in both lungs. RR – 16.

GIT: Nil orally 1L N/Saline 6 hourly rate

RENAL Passing urine in toilet

As Ysabel’s surgery kept getting delayed, both Ysabel and Tom were becoming increasingly anxious and concerned that the delay would complicate her medical condition. Tom also had great difficulty organising carers for their children so that he could visit his wife. When Tom telephoned to speak to either nursing or medical staff for an update on his wife’s condition, he received very limited information. So communication regarding his wife’s condition occurred mainly via Ysabel herself. Ysabel was further distressed that Tom was left alone to care for their 3 children, two of them very young babies.

Day 3 (Saturday)

On the Saturday morning, Ysabel was taken to the operating room at 8 am for surgery. Although the staff had advised Tom that he would be contacted once his wife was taken to surgery, this did not occur. Ysabel sent her husband a text message advising him just prior to being wheeled to surgery. At 11 am Tom telephoned the ward enquiring about his wife’s condition and to check if her surgery was completed and when he might be able to visit. The Assistant Nurse Unit Manager (ANUM) advised Tom that Ysabel had not returned to the ward,

and she did not know what was happening with her care. However, if he wished he could ring through to the operating room directly and ask for information regarding his wife. However, she informed Tom that she thought Ysabel would most likely return to the ward in the next hour or so as laparoscopic cholycystectomy surgery was usually not lengthy. She reassured him that she would telephone him as soon as Ysabel returned to the ward. At 2pm Tom was quite concerned at no news about his wife. He had difficulty being transferred through to the operating room, so had telephoned the hospital ‘patient enquiry’ number to find out more information about his wife. He was advised by ‘patient enquiry’ that his wife had returned to the ward. Tom visited the ward at 3.30 pm to find that Ysabel had not yet returned from theatre. The nurse in charge of the afternoon shift was unable to advise Tom regarding his wife’s condition. At 5pm Ysabel was transferred from the recovery room back to the ward. When Tom asked staff about his wife’s surgery and why it had taken so long, he was advised that he would need to speak with her doctor, as they were not able to tell him the specifics of the surgery.

Ysabel had returned to the ward with a PCA infusion, 4 laparotomy wound sites and a drain tube.

Tom was becoming increasingly anxious about the lack of information being offered by staff regarding his wife’s condition.

Day 5 (Sunday)

On the Sunday morning, Tom was contacted by Ysabel who told him that she had just been reviewed and advised by the surgical registrar that during surgery her gall bladder had burst and gall stones had blocked her bile duct. Meanwhile, Ysabel was to remain nil orally in preparation for an MRI to be conducted later that day to investigate if there were any complications following her surgery. Later that evening Ysabel was advised by nursing staff, that she would have the MRI the next morning and she would need to remain nil orally for the present.

Day 5 (Monday)

The next morning (Monday) was a public holiday and while Ysabel and Tom waited patiently for the MRI, it was not until later that evening that they were advised that the MRI would not be conducted due to the shortage of radiology staff on the public holiday.

Day 6 (Tuesday)

On the Tuesday morning, Ysabel was taken to the medical imaging department for an MRI. The MRI results showed that the bile duct was clear of gall stones. On return to the ward Ysabel was advised that she could go home later that day after having her drain tube removed and having something to eat and drink. To assist with her discharge preparation, the nurse caring for Ysabel decided to quickly remove the drain tube so that Ysabel was able to shower without having tubes attached. Ysabel was discharged home at 4pm that day.

Day 8 (Thursday)

Over the next few days Ysabel started to feel very unwell. She became nauseated, vomited twice, struggled to consume any food and fluids and had difficulty taking her pain medication. She felt dizzy, hot and very lethargic. Tom telephoned the hospital and was instructed to take Ysabel back into the Emergency Department for review.

Assessment in ED:

CNS: Pain reported to be 4/10 at the wound site area of the removed drainage tube.

CVS: Vital signs HR – 110, BP – 100/65, T – 38.8°C RESP: No wheeze, equal air entry in both lungs. RR – 20. GIT: Nil orally – awaiting further test results. Commenced on IV fluids: 1L N/Saline 6 hourly rate RENAL Passing small amount of urine in toilet. Commenced on 1 hourly urine measures

SKIN: Wound site area where drainage tube had been removed was swollen and inflamed and tender on palpation. Laparotomy wound sites x 4 – NAD.

The doctor who assessed Ysabel suspected that she may have a wound infection at the drainage tube site. He was also concerned that she may be developing sepsis. To investigate this further, he ordered blood tests for FBC, CRP, PCT, Lactate and a full set of Blood Cultures. The nurse caring for Ysabel in ED had difficulty accessing Ysabel’s veins for venepuncture due to Ysabel’s mild hypotension. She decided to make use of Ysabel’s pre-existing IVC to draw up blood for investigations and blood cultures.

Please answer the following questions, using academic language and format. Questions: 1. Identify all clinical practice issues in Ysabel’s care during all of her hospitalisation.

2. Identify all National Health and Safety Standards that have been breached in Ysabel’s care and discuss how these standards have been breached.
3. From your list of identified National Health and Safety Standards, choose two (2) standards, review literature and discuss how those 2 standards could have been maintained by health care staff in the care of Ysabel and her family during her hospitalisation. 
4. Based on your 2 chosen standards, what recommendations would you make for changes to health care practice at the ward level? Support your recommendations with rationales supported by evidence-based literature.