401021 Being A Professional Nurse Or Midwife
Question:
Alm of assessment
Details
Nursing 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
Answer:
Introduction
When the new graduate nurses enter into the professional force, they find difficult to practice as they neither had practice expertise nor they have the required confidence to navigate in order to become dynamic under intense clinical requirement (Duchscher, 2018). The following essay is based on the case study showing how negligence due to lack of proper professional goals and lack of awareness in the professional code of conduct might lead to fatal outcomes in patient care. The essay will initiate with critical analysis of the case study followed by discussion and personal reflection of the author.
Critical analysis
The case study is mainly centred on 81 year female patient who was initially presented to a GP with breathlessness while lying fat. GP observed that she has fine crepes at the base of both lungs, elevated jugular venous pressure and normal renal function and prescribed oral Lasix for two days. On next day only patient reported to local (rural) hospital with shortness of breathe and subsequently she was admitted as oral Lasix failed to improve her symptoms. According to Pellicori, Kaur and Clark (2015), oral Lasix is not functioning and the breathless is persisting hospitalization is recommended. However, the case study did not provided any documentation of the patient’s vital parameters which prompted urgent hospitalization like heart rate, respiratory rate, blood pressure. Esmailian and Nasr-Esfahani (2014) is of the opinion that it is the duty the outdoor nursing professional to keep a detailed tabulation of the patient’s vital parameter while the patient is being hospitalised and report the same to the medical officer. Three days after patient refused food and water intake and was complaining for being weak, abdominal pain along with atrial fibrillation (120 beats per minute). On basis of the reported symptom, VMO was called. This again highlighted that it is the role of the nursing professional to communicate the patient’s problem to the medical officer in order to ensure fast recovery of the patients (Arnold and Boggs, 2015). VMO concluded that patient was depressed and anxious and recommended nursing staff to mobilise patient and then frame the discharge planning and the same has been documented by the nursing professional. According to the Nursing Code of Professional Conduct Australia (2018), it is the duty of the nursing professional to provide a detailed documentation of the discharge planning in order to assist the care giver at home. Later patient’s respiratory rate was recorded and was found to be 28 to 30 minutes and other vital signs was found to be normal. However, the attending nurse did the same to the medical officer. Dwyer, Gabbe, Stoelwinder and Lowthian (2014) reported that high respiratory rate (normal 12 to 20 beats per minute) can be fatal and required non-invasive monitoring. During the evening also, patient’s condition did not improved as she refused to have dinner along with further high respiratory rate and tachycardic (122/min). However, when the patient stated feeling “woozy” with skin turning pale and cold, and heart rate of 168/min, VMO was called. This delay in VMO intervention might have increased the severity of the disease. However, Smith et al. (2014) are of the opinion when a patient is showing no promising improvement or rather experiencing further deterioration, it the duty of the attending nursing professional to go for MET call or Medical Emergency Team call. Smith et al. (2014) are of the opinion that MET call is a sentinel event that promotes intervention from multidisciplinary team of healthcare professionals and thereby helping to overcome the critical situation. Boniatti et al. (2014) stated that Delayed MET call can caused adverse health outcome and this is what the cause with this 81 year old patient. Intervention of the VMO prompted administration of Digoxin (medicine for arterial fibrillation) and Valium (medicine for anxiety). Later when Digoxin failed to produce quality results, blood test and chest X-ray was prescribed which revealed urinary tract infection and thereby explaining the reason behind abdominal or back pain along with high white blood cell count in the absence of fever (Foxman, 2013).
The registered nurse (RN), John, who joined on the next shift (noon shift) studied the patient history in detail in and become concerned about it. According to Nursing and Midwifery Board of Australia (2018), it is the duty of a RN to check the patient history in detail immediately after commencing the shift. However, Nursing and Midwifery Board of Australia [NMBA] (2018) also stated that it is also the duty of the nurse who is leaving the shift to notify the joining shift nurse about specific clinical details of patients, which must be taken under detailed consideration. This falls under the non-clinical skills but is of clinical importance. Moreover, when enrolled nurse notified John about the deteriorating condition of the patient, he did not reacted on an immediate basis. Moreover, even when he addressed that patient, he did not document his observation. The reports highlighted by Esmailian and Nasr-Esfahani (2014) state that it is extremely important for a nursing professional to document each and every information in relation to patient’s health in a pre-defined structure such that the change in shift nurse or the VMO might not suffer from gap of information about patient’s condition. When the Clinical Nurse Manager, Sophie Smith, came, John did not raise the concern of the patient (patient A). effective communication between the colleagues and taking active steps in cascading the information of the patient to the senior nurse falls under the professional code of conduct of the nursing professionals this promote active intervention and fast recovery of the patient (O’hagan et al., 2014). Later while completing ISBAR form, it was highlighted for “ASAP” intervention. This delay in the overall intervention coming from VMO and emergency on-call doctor and he condition was so critical that it was difficult to shift her to a different hospital and subsequently the patient died while from septicemia. Thus, the professional conduct as expressed by John highlighted that there is negligence from his end, which complicated the overall situation leading to unwanted casualty. Though initially John became concerned about the patient at the starting of his duty, he failed to take desired actions during the time of emergency.
Discussion
Nursing and midwifery occupation deals with active patient care, monitoring, critical analysis of the condition of the patient and active decision making process (Arnold & Boggs, 2015). According to the NMBA standard, a nursing professional is required to practise in a safe and competent manner. This safe and competent practice deals with a mixture of both clinical and non-clinical skills. According to Carvalho (2016) important non-technical skills of the nursing and midwives include team-work, effective communication, proper management of stressful situation, expression of leadership, problem solving skills and decision making process. However, the RN, John significantly lack in the domain of non-technical or non clinical skills. The lack of effective communication, active decision making process and problem solving skills of John has lead to the tragic outcome of the case. The clinical skills of the nursing professional include recording the vital signs of the patients, monitoring the patients’ mental health condition and taking appropriate actions. However, the case study has highlighted that John lack clinical skills as the documentation and ascertain the clinical condition of the patient was mostly done via the enrolled nurse. Moreover, when the nurse noticed that the condition of the patient is serious, John kept on waiting for the locum. According to active communication, effective decision making skills and taking prompt actions are the few things which cannot be practiced in detail while working as a trainee nurse or while pursuing the graduate course. These secondary skills are mostly acquired during the professional practice and dedication to work (Carvalho, 2016). Thus this transition phase is extremely important in the nursing profession and the required nurse is need to act proactively in order to refine both clinical and non-clinical skills.
Reflection
My main values for practice are strictly guided by the NMBA standards. Which again vouch for practicing in accordance with the standards in order to uphold the quality of care. I believe effective communication and cascading the right information at right time to right person can help to solve critical situation. Had I been in the position of John, RN, I would take active step of informing the VOM or the reporting RMO (residential medical officer) just at the time when the enrolled nurse reported that the condition of patient is severe. Taking this age and physical condition into consideration I would have framed the required steps to actions. My personal goal is to meet my professional responsibilities during my shift timing. I think a new graduate nurse, when I join into professional practice, I will work on my effective communication skills and the decision making power. This I will do under the guidance of the senior RN as this training and learning while practising will help me to achieve the desired non-clinical skills important for RN.
|
Personal Smart Goal on Professional Practice |
|
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Specific (S) |
Training on effective communication and decision making skills |
|
Measurable (M) |
The outcome in the care plan as evaluated by the senior nurse |
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Achievable (A) |
The training will be done under the supervision of the senior registered nurse |
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Reliable (R) |
The training will be provided under work settings |
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Timeline (T) |
Six months |
Source: Created by author
Conclusion
Thus from the above discussion, it can be concluded that nurse plays an important role in the overall process of care. Since nursing professional is the main medium of constant between the patients and the doctors, they are required to act diligently in order to avoid fatal or severe outcome of the patients. The essay also highlighted that how both clinical and non-clinical skills are important in the nursing profession and for a new graduate nurse, it is the duty to work on their non-clinical skills and take active role in communicating important information and decision making process in order to improve the overall quality of care.
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=uYuzQXsDUn&sig=88s_Ic5dZCWaXjurIwIq4MEc62I#v=onepage&q=Interpersonal%20Relationships-E-Book%3A%20Professional%20Communication%20Skills%20for%20Nurses&f=false
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
Carvalho, E. C. D. (2016). A glance at the non-technical skills of nurses: simulation contributions. Revista latino-americana de enfermagem, 24. doi: 10.1590/1518-8345.0000.2791
Duchscher, J. B. (2018). A process of becoming: the stages of new nursing graduate professional role transition. The Journal of Continuing Education in Nursing, 39(10), 441-450. https://nursingthefuture.ca/assets/Documents/Stages2008.pdf
Dwyer, R., Gabbe, B., Stoelwinder, J. U., & Lowthian, J. (2014). A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age and ageing, 43(6), 759-766. https://doi.org/10.1093/ageing/afu117
Esmailian, M., & Nasr-Esfahani, M. (2014). The Quality of Patients’ Files Documentation in Emergency Department&59; a Cross Sectional Study. ?ibb-i urzh?ns-i ?r?n, 1(1), 16-21. Retrieved from: https://www.ingentaconnect.com/content/doaj/23833645/2014/00000001/00000001/art00003
Foxman, B. (2013). Urinary tract infection. In Women and Health (Second Edition) (pp. 553-564). https://doi.org/10.1016/B978-0-12-384978-6.00036-4
Nursing and Midwifery Board of Australia. (2018) Fact sheet: Recency of practice. Access date: 8th August. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/recency-of-practice.aspx
O’hagan, S., Manias, E., Elder, C., Pill, J., Woodward?Kron, R., McNamara, T., … & McColl, G. (2014). What counts as effective communication in nursing? Evidence from nurse educators’ and clinicians’ feedback on nurse interactions with simulated patients. Journal of advanced nursing, 70(6), 1344-1355. https://doi.org/10.1111/jan.12296
Pellicori, P., Kaur, K., & Clark, A. L. (2015). Fluid management in patients with chronic heart failure. Cardiac failure review, 1(2), 90. doi: 10.15420/cfr.2015.1.2.90
Smith, R. L., Hayashi, V. N., Im Lee, Y., Navarro-Mariazeta, L., & Felner, K. (2014). The medical emergency team call: a sentinel event that triggers goals of care discussion. Critical care medicine, 42(2), 322-327. doi: 10.1097/CCM.0b013e3182a27413
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