Background case study 1
Natalie is a 21 year old woman who was admitted to an acute psychiatric unit following a suicide attempt. She had taken an overdose of quetiapine (~800 mg). A flat mate found her difficult to rouse in the bath in the early evening (~ 2 hours latter) and called an ambulance. Natalie had previously presented with generalised anxiety disorder and hypomanic symptoms at the student health clinic and she had been prescribed quetiapine (200 mg daily) after consultation with a visiting psychiatrist.
Context
Natalie was admitted to the emergency department. She initially presented with drowsiness, tachycardia (160 / min), hypotension (90/60) and akathisia. After gastric lavage and 2mg lorazepam IV she was monitored for 8 hours before transfer to the psychiatric ward at 2200 hrs.
You are the nurse assigned to care for her on the morning shift and to complete an initial assessment.
Handover
Natalie is a 21 year old student who attempted overdose yesterday afternoon on Seroquel. She was transferred to us at 2200. She was quite drowsy at the time and not very coherent but did indicate that she had intended to die and did not anticipate her flatmates discovering her so soon. She has been experiencing considerable stressors recently: She has been struggling with her studies… She is in her second semester at University studying statistics and believes she is failing… She recently split up with a boyfriend of several years who lives in her home town (about three hours drive away) because of the difficulty maintaining a relationship over such a distance, and she appears to have depleted most of her savings by gambling on an on-line casino several months ago.
Natalie was fairly sleepy so we didn’t glean much more history from her. Her obs are all fine, we’ve been checking hourly. She has a ferociously dry mouth and she’s drunk approximately 2 litres of water over night. She’ll need to see the psychiatrist this morning and have repeat bloods.
Natalie has been admitted to the ward for post-attempted suicide for monitoring. The Health team (nurses) will have to gain a better understanding on Natalie’s background, and future thoughts. For instance, Natalie is a college student and therefore, will constantly be under pressure for submission of assessments. The following questions seek to establish why Natalie tried to commit suicide:
? Whether she is under any form of stress?
? What is the relationship between Natalie and the boyfriend, teachers and students at college?
? What is pushing Natalie to commit suicide?
? Does Natalie take illegal drugs/ substance?
Taking these questions into account the nurses will professionally formulate the clinical strategies that will seek to address Natalie’s problem. In order, to come up with these strategies the nurse will critically reason professionally. The nurse from her findings will formulate a working policy to be used by the psychiatrist and expected medical treatment. This therefore, demands that Natalie should be given special and proper attention by the mental health facility whilst in her condition. The nurse should try as much as possible to check on Natalie from time to time to see whether there are changes. By doing so, the nurse should keep records for both negative and positive changes on Natalie. This will enable the psychiatric to make necessary recommendations on Natalie. (Scheffer & Rubenfeld, 2000)
Scheffer, B. and Rubenfeld, M. (2000). A consensus statement on
critical thinking in nursing. Journal of Nursing Education, 39, 352-359
Clinical reasoning strategies are needed to establish a working formulation by nurse to handle the situation effectively with Natalie by asking questions such as;
? Are suicidal thoughts present?
? When did these thoughts begin?
? How persistent are they?
? Can you control them?
The working formulations that the nurse will present should clearly state the problem of Natalie based on the findings and investigations carried out on presentation/ admission. By identifying problems/ issues this will consequently structure the problem whether it is mental, adult illness or a community situation. This will help, act accordingly on the interpretation, analysis on the earlier documents presented when Natalie was admitted to the facility. The nurse will make the right decisions and make recommendations that will address the problem at hand.
Reflection plays a major key to identifying another aspect that will help the nurses and psychiatrist to contemplate and carefully evaluate and structure a care plan for Natalie best alternative, for recover and diagnosis. (levett-Jones et al, 2010)
Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515 -520.
Each Question must be answered separately in alignment with marking rubric and clinical reason cycle and contain 150 words.
Section 3 Question 1
What have you learned from this scenario?
Section 3 Question 2
How will you apply this to future practice?
BACKGROUND case study 2
Betty, aged 88, was admitted to hospital following a fall in which she fractured her right neck of femur (#NOF). Betty fell at home in her backyard and was found by her neighbour who heard her cries for help. Betty’s daughter lives 800km away and has been concerned about her mother’s memory and general health for the past 18 months and wants her to move into a nearby aged-care facility. Betty has a history of hip and wrist pain for which she takes osteo-eze and ibuprofen.
CONTEXT
Betty was admitted to the orthopaedic ward on a Saturday morning where a fentanyl PCA and bucks traction were commenced and surgery scheduled for the following Monday. It is now Wednesday and Betty is day 2 following an open-reduction and internal fixation (ORIF) for her #NOF. Her surgery went well except for a 2 hour period of hypotension requiring fluid resusitation and a blood transfusion. It is 0800hrs and you are allocated to care for Betty on the morning shift.
HANDOVER
Betty appeared to sleep intermittently and was stable until this morning. At 0600 hours Betty needed to use her bowels and mobilised to the bathroom on her forearm support frame with assistance. We opted to shower her whilst up but she became short-of-breath and somewhat confused and mildly agitated. She appeared tachypneoic though less so once resting on a chair. Her oxygen saturations ranged from 90%-94% on a Hudson mask though she kept moving her hand and removing her mask so I don’t know how reliable these readings were. We returned Betty to bed as she was attempting to get out of the chair without her FASF. She remained a bit tachycardic around 100 and hypertensive but not so much once resting. She complained of some chest pain but provided a vague description. We did an ECG which showed sinus tachycardia with no ST changes. Betty was encouraged to use her PCA more and she has since settled down somewhat though I think she may be developing some post-op delirium as she is not orientated to time or place. Her vital signs have settled somewhat but it might be worth requesting a clinical review as her heart rate is still elevated and her oxygen sats remain borderline around 95%. Oh well, at least she has been showered and used her bowels though she has not voided much over the past 24 hours. Her wound looks good, there’s minimal drain loss and she’s afebrile. She’s not trying to get out of bed just now but if she does she might need specialling.
Each Question must be answered separately in alignment with marking rubric and clinical reason cycle and contain 150 words.
Section 1 Question 1
Following this handover, outline how you would collect more data about Betty’s clinical status/condition (as per the orange section of the clinical reasoning cycle)
Section 1 Question 2
Recall concepts and knowledge that may be relevant to consider regarding Betty’s change in condition. (For example, physiology, pathophysiology, psychological, phaarmacological or best practice evidence concepts).
Section 3 Question 1
What have you learned from this scenario?
Section 3 Question 2
How will you apply this to future practice?
BACKGROUND case study 3
Michael Grasslands 63 years chest pain whilst fishing. The pain lasted for 1 hour but Michael did not seek assistance straight away as he thought it was indigestion. At 1430 hours he arrived home and collapsed on the sofa clutching his chest. His daughter called an ambulance which arrived at 1450 hours. The ambulance officers placed Michael on a cardiac monitor, applied oxygen at 10L/min via a Hudson mask, and gave him Aspirin 300mg orally and an Anginine tablet 600 microgram sublingually. Michael was then transferred to the Emergency Department of a rural base hospital 30 min away and diagnosed as having an acute episode of chest pain.
CONTEXT
You are working in the acute observation section of the ED where Michael Grasslands arrives after being triaged as a category 2.
HANDOVER (from ambulance officer)
Michael Grasslands is a 63 year old Aboriginal man we found at home on his sofa complaining of chest pain that came on around 1.30pm today while he was fishing. On arrival he rated his pain at 9/10 radiating from his chest into his left shoulder. He was diaphoretic and stated he also felt some palpatations which made him feel short of breath. He’s been monitoring in sinus tachycardia with a few ectopics with a heart rate of 100 to 120. His respiratory rate was 28 and oxygen saturations 95% on 8L/min via a Hudson mask. We gave him Aspirin 300mg and Anginine 600mg at 1455 and 1500 hours. His BP came down a bit but he still complained of 8/10 pain so we popped an 18 gauge cannula in his left arm and gave him Morphine 2.5mg. As you can see, his heart rate is a bit irregular around 100 and at 1515 his BP had come down from 180/100 to 130/85. His respiratory rate has dropped a bit to 20 but his saturations have not picked up. He states he has diabetes and is on tablets for high blood pressure and cholesterol.
This rhythm strip print out is attached to the ambulance paper work.
Each Question must be answered separately in alignment with marking rubric and clinical reason cycle and contain 150 words.
Section 1 Question 1
Following this handover, how would you gather more cues and information about Michael when taking over his care?
Section 1 Question 2
Recall concepts that may be relevant to consider regarding Michael’s change in condition (physiology, pathophysiology, psychological, cultural, spiritual, best practice evidence concepts). State the level of urgency regarding diagnosis and intervention required.
Section 3 Question 1
What have you learned from this scenario?
Section 3 Question 2
How will you apply this to future practice?
CONTEXT case study 4
It is 11am and you are working in a high dependency unit and have been notified that you will be looking after a new admission that will be shortly transferred from the emergency department. After checking your equipment and setting up a bay, your patient arrives.
HANDOVER from ED nurse.
‘Hi, this is Sue’ (you say hello to Sue and introduce yourself as the nurse who will be looking after her in the high dependency unit.)
‘Sue is 52 and has presented to ED at 8am today complaining of continuous epigastric pain radiating to her back. The pain came on last evening and was associated with nausea and vomiting overnight. Sue said she has had similar pains but not as bad on and off for a few days and at times over the past few weeks.
On admission Sue was moaning and quite distressed and was rating her pain as 9 out of 10. It was difficult to do any abdominal assessments so we inserted an IV and gave her some PMP morphine and some maxalon. Initially she was tachycardic and normotensive but following 2 lots of IV morphine 2.5mg she became quite hypotensive (down to 85 systolic). She was reviewed by the team and given a litre of normal saline. She was also febrile 38.5C but her temp is now 37C following some IV perfalgan.
Sue’s had a chest and abdominal xrays which were apparently normal except for a small left pleural effusion. A whole stack of bloods have been sent but the results are not in the system yet. Sue’s been seen by the surgical registrar. He requested an abdominal ultrasound and CT scan which are scheduled for tomorrow morning. As you can see, she has a naso-gastric tube in which has been draining small amounts of bile fluid. She’s NBM and there are further IV fluid orders. She hasn’t needed to void as yet.
There’s not much significant history, Sue said she had asthma as a child but rarely gets it these days and only during winter. She has a hysterectomy 5 years ago and the only medication she takes is hormone replacement therapy. Sue works part-time at the local services club and lives with her youngest daughter who is doing her HSC? (Louise verifies this with Sue).
I think the surgical reg has written cholelithiasis or cholecystitis as the differential diagnosis, though there’s a couple more things written with question marks but I can’t make them out. They wanted her monitored here because she remains quite tachycardic around 110 and her BP has not improved much. Sorry… that sounded a bit vague but you know what it’s like downstairs in ED and I’ve got to get back.’ (Turns to Sue – ‘Bye Sue… you’re in good hands now. It will be much quieter here.’)
Each Question must be answered separately in alignment with marking rubric and clinical reason cycle and contain 150 words.
Section 1 Question 1
Following this handover, outline the assessments you would do and the rationale for doing them.
Section 1 Question 2
Recall concepts that may be relevant to consider regarding Sue’s condition on arrival. (These include physiological, psychological, pharmacological, social, cultural, spiritual and best practice evidence concepts.)
.
Section 3 Question 1
What have you learned from this scenario?
Section 3 Question 2
How can you apply this to future practice?
