Nsg2Nci | Nursing | A Assessment Answers
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.
You are to draw on the National Safety and Quality Health Service Standards and the NMBA professional practice documents to develop critical responses to the clinical incident. The following questions are required to be answered for this assessment:
1. What happened in this clinical incident?
2. What activities did the nurse or midwife need to complete in the immediate situation?
3. What professional behaviours may have made a difference in this situation?
4. What do you learn from this case study about your own preparedness for professional practice?
Answer:
1. The case study depicts the clinical scenario of 81 year old, patient A who had initially complained about shortness of breath while lying flat on the bed on 5th of January. She was recommended oral Lasix and was asked to report again after two days. However, the patient did not find much relief with the use of oral Lasix and reported the very next day to a rural hospital. On January 9th, the patient complained of dizziness with an increased heart-beat. The patient further refused food and also stated to have severe abdominal pain. On reviewing the patient, the VMO concluded the patient to have been feeling depressed and at the same time analysed the condition of the patient on the ECG report and prescribed Digoxin and Valium to control the accelerated heart-beat of the patient. Later during the day the progress notes revealed the patient to be tachycardiac, with cold and clammy skin and back ache. The VMO diagnosed the patient again and the progress notes mentioned Patient A to have an increased WBC count despite having fever, with urinary tract infect ions, severe abdominal pain and administered antibiotics intravenously (National Safety and Quality Health Service Standards, 2018). Gradually the patient developed diarrhoea and ultimately due to critical weakness passed away on 11th January. The identified reason for death was septicaemia.
2. According to the NMBA standard guidelines that are followed on a mandatory basis in nursing a number of measures could have been adopted that would have helped in preventing the deteriorating condition of the patient (Andrew, 2015). The first and foremost measure that could have been taken was an elaborate documentation (Boyd & Sheen, 2014). The case study reveals that a number of observations were not taken note of and also the casual approach of RN John led to the worsening of the health condition of patient A. Registered nurse John could have immediately informed the clinical manager MS. Sophie Smith and requested her to urgently design a course of action. It should be noted that RN John despite being informed by the enrolled nurses about the worsening condition of the patient did not review the patient and waited for the locum to arrive. Further, the case study also states that RN John did access patient A but did not document the observation (National Safety and Quality Health Service Standards, 2018). It is also mentioned that he telephoned the clinical manager and asked her to arrange medication for another patient other than patient A. Even when Ms. Smith had arrived with the medication, RN John did not convey any information regarding the degrading medical condition of patient A. Also, it is stated that the after the successful completion of ISBAR evaluation, the documentation by RN John and another fellow nursing professional it was recorded that patient A’s medical condition was worsening and that her family members had been contacted. Although, the nurse had mentioned these characteristics in the ISBAR evaluation form he had absolutely taken no initiative to prevent the condition from deteriorating 9 National Safety and Quality Health Service Standards, 2018). Patient A constantly complained of back pain and the progress notes that were handed over to RN John on commencement of his shift stated that the patient had clammy skin and found it difficult to mobilise. RN John did not take note of the crucial observations. He failed to identify the symptoms of septicaemia. The progress notes also mentioned the patient had been refusing meals and was severely dehydrated. RN John as a responsible professional must have proactively administered medication to combat dehydration and must have checked the vital signs of the patient and recorded the detailed observation Aebersold & Tschannen, 2013). RN John and the enrolled nurses must have taken an immediate clinical decision based upon the urgency of the situation and arranged for an emergency MET call (Cusack, 2015).
3. Professional approach that could have been incorporated in order to avoid the fatal situation could be proper documentation of observation, effective communication and better decision making ability. The nurse could have recorded the patient observation on hourly basis. According to the NMBA standard recording observations on hourly basis helps in being able to monitor the condition of the patient in a detailed manner as it provides an over view about the deteriorating or improvement health status of the patient in a concise and accurate manner (Keast,2015). Also, RN John could have checked vital signs which was not done by him. Further, when the patient repeatedly complained about back pain and the progress notes revealed restricted mobility due to back pain and pain in the abdomen, the RN could have arranged for physiotherapy so as to help the patient with mobility (National Safety and Quality Health Service Standards, 2018). The progress notes also revealed that the patient had refused meals. It should additionally be stated that there was no documentation about the bowel movement of the patient Aebersold & Tschannen, 2013). It might have been possible that the patient was constipated before. The case study does not mention any documentation of the dietary or the fluid intake of the patient. RN John prior to the arrival of the locum could have organized for fluids that would have helped the patient with dehydration and would have helped the patient in urinating frequently. This would have helped the patient in getting relieved of the urinary tract infection. Further, it is important to consider here that the patient with proper assistance of fluid intake would have not been dehydrated and would not have refused meals. It can be said that the refusal of the meals was primarily due to severe dehydration (National Safety and Quality Health Service Standards, 2018). Further, as supported by the patient safety guidelines it should be stated that the registered nurse should have immediately arranged a MET call or consulted with the clinical manager so as to improve the deteriorating health of the patient (Scanlon et al., 2016). Hence, it can be said that comprehensive documenting is described as a pivotal tool that determines best nursing practice (Levada et al., 2015). It is highly recommended to the nursing professionals to document the observations in a detailed manner in the progress notes in order to ensure that every significant information of the medical status of the patient is recorded in a detailed manner (McCabe & Timmins,2013). RN practise requires a comprehensive thinking and efficient decision making so and deliver the medical services with close association to the safety standard of the patient.
4. According to my understanding and critical evaluation of the case study, I believe that I am not yet entirely prepared for my professional practice. In order to improve my preparedness for professional practice, I would like to develop my decision making ability complying with the reflective framework of Rolfe’s reflective framework (National Safety and Quality Health Service Standards, 2018). This framework is primarily based upon the three vital considerations that accesses what is the situation, what can be done according to the theoretical and practical experience in the situation and finally the attempt that can be taken to improve the situation (Rolfe, 2014). It has been stated as per the facts furnished by scholarly references that the third aspect is the most critical aspect of Role’s reflective framework (Heckemann et al., 2015). Therefore, the efficient use of Rolfe’s reflective framework would help in successfully evaluating the course of actions undertaken by me to serve the patient in with respect to the social policy, legislative policies and my personal attributes (National Safety and Quality Health Service Standards, 2018). Further, I would make use of these considerations and address the third and the most vital part of the reflection framework that would help me judge my own course of action and help me design better intervention strategies. Also, I believe that on working with my supervisors I would be able to develop my professional skills on the basis of the knowledge gathered through observation and their experience of dealing with patients over a considerable time period.
References:
Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing, 18(2). DOI: 10.3912/OJIN.Vol18No02Man06
Andrew Scanlon, D. N. P. (2015). Doctor of nursing practice: Australia. Journal of Doctoral Nursing Practice, 8(1), 98. retrieved from: https://search.proquest.com/openview/14175631f8d6f2fbb5e4f5b0e8e05105/1?pq-origsite=gscholar&cbl=1016349
Boyd, L., & Sheen, J. (2014). The national safety and quality health service standards requirements for orientation and induction within Australian Healthcare: A review of the literature. Asia Pacific journal of health management, 9(3), 31-37. Retrieved from: https://hdl.handle.net/10536/DRO/DU:30069760
Cusack, L. (2015). Revised registration standards approved. Australian Midwifery News, 15(4), 14. ISSN: 1446-5612
Cusack, L. (2015). Update from Nursing and Midwifery Board of Australia. Australian Midwifery News, 15(3), 12. ISSN: 1446-5612.
Heckemann, B., Schols, J. M., & Halfens, R. J. (2015). A reflective framework to foster emotionally intelligent leadership in nursing. Journal of nursing management, 23(6), 744-753. DOI: https://doi.org/10.1111/jonm.12204
Keast, K. (2016). Taking enrolled nursing into a new era. Australian Nursing and Midwifery Journal, 23(8), 20. ISSN: 2202-7114
Levada, L., Johnson, J., Gore, A., & Ireland, S. (2015). Standards are living documents... ACORN, 28(1), 25-27. ISSN: 1448-7535.
McCabe, C., & Timmins, F. (2013). Communication skills for nursing practice. Macmillan International Higher Education. https://books.google.co.in/books?hl=en&lr=&id=7EcdBQAAQBAJ&oi=fnd&pg=PP1&dq=McCabe,+C.,+%26+Timmins,+F.+(2013).+Communication+skills+for+nursing+practice.+Macmillan+International+Higher+Education.&ots=iE_8qTHBbw&sig=CJ-_sWV99og4opEDRtd4f_Wie3Q#v=onepage&q=McCabe%2C%20C.%2C%20%26%20Timmins%2C%20F.%20(2013).%20Communication%20skills%20for%20nursing%20practice.%20Macmillan%20International%20Higher%20Education.&f=false
National Safety and Quality Health Service Standards. (2018). National Safety and Quality Health Service Standards. Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf
Pretorius, L., Bailey, C., & Miles, M. (2013). Constructive Alignment and the Research Skills Development Framework: Using Theory to Practically Align Graduate Attributes, Learning Experiences, and Assessment Tasks in Undergraduate Midwifery. International Journal of Teaching and Learning in Higher Education, 25(3), 378-387. ISSN: ISSN-1812-9129
Rolfe, G. (2014). Rethinking reflective education: what would Dewey have done?. Nurse Education Today, 34(8), 1179-1183. DOI: https://doi.org/10.1016/j.nedt.2014.03.006
Scanlon, A., Cashin, A., Bryce, J., Kelly, J. G., & Buckely, T. (2016). The complexities of defining nurse practitioner scope of practice in the Australian context. Collegian, 23(1), 129-142. DOI: https://doi.org/10.1016/j.colegn.2014.09.009
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