401021 Being A Professional Nurse or Midwife: Case Of GP Clinic

Case Study

On 5 January 2013, Patient A, who was 81 years old, presented to a GP clinic complaining of two nights of breathlessness when lying flat and shortness of breath. On examination, Patient A was found to have fine creps at the base of both lungs and slightly elevated jugular venous pressure. Her renal function was normal. She was commenced on oral Lasix and was recommended to have a clinical review two days later.

On 6 January 2013, Patient A attended a local (rural) hospital again with shortness of breath. Patient A was admitted to hospital as the oral Lasix had not improved her symptoms.

On 9 January 2013, Patient A reported dizziness. This coincided with an atrial fibrillation (AF) rate of 120/ min. The VMO was called to review Patient A. Patient A was refusing food and liquid at this time and was complaining of feeling very weak and having abdominal pain.

At 0830 hours on 10 January 2013, the VMO again assessed Patient A. He concluded that Patient A was depressed and anxious. He encouraged nursing staff to mobilise Patient A. The nursing notes that follow the VMO attendance refer to discharge planning at 1021 hours, and then, at 1315 hours, comment that Patient A felt unwell, had refused breakfast and lunch, had no energy and required encouragement to mobilise. Patient A's respiratory rate was recorded as 28-30/ minute, but other vital signs were within normal limits.

At 1820 hours, the progress notes state that Patient A refused to tolerate her dinner. At 1910 hours, Patient A was observed to have a respiratory rate of 40/min and she was tachycardic at 122/min. At 1930 hours, Patient A was documented as feeling "woozy", her skin was cold and clammy and she was complaining of severe back pain. Her BSL was 16.1mmmol/I. An ECG was conducted, which showed a heart rate of 168/min. The VMO was again called. He stated that Patient A should be administered Digoxin and Valium. At 2110 hours, showing Patient A's respiratory rate was still at 40/min.

At 0530 hours on 11 January 2013, nursing notes state that Patient A was unable to void, was pale and grey, and had clammy skin and nausea. At 0830 hours on 11 January 2013, the VMO assessed Patient A and wrote "?Significant medical illness". An abdominal x ray and pathology were ordered. The VMO returned at 1330 hours and noted that Patient A "won't/ can't mobilise [because of] pain in back and abdo" and that her white cell count had risen to 17.5, despite an absence of fever. A urinary tract infection was subsequently diagnosed and intravenous antibiotics were commenced at approximately 1430 hours.

Registered Nurse (RN) John* commenced his afternoon shift as the nurse in charge at 1430 hours on 11 January 2013. He read Patient A's progress notes at approximately 1445 hours. RN John was immediately concerned about Patient A's condition.

At approximately 1720 hours, Patient A reported to nursing staff that she was feeling dizzy and had abdominal pain (8/10). She was observed to have a respiratory rate of 40-44/min, very low blood pressure of 89/53 and a heart rate of 88.

Shortly before 1810 hours, RN John was advised of Patient A's condition by an enrolled nurse. RN John said he would have Patient A reviewed once the locum arrived. At around 1810 hours, Patient A had continual diarrhoea. RN John again stated that Patient A would be reviewed when the locum arrived. RN John did assess Patient A, but did not document the observations.

At approximately 1910 hours, RN John arranged for a further ECG to be undertaken for Patient A.

At approximately 2020 hours, RN John telephoned the Clinical Nurse Manager, Ms Sophie Smith*, to arrange for medication to be obtained from the drug safe (for a patient other than Patient A). At approximately 2030 hours, Ms Smith attended the hospital and signed for the medication. RN John did not raise any issues concerning Patient A with Ms Smith at this time.

At approximately 2100 hours, RN John and another registered nurse completed an ISBAR (Introduction Situation Background Assessment Recommendation) form. In that form, the respondent described Patient A as "deteriorating", and recommended that Patient A's condition be reviewed "ASAP''. He also stated that Patient A's family had been contacted.

The VMO, arrived at 2200 hours. By this time, Patient A was critically unwell. The emergency on-call doctor, Dr Aboud*, arrived at approximately 2300 hours and inserted a large bore IV cannula to treat Patient A's severe dehydration. Over the course of the night, attempts were made to transport Patient A to referral hospital. The ability to transfer Patient A was significantly complicated by Patient A's critical condition. Tragically, Patient A died whilst she was being assessed by the air evacuation team the following morning. The primary cause of death was stated to be septicaemia.

1.

Patient A was hospitalised and reported atrial fibrillation and dizziness with rapid heart rate. He was reported weakness and abdominal pain. Assessment was done by the VMO and it was identified that the patient was distressed, depressed and anxious as well and ordered the nursing staff to encourage the patient to mobilize. Poor intake of food and increased RR was also noted. Patient A gradually start deteriorating with the high RR and rapid heart rate. Patient also reported about feeling woozy and cold and clammy skin. Complain regarding severe back pain was also reported. 16.1 BSL and heart rate of 168/m in ECG have been found. Patient was taken digoxin and Valium, but no improvement was recorded.

During further assessment VMO reviewed and UTI diagnosed and provided IV antibiotics. The registered nurse john from afternoon shift has failed to escalate the care in urgent basis when Patient A complained about abdominal pain and dizziness. His observation was increased RR and very low BP and severe diarrhoea. RN john assessed the patient but escape documentation and esca

2.

RN John should respond to the critical condition of the Patient and identify the patient’s deteriorating health condition including organise a medical review when very low blood pressure such as 89/53 mmHg, high respiratory rate such as 40 to 44 breaths per minute, abdominal pain and diarrhoea were observed. With the vital sign assessment the registered nurse should have collect past medical history and current medication. It could help him to recognize that whether the increase in breathlessness is due to the adverse effect of some drugs for example, Lasix (Gulanick & Myers, 2016). After observing high respiratory rate the registered nurse should have assessed the air way and provide adequate oxygen therapy to manage the shortness of breath in an effective manner. It could help him to relief the patient (Doenges, Moorhouse & Murr, 2014). The nurse should have introduced some relaxation techniques to relax the patient and inform the patient regarding the effectiveness of the treatment as well. It could help the registered nurse to reduce the pain, depression and anxiety of the patient and help the patient in improving mobilization in an effective manner (Acebedo-Urdiales, Medina-Noya & Ferré-Grau, 2014). As the pain was measured 8/10 in the pain scale, it was important to introduce effective nursing interventions in order to reduce the pain. Effective medication could be provided to the patient in order to manage rapid heart rate and low blood pressure (Gulanick & Myers, 2016).

As a registered it was the duty of John to provide adequate mental support to the patient beside medical support. As the patient has refused to take any food or fluid the registered nurse should have communicated with the patient and made her understand about the importance of healthy food habit in such critical health condition. In such way the registered nurse could convince the patient for healthy diet and improve the blood pressure as well (Doenges, Moorhouse & Murr, 2014). In this way the RN should have maintained the standard 1 of Australian commission on the safety and quality in health care that provides guidelines for safety and quality in health service (Australian Commission on Safety and Quality in Health Care, 2012). In addition the registered should have conducted documentation of the patient’s health condition. It could help to prioritise the area of care and introduce adequate health interventions to cure the patient. This activity could help to maintain the standard 9 of Australian commission on the safety and quality in health care that indicates recognising and responding to clinical deterioration in acute health care (Australian Commission on Safety and Quality in Health Care, 2012). With such the registered nurse could save the life of patient A.

3.

As seen from the case of patient A, the nurses that were engaged in caring of the patient A lacked the safe and responsive nursing practise with quality care. The registered nurse should have maintained the professional behaviour in nursing. For example, the nurse should have escalated the care to the VMO when deterioration in the health of patient has been measured. It could help the registered nurse to provide adequate care to the patient during the time of need and could save the life of patient A (Faden, Beauchamp & Kass, 2014). The nurse should have taken the vital signs properly and document each findings appropriately. It could help the registered nurse to comply with Standard 4 and standard 5 of NMBA that provides guidelines for holistic assessment in order to recognize the severity and introducing proper plan of care to provide adequate health service (nursingmidwiferyboard.gov.au, 2018). In this way the nurse could help the patient to improve her condition and avoid the incident of death.

Furthermore, the registered nurse should have reviewed the health condition of the patient and follow up the patient effectively. In this regards the registered nurse should have discussed with the clinical nurse manger regarding the health condition of patient A and would have asked for effective medication to manage the severe condition. Such communication would help the registered nurse to collaborate with the nursing practice and build professional relationship in an effective manner (Kourkouta & Papathanasiou, 2014). According to the standard 2 of NMBA, it is impor5ant to establish therapeutic relationship in the nursing practice in order to collaborate effectively and enhance the quality of service (nursingmidwiferyboard.gov.au, 2018). Person centred care is another important behaviour that could be used by the registered nurse in case of patient A. Person centred care focuses to the requirement of individual patient and prepare care plan according to the need. It helps to provide effective care and resolve the health issue in an effective manner. In this case the registered nurse should have prepare the care plan based on diarrhoea, abdominal pain, rapid RR and heart rate and breathlessness. Such person centred care would help to improve the health condition and could save the life of the patient (Broderick & Coffey, 2013). In addition the registered nurse should have used the skill of critical thinking in nursing to evaluate the health condition of the patient and introduce appropriate nursing interventions to help the patient to recover faster (Gulanick & Myers, 2016). Such behaviours could help to provide quality service and ensure patient safety, thus, the healthcare team could avoid the incident of patient mortality.

4.

The case study has helped me to learn about the necessity of utilising the guidelines provided by NMBA standard of nursing and standards of Australian commission on safety and quality in health care. The case study has demonstrated the importance of skill for documenting the health condition of the patient. It would help to identify the priority of care and introduce effective care plan. Through this case study I was able to understand the importance of professional accountability in the nursing practise. I have learned that it is important for a registered nurse to become professionally accountable as it helps to expand the nursing skills and introduce evidence based practice to guide the clinical practice. In addition the case study has elaborated the escalation of care. It determines the proportion of patients that are audited but lack adequate care. I have learned that if a nurse delays to escalate care it could leads to the consequence of morbidity and mortality as well. As a new nurse I have gather knowledge from the case study and would like to implement the learnings in my clinical practice. I would like to utilise the guidelines provided by NMBA standard of nursing care and standards of Australian commission on safety and quality in health care to improve my service quality and ensure patient safety. I will escalate the care where necessary without any delay. However, I have identified that my communication skill is not that good, therefore I would think about some strategies for preparedness of practice. It is expected that with such strategies I could improve my skills and establish myself as a successful nurse in future.

References

Chang, E. (2015). Transitions in nursing: Preparing for professional practice. Elsevier Health Sciences.

Acebedo-Urdiales, M. S., Medina-Noya, J. L., & Ferré-Grau, C. (2014). Practical knowledge of experienced nurses in critical care: a qualitative study of their narratives. BMC medical education, 14(1), 173.

Australian Commission on Safety and Quality in Health Care. (2012). National safety and quality health service standards. Australian Commission on Safety and Quality in Health Care.

Broderick, M. C., & Coffey, A. (2013). Person?centred care in nursing documentation. International journal of older people nursing, 8(4), 309-318.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. FA Davis.

Faden, R. R., Beauchamp, T. L., & Kass, N. E. (2014). Informed consent, comparative effectiveness, and learning health care. N Engl J Med, 370(8), 766-768.

Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans-E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences.

Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in nursing practice. Materia socio-medica, 26(1), 65.

nursingmidwiferyboard.gov.au (2018). Nursing and Midwifery Board of Australia - Registered nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx