Assignment Task

Aim

In this assessment item you will have the opportunity to apply your critical thinking skills to develop a nursing care that focuses on clinical deterioration and the potential for failure to rescue. Nursing care planning enables nurses and student nurses to demonstrate their clinical decisionmaking capabilities and supports safe evidence-based practice.

Task Description

Within the online content, you have explored complex nursing care, with a focus on acute deterioration and the importance of nursing care plans. For this task, you need to examine a case study and create an appropriate nursing care plan for the patient in the case study.

nstructions: Examine ONE of the following case studies, and with reference to appropriate scholarly literature:

1. Identify TWO (2) actual or potential priority problems related to failure to rescue described in the selected case study. For each problem, justify your choice as a priority (e.g., by referring to the patient’s assessment data in the selected case study and to appropriate literature)

2. For EACH priority problem, identify ONE (1) SMART goal for care of the selected patient (total 2 goals). Remember a SMART goal is specific, measurable, attainable, realistic, and timely

3. For EACH goal, describe TWO (2) evidence-based nursing interventions you would implement to meet the goal (total 4 interventions). For each nursing intervention, justify your choice by referring to appropriate literature.

4. For EACH goal, identify the expected outcomes and describe your evaluation approach (e.g., how, and when, would you evaluate whether your interventions have been effective or not?)

5. Analyse the impact of failure to rescue on the patient, their family, and the health care system.

Case Study

1. Rapid Deterioration of Cecil Jones at Griffith University Hospital

Medical History: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (Stage 3), Congestive Heart Failure, Osteoarthritis, Chronic Obstructive Pulmonary Disease (COPD)

Social History: Cecil lives alone in Kippa-Ring, in a single-story house. He does not have any live-in family members, as he is widowed. Cecil is a retired high school teacher and has been living on his pension since then. Cecil has limited social support. His children and close relatives live in Melbourne and Adelaide, and he rarely sees them. Cecil is a current smoker and started smoking at the age of 18, Cecil smokes approximately 15 to 20 cigarettes a day.

Cecil takes Aclidinium long-acting muscarinic antagonist (maintenance medication) for COPD, whilst using a short-acting bronchodilator as a reliever, however, Cecil recently has stopped using Aclidinium.

Cecil is a moderate drinker, consuming up to two standard drinks per day. He does not engage in regular exercise due to his chronic health conditions but used to be physically active in his younger years. Cecil can mobilise independently at home but does become short of breath on exertion.

Presenting Condition

Cecil Jones was admitted to Griffith University Hospital on October 10, 2023, with a chief complaint of increased shortness of breath, generalised weakness, peripheral oedema, cough, and loss of appetite. He was not able to recall if he had been experiencing fevers. He has a complex medical history and has been under the care of several specialists for the past few years. Cecil had previously been hospitalised three times in the last six months due to exacerbations of his chronic conditions. Chest X-ray on admission shows consolidation.

ISOBAR Communication Approach

In Cecil Jones’s case, the ISOBAR approach was used to facilitate communication between the registered nurse (RN), Emily, and the registered medical officer (RMO) covering the late shift. Emily introduced herself to Cecil at the commencement of the shift, gathered key patient information, and ensured the patient’s identity. She also confirmed Cecil Jones’s current health issues, medications, and relevant history.

Introduction: RN Emily contacted the RMO at 21:30hrs, introduced herself, and identified the ward calling from and patient of concern.

Situation: Cecil was noted to have a QADDS score of 5 at 21:25hrs (Case Study 1 – Adjunct Data QADDS). RN Emily outlined Cecil Jones’s current situation, emphasising the worsening shortness of breath, low oxygen saturation, increased blood pressure, elevated heart rate, and the presence of atrial fibrillation. She also highlighted the patient’s profound lower extremity oedema and difficulty in speaking full sentences due to dyspnoea.

Observation: RN Emily provided observations, including, bilateral crackles on lung auscultation, the patient`s fatigue and weakness, and the titration of supplemental oxygen to maintain SpO2 between 88-92%, via nasal prongs at 0.5-2L/min1 .

BP - 145/100 mmHg (post daily dose of antihypertensive medication)

HR - 118bpm and irregularly irregular

Respiratory rate - 21 bpm

Temperature - 37.5 Degrees Centigrade

SpO2 88%

Capillary Refill - Greater than 2 seconds

Glasgow Coma Score -15/15

Background: RN Emily shared Cecil Jones`s relevant medical background, including his complex medical history, recent hospitalisations, and the chronic conditions he was managing.

Assessment: RN Emily discussed her assessment findings, including the need for diuretic therapy to manage fluid overload and the presence of new-onset atrial fibrillation on the ECG.

Chest X-ray (Case Study 1 – Adjunct Data)

Full Blood Test Results (Case Study 1 – Adjunct Data)

ECG (Case Study 1 – Adjunct Data)

Urinalysis (Case Study 1 – Adjunct Data)

Recommendation: RN Emily immediately notified the team leader and planned a medical resident review within 30 minutes. Cecil was commenced on hourly observations. RMO reviewed Cecil at 21:45 and ordered a stat IV dose of Frusemide 40mg and to monitor vital signs hourly.

Deterioration: Despite RN Emily`s utilisation of the ISOBAR communication approach, Cecil Jones`s condition continued to deteriorate rapidly over the next 2 hours. His oxygen saturation did not improve, and he required increased oxygen support. His heart rate remained elevated, and his blood pressure continued to rise, along with his respiratory rate. He became more dyspneic and fatigued, cooling peripherally with a prolonged capillary refill time and reduction in GCS, arterial blood gas indicates respiratory acidosis. 

2. Kimberly Peters Hospital Admission for Stable Hypoglycaemia at Griffith University Hospital

Medical History: Type 2 Diabetes Mellitus, hypertension, and hyperlipidaemia. Kimberly weighs 72.6kg, her height is 167 cm, and her waist circumference is 86 cm. Kimberly takes Metformin extended release for blood glucose control, Captopril for hypertension (target systolic < 120>

Social History: Kimberly is married and lives with her spouse and two young children in a suburban home, working full-time as a project manager in a local IT company. Kimberly and her family maintain a balanced diet and try to make healthy food choices. Kimberly tries to incorporate regular physical activity into her routine but has recently dropped off her exercise due to increasing work demands. Work pressures have also meant she not monitoring her blood glucose levels routinely.

Presenting Condition

Ms Kimberly Peters presented to Griffith University Hospital Emergency Department (ED) at 4 a.m. on November 1, 2023, with symptoms of hypoglycaemia stating she felt lethargic, following a recent viral illness, including 24 hours of vomiting and diarrhoea. Kimberly was administered IV antiemetic medication and IV Glucagon. The ED RMO inserted a peripheral intravenous cannula and ordered IV sodium chloride 0.9% with glucose 5% 1 Litre, delivered at 125 ml/hr. At 9 a.m. (same day), Kimberly was transferred to the medical ward for the continuance of IV fluid therapy and stabilisation of blood glucose.

ISOBAR Communication

Approach In Kimberly Peter`s case, the ISOBAR approach facilitated communication between the registered nurse (RN), Hamid, and the registered medical officer (RMO) covering the morning shift. Hamid introduced himself to Kimberly on transfer to the ward, gathered key patient information, and confirmed the patient`s identity in addition to Kimberly Peters’ current health issues, medications, and relevant history.

Introduction: During the morning medical round RN Hamid, introduced himself, and Kimberly Peters, a 36-year-old female, who was admitted with hypoglycaemia and dehydration due to a recent viral illness accompanied by vomiting and diarrhoea for 24hrs, before admission. No further vomiting or diarrhoea since presenting to the Emergency Department at 4 am.

Situation: Kimberly has a known history of Type 2 Diabetes Mellitus coexisting with hypertension and hyperlipidaemia. Current blood glucose level is within normal range (4-8mmol/L).

Observation: Upon admission to the medical ward, Kimberly`s baseline assessment was:

Background: Kimberly has a 2-year history of Type 2 Diabetes Mellitus, hypertension, and hyperlipidaemia. Up until recently, Kimberly had consistently monitored blood glucose levels. Most recent documented HbA1c result was 7% (53mmol/mol).

Assessment: Kimberly is currently stable, with Blood Glucose Level within normal range.

Recommendations: Further evaluation revealed that Kimberly had been missing meals before the viral illness due to work pressure and an increased feeling of being overwhelmed and helplessness. Kimberly revealed she had also forgotten to regularly test her blood glucose levels and take Metformin. Referral to a Diabetic Educator to discuss recent difficulties in monitoring blood glucose levels was commenced and a planned visit by the social worker.

Approximately 2 hours later, Kimberley experienced a sudden deterioration. Kimberly reported feeling nauseated and dizzy before starting to slur speech. RN Hamid notified the medical officer to report the observations and assessment data gathered using a primary survey:

Airway: patent Breathing: borderline bradypnea (8 bpm), shallow breathing, SpO2 92-93% on room air (Case Study 2 – Adjunct Data Pulse Oximeter image)

Circulation: Hypotensive - Blood pressure 100/60 mm Hg, bradycardic, 50 bpm (Case Study 2 – Adjunct Data ECG), severely diaphoretic and peripherally cool, with capillary refill time > 2 seconds.

Disability: decreased level of consciousness, eyes = 2, Voice = 3, Motor = 5 GCS of 10/15, Blood Glucose Level = 1.776 mmol/L (venous sample) Exposure: Temperature 36.6 degrees centigrade