401021 | Nurse | A Case Study on Activities of the Nurse or Midwife
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.
a. What happened in the incident?
b. What activities did the nurse or midwife need to need to complete in immediate situation?
c. What professional behaviours might have made a di?erence in this situation?
d. What do you learn from this case study about your own preparedness for professional practice?
Answer:
a. The case study centres on 81 year old patient who was admitted to local (rural hospital) due to shortness of breath, she was admitted to the local (rural) hospital. VMO reported that she depressed and anxious and encouraged nursing staffs to mobilise the patient and referred to discharge planning. On the same day, the respiratory rate of the patient increased (28 to 30 beats per minute) and her condition showed no improvement till the evening. VMO recommended Digoxin and Valium with patient’s respiratory rate recorded 40 beats per minute. On the next day, patient was found pale and abdominal X-ray was recommended by VMO. When patient was found unable to move due to the back pain with increase in the white blood cell count, urinary tract infection was diagnosed and proper intravenous antibiotics were charged. Registered nurse, John commended his afternoon shift and patient reported dizziness with high abdominal pain. Her high respiratory rate was high with low blood pressure and heart rate. Though enrolled nurse reported that patient’s condition was alarming, John insisted that he will only check patient’s condition once the locum arrives. John though checked patient’s condition but did not documented any information. RN John telephoned the clinical manager to Sophie smith but did not raised concerns for Patient A. Instead, she called her to ask for medication for another patient. When ISBAR form was filled respondent described patient’s situation to the “deteriorating” and recommended for ASAP interventions and immediate contact to patient’s family. The VMO arrived and emergency on-call doctor arrived post one hour and took initiatives to treat patient’s dehydration. Though proposal for patient’s transfer was signed, the critical condition of the patient, prevented from doing so. Patient later died while she was being assessed by the air evacuation team on the next morning and septicaemia has highlighted as the primary cause of death.
b. According to the Nursing and the Midwifery Board of Australia (2018), it is the duty of the nursing professionals to practice in accordance with the prevailing nursing standards in order to avoid any further complications. However, in the case study, when enrolled nurse informed John (RN), that patient condition is critical, John refused to take active initiates and unnecessarily delayed the situation stating that he can only attend the patient once the locum arrives. According to the Nursing Competency Standards (2018), it is the duty of the nurse of midwives it document each and every parameters of patient physiological health status when the patient is complaining for being unwell. The main parameters which must be taken into consideration include heart rate, respiratory rate; pulse, body temperature; oxygen saturation, blood pressure and the pain score (if any) (Smith, Prytherch, Meredith, Schmidt & Featherstone, 2013). This detailed documentation of the patient’s information helps the attending doctors to take necessary actions immediately. However, analysis of the case study highlight that when John assessed patient’s condition (11th Jan 1810 hours), he did not documentation the observations.Poor documentation of the information delayed the overall process of diagnosis when the VMO arrived. It is also the duty of the nurses and midwives to initiate MET (Medical Emergency Team) Call at the time of emergency when the patient condition was found deteriorating (Boniatti et al., 2014). A registered nurse or midwife must also indulge in effective communication with the senior colleagues in order take prompt decision (Arnold & Boggs, 2015). According to the National Competency Standards for the Nurses and Midwives in Australia (2018), it is the duty of the nursing professional to communicate effectively with individuals with range of communication techniques to increase the provision for care. Bramhall (2014) stated that effective communication is an important aspect of multidisciplinary care approach in the healthcare. Such communication helps in taking proper decision in order to alleviate unnecessary complications. However, John lacks the skill of effective communication and this is highlighted when he bought no reference of the ailing patient when Sophie Smith (clinical nurse manager) came to sign the medication of another patient. This lack of effective communication prevented transfer of the effective information and this delayed immediate initiatives on the basis of patient’s condition.
c. The clinical incidence highlighted, that when RN John was notified about the deteriorating condition of the patient by the enrolled, John delayed the situation via stating the excuse of locum. Locum is a person who stands in temporarily for someone else in the same profession like a substitute doctor or a nurse (Thiele, Doarn & Shore, 2015). When the enrolled was present there, he or she could have acted as the locum for the time being while John could have analysed the emergency situation of the patient. This could have saved much time while preventing from the situation from deteriorating further. Uscher-Pines, Pines, Kellermann, Gillen and Mehrotra (2013) highlighted that any emergency inside the hospital unit requires prompt intervention by the RN and any delay in the same may result in fatal consequences. When John addressed patient, he did not documented any information. ISBAR form filling was also delayed by John. Proper documentation of the information like patient’s vital parameters or the pain scale might have helped the VMO to take immediate actions or the follow up nurse to grasp the overall situation quickly while taking the necessary actions. Even when RN John telephoned the clinical nurse manager, Ms Sophie Smith, he did not highlight the critical situation of the patient. Had John highlighted the issue to the clinical nurse manager then the emergency on-call doctor might have intervened immediately preventing the situation from becoming worse. De Meester, Verspuy, Monsieurs and Van Bogaert (2013) stated that proper introduction of the SBAR (situation, background, assessment and recommendation) help to increase the perception of effective communication and collaboration among the nursing professionals along with a decrease in unplanned death.
In order to make a difference in the overall situation, RN John might have acted in accordance to National Safety and Quality Health Service Standard (NSHSS) 9 by Australian Commission on Safety and Quality in Health Care (2012). According to this standard, it is important to recognise and respond to clinical deterioration during acute health care. This can be done through proper physiological observation. The main physiological observation includes measuring oxygen saturation, heart rate, blood pressure, body temperature, level of consciousness and respiratory rate. This period assessment of the vital parameter of patient will help to avoid serious health outcome and unnecessary delay in care.
d. What?
My present reflection is based on the analysis of the case study, where negligence of the nursing professional lead to fatal outcome of the patient. While narrating my reflection, I will follow Rofle’s Reflection Framework (Rolfe, Freshwater & Jasper, 2001).
So what?
The overall analysis of the case study helped me to understand that the amount of promptness or preparedness required in the professional of nursing. While reviewing the case study, I understood that in the professional of nursing, there is no scope for negligence in work. This is because; any negligence in the job place can cost a patient’s life. It is the duty of the nursing professionals to practice proper critical thinking skills in order to increase the provision or co-ordination of care. It is also the duty of the nursing professional to analyse and interpret the assessment data accurately and then take necessary actions.
Now What?
During my professional practice I will employ my critical thinking skills in order to take proper decision in the domain of patient care. I will accurately access patient’s data in order to take the any further steps. The moment I will feel that the patient condition is deteriorating, I will take active initiative in order to fill the ISBAR from in order to avoid any further complications. I will also take prompt action during critical patient situation via identifying proper information in relation to patient health and taking proper care or action plan. I will also demonstrate proper analytical skills in accessing and evaluating patient’s health information and will take proper decision without any delay. I will also effectively communicate with the patient’s condition with the other healthcare professionals. With will increase the provision of care under the domain of multidisciplinary approach.
References
Arnold, E. C., & Boggs, K. U. (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=7DAxBgAAQBAJ&oi=fnd&pg=PP1&dq=Interpersonal+Relationships-E-Book:+Professional+Communication+Skills+for+Nurses&ots=uYuBI4wCVl&sig=u_r345tMYWOxXBlgvDLWveHskAM#v=onepage&q=Interpersonal%20Relationships-E-Book%3A%20Professional%20Communication%20Skills%20for%20Nurses&f=false
Australian Commission on Safety and Quality in Health Care. (2012). National Safety and Quality Health Service Standards. Access date: 28th August 2018. Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf
Boniatti, M. M., Azzolini, N., Viana, M. V., Ribeiro, B. S., Coelho, R. S., Castilho, R. K., ... & Rodrigues Filho, E. M. (2014). Delayed medical emergency team calls and associated outcomes. Critical care medicine, 42(1), 26-30. doi: 10.1097/CCM.0b013e31829e53b9
Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard (2014+), 29(14), 53. DOI:10.7748/ns.29.14.53.e9355
De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation, 84(9), 1192-1196. https://doi.org/10.1016/j.resuscitation.2013.03.016
Nursing and Midwifery Board of Australia (NMBA) (2018). National competency standards for Nurses. Access date: 23rd August 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Search.aspx?q=National+competency+standards+for++++++Registered+Nurse
Rolfe, G., Freshwater, D., & Jasper, M. (2001). Critical reflection for nursing and the helping professions: A user's guide. Basingstoke: Palgrave.
Smith, G. B., Prytherch, D. R., Meredith, P., Schmidt, P. E., & Featherstone, P. I. (2013). The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation, 84(4), 465-470. https://doi.org/10.1016/j.resuscitation.2012.12.016
Thiele, J. S., Doarn, C. R., & Shore, J. H. (2015). Locum tenens and telepsychiatry: trends in psychiatric care. Telemedicine and e-Health, 21(6), 510-513. https://doi.org/10.1089/tmj.2014.0159
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013). Deciding to visit the emergency department for non-urgent conditions: a systematic review of the literature. The American journal of managed care, 19(1), 47. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/
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