NUR251 Medical Surgical Nursing 2 – Nursing Case Scenario
Assignment Help on Case Scenario – Vanessa Anderson

Written Assessment 2: Tasks

Aspects of nursing care and responsibilities in an acute care setting

Priority Nursing Assessments

At the commencement of the shift, three priority nursing assessments for Vanessa Anderson include neurological assessment, pain assessment, and vital signs monitoring.

Neurological Assessment
A comprehensive neurological assessment is crucial for Vanessa due to her traumatic head injury and diagnosed depressed focal right temporal skull fracture. This assessment should include evaluation of consciousness level using the Glasgow Coma Scale (GCS), pupillary responses, and motor function (Braine and Cook, 2021). The underlying pathophysiology involves potential intracranial pressure changes and cerebral oedema following the trauma. Failure to accurately assess neurological status could result in missed signs of deterioration, leading to delayed interventions and potentially irreversible neurological damage. The Glasgow Coma Scale chart can be used to record and track neurological status over time.

Pain Assessment
Given Vanessa’s complaint of headache, a thorough pain assessment is necessary. This should include pain intensity, location, quality, and aggravating or alleviating factors. The pathophysiology relates to tissue damage, inflammation, and potential pressure on pain-sensitive structures within the cranium. Inaccurate pain assessment may lead to inadequate pain management, potentially masking important neurological changes or causing unnecessary suffering. A numeric pain rating scale or visual analogue scale can be utilised to document pain assessments.

Vital Signs Monitoring
Regular monitoring of vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature, is essential. The pathophysiological basis involves potential autonomic nervous system disruptions and systemic responses to trauma. Failure to accurately monitor vital signs could result in missed indications of shock, intracranial pressure changes, or infection. A standard observation chart can be used to record and trend vital signs.

Nursing Actions

Appropriate Course of Action
The most appropriate course of action to achieve the goals of care for Vanessa includes:

1. Implementing a structured neurological observation protocol, with frequency based on her current GCS score and risk of deterioration.
2. Administering prescribed analgesics as per medication orders, utilising a multimodal approach to pain management.
3. Maintaining strict fluid balance monitoring and ensuring adequate hydration.
4. Implementing fall prevention strategies due to her intermittent confusion and mobility issues.

Addressing Nursing Diagnoses
Based on current evidence-based practice, the following interventions address key nursing diagnoses:

For “Risk for Increased Intracranial Pressure”:
– Elevate the head of the bed to 30-45 degrees to promote venous drainage (Jiang et al., 2020).
– Maintain a quiet environment and minimise stimuli to reduce metabolic demands on the brain.

For “Acute Pain”:
– Administer analgesics as prescribed, assessing effectiveness and monitoring for side effects.
– Implement non-pharmacological pain management strategies such as positioning and relaxation techniques.

For “Risk for Falls”:
– Conduct regular environmental safety checks and ensure call bell is within reach.
– Assist with mobilisation as needed and encourage use of appropriate mobility aids.

Personnel for Interventions
The registered nurse is best placed to undertake the majority of required interventions due to their comprehensive assessment skills, medication administration authority, and ability to coordinate care. However, collaboration with the multidisciplinary team is essential:

– Neurological assessments: Registered nurse, with escalation to medical staff for significant changes.
– Pain management: Registered nurse for assessment and medication administration, with input from pain specialists if needed.
– Mobility assistance: Nursing assistants or physiotherapists can assist with mobilisation under the direction of the registered nurse.

Notification Parameters
Key parameters requiring notification of medical staff include:

– GCS score decrease of 2 or more points
– New onset of pupillary abnormalities or focal neurological deficits
– Systolic blood pressure <90 mmHg or >160 mmHg
– Heart rate <50 bpm or >120 bpm
– Respiratory rate <10 or >25 breaths per minute
– Temperature >38°C
– Pain score >7/10 despite prescribed analgesia

The registered nurse should notify the medical officer immediately if any of these parameters are met, to ensure timely intervention and prevent further deterioration.

References

Braine, M.E. and Cook, N., 2021. The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. Journal of Clinical Nursing, 30(1-2), pp.45-61.

Jiang, Y., Ye, Z.P., You, C., Hu, X., Liu, Y., Li, H., Lin, S. and Xiao, Y., 2020. Systematic review of decreased intracranial pressure with optimal head elevation in postcraniotomy patients: a meta-analysis. Journal of Advanced Nursing, 76(7), pp.1616-1626.

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NUR251 Medical Surgical Nursing 2 – Nursing Case Scenario
Assignment Help on Case Scenario – Vanessa Anderson

Written Assessment 2: Tasks:

Using the template provided in the Written Assessment 2 folder and, based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following tasks.

Do not make up or assume information in relation to or about your chosen patient. Only use what you know from the information you received today.

This assignment has been split into two parts.

Part 1:

Based on your chosen case scenario and using the information from the ISBAR handover only, complete stage 2 (collect cues/information) and stage 6 (take action) of the Clinical Reasoning Cycle to;

Stage 2 (collect cues/information): Identify three (3) priority nursing assessments that you would conduct at the commencement of your shift. For each assessment you have identified explain the following;

Why it is necessary for the patient’s condition and nursing care? Consider and recall your knowledge explaining the underlying pathophysiology around the concerns you discuss.
What consequences can occur if this assessment is not completed accurately?
What chart or document could you use to assist with/record your assessments?

(500 words)

Stage 6 (take action): Utilising stage 6 of the Clinical Reasoning Cycle, discuss your nursing actions. These must include;

The most appropriate course of action to achieve your goals of care.
Address your nursing diagnoses, using current evidenced based practice.
Discuss who is best placed to undertake the required interventions and why.
Detail your chosen parameters, to include who should be notified and when.

(500 words)

Part Two:

Step 8 of the Clinical Reasoning Cycle requires a nurse to reflect on process and new learning. Based on your chosen case scenario and using the information from the ISBAR handover and the shift events, critically reflect on the role and responsibilities of the registered nurse. Your reflection must demonstrate how your thinking or assumptions have been challenged, and the deeper insights you have gained. You should use a reflective cycle to guide your reflection, such as the Gibbs Reflective Cycle. Your reflection should be informed by the latest research and guidelines.

The following points must be discussed.

Critically analyse pain and medication management in the treatment of your patient, included associated risk management.
Consider culturally safe, age-appropriate strategies for promoting health and wellness.
Critically reflect on your role, responsibility, scope of practice to include legal and ethical frameworks in the management of patient care in an acute care setting.

(1000 words)

Your assignment must include a reference list after the completion of the tasks and a key is permitted if you have used any abbreviations.

Choose one of the below two case studies. Both case studies are real life cases, with some embellishments.

Written Assessment 2: Case Scenario One – Vanessa Anderson

Shift handover:
Identify: Miss Vanessa Anderson, HRN: 123456, DOB: 25/12/2004
Situation: Vanessa is a 16yo, healthy active female living in Darwin who was admitted after experiencing a traumatic head injury after being struck on the R) side of her head, behind her ear by a golf ball at approx 0825.

Paramedics attended and brought her into ED. She was sent for an urgent CT which diagnosed depressed focal right temporal skull fracture. Bone fragments in brain matter and dural lacerations present.

She has been complaining of a headache and has a GCS of 14-15.

She has been transferred to the CDU Neurological ward for continuing care, it is now Sunday 1300.
Background:

Vanessa lives with her parents and has an older brother Jason. She plays golf 3-4x a week and is in yr11 at High School.

Pmh – Asthma – Seretide and Ventolin

Allergies – Shellfish and nuts

60kgs, normal BMI
Assessment:

Airway: Own, patent

Breathing: RR 23, O2 Sats 98% on RA.

Circulation: HR 68bpm, BP 120/65 mmHg.

Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 5.0mmol/L

Exposure: Temp 36.5 oC,

She has 1 x PIVC inserted to her R) ACF, it is patent.
Recommendations/Read back:

Medical orders

· Routine ward assessments and observations

· 4/24 full neuro observations

· Administer analgesia as prescribed

· Diet and fluids as tolerated

· TED stockings and DVT prophylaxis

Medication orders

· Panadeine Forte 1000mg/60mg QID

· Oxycodone 5mg PRN (Max dose 30mg in 24hrs)

· Phenytoin 100mg IV over 6hrs

Nursing orders

· Devise a plan of care for your patient

The following events transpired over the course of the next few shifts.
Monday

0830
Medical review.

GCS 15.

Continue with regular Panadeine Forte

Oxycodone changed to 5-10mg 3hrly PRN

You return on Monday for the nightshift, and you are allocated to care for Vanessa.
2100hrs

On handover at 2100hrs you are told that Vanessa last had the following analgesia.

1900 – Panadeine Forte

2000 – PRN Oxycodone 10mg

You perform your assessment and note the following:

Airway: Own, patent

Breathing: RR 16, O2 Sats 96% on RA.

Circulation: HR 62bpm, BP 105/58 mmHg.

Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 6.0mmol/L

Exposure: Temp 36.2 oC,
2300hrs

Vanessa rings the bell and complains of a continual headache, you administer:

2300 – PRN Oxycodone 10mg
0000hrs

You review Vanessa and she complains of no improvement in her headache, pain is 9/10, you administer her scheduled Panadeine Forte.
0100hrs

At 0100 Vanessa rings her bell for assistance, she tells you, in a distressed voice that she cannot move.

You attempt to do a full set of neurological observations and ask Vanessa to lift her arms, she cannot, she is frightened. There is no shaking, no stiffness to her limbs and her breathing is normal. She feels warm to touch and has a normal skin colour. You do not assess any other limbs nor do you assess her GCS.

You do not believe she is in immediate danger and assume she has had a bad dream. You offer reassurance and leave the room as you have a new admission you must attend to urgently.

Within 10 minutes you return to Vanessa and perform a full set of neurological observations, with no deficits noted, you are happy with your original assumption that she had a bad dream.
0200hrs

Vanessa rang the bell to ask for assistance to use the toilet, she is able to mobilise with some assistance.

Her pain remains unresolved, you give her PRN Oxycodone 10mg.
0400hrs

You have routine and neurological observations to conduct but as she was ok when you walked her to the toilet 2hrs you decide to not conduct these.

Her Dad arrived on the ward at 0345 and he is fast asleep in the chair in her room, you decide not to disturb them as she is finally settled after her analgesia.
0530hrs You go to check on Vanessa and find her unresponsive.

You initiate a MET call.
0635hrs Vanessa is pronounced dead, despite all attempts to resuscitate her.
Coroners review – cause of death.

Post-mortem:

• Blunt head injury and mechanism of death most likely a seizure. Unable to be formally determined.

• Difficult to determine whether analgesia contributed – may have caused respiratory depression.
Formal finding – Respiratory arrest due to depressant effect of opioid medication

Written Assessment 2: Case scenario two – Alex Braes

The below details the history of Alex’s multiple presentations before you are given handover.
Wednesday

0318
Alex attends ED with his Dad, complaining of knee pain.

No observations were taken and Alex was told to go home and come back later in the morning for an ultrasound.
0800 Alex returns to ED with his Dad for the ultrasound.

They assumed Drs would review his results, but ED was so busy that no one was available to see him.

His vitals were not checked and again they were told to go home and come back later.
1800 Alex and his Dad return to the hospital.

They are reviewed by a Dr with his ultrasound results. It states that he ‘may have a torn tendon’. He was told to rest, ice, and elevate his leg and to come back in 2wks if the pain wasn’t better.

Again, no one checked his vitals.
Thursday

1000

Alex called his Dad early in the morning, who was at work telling him the pain was worse and he was unable to walk.

His Dad immediately came home and called an ambulance. No ambulance was available.

His Dad took him to emergency for a fourth time.

Alex was in so much pain he could not get out of the car so his Dad asked the triage nurse for a wheelchair.

It took 25minutes for this to be brought to his Dad.
1139 Alex was observed by the triage nurse through the window and was asked to wait.

Alex asked his Dad for a pillow as he felt like he was going to pass out.

His Dad went and spoke to the nurse and asked her for a pillow, she didn’t provide one but left her post to check on him.

She noticed Alex was sweaty and moved him into a bed in the emergency department.
1217 33hrs after Alex’s initial presentation to emergency, his vitals were taken.

The triage nurse gives you this handover.
Identify: Mr Alex Braes, HRN: 123567, DOB: 07/05/2003
Situation: Alex is a 18-year-old male from a remote community in remote NSW.

He has been admitted to the emergency department with knee pain.

His Dad was worried as he has been complaining of increased pain and now cannot weight bear.

Alex feels like he is going to pass out.

You are caring for him in the ED.
Background:

He lives with his parents.

Recent ultrasound shows ? tendon tear to the R) knee.
Assessment:

Airway: Own, patent

Breathing: RR 30, SP02 91% on RA.

Circulation: HR 125 bpm, BP 85/42mmHg (Map 56mmHg).

Disability: GCS 13/15

Exposure: Temp 38.5 oC

Alex has 2 x IVC’s inserted to both ACF’s.

Venous Blood Gas attended shows Potassium 3.1mmol/L

pH 7.10

Lactate 4mmol/L

PO2 77mmHg

PCO2 35mmHg

HCO3 19mmol/L
Recommendations/Read back:

Medical orders

· Routine ward assessments and observations

· Strict fluid monitoring

· Administer Intravenous fluids as prescribed

· TED stockings and DVT prophylaxis

IV Fluid orders

· Gelofusin 1000mls STAT

· Intravenous compound sodium lactate (CSL) 1000mls over 2 hours

Medication orders

· Tazocin 4.5g IV TDS Immediate STAT dose

Nursing orders

· Devise a plan of care for your patient
1228

Alex’s vital signs were quickly getting worse and a rapid response team was called.

By this time, Alex needed resuscitation. He was semi-conscious, he was rambling and he was not responding to simple questions.

When Alex was stripped off the source of infection was discovered. He had an infected toenail on his R) great toe which had developed into necrotising fasciitis.

His kidneys were starting to fail and the decision was to immediately transfer him.
1325

The director of medical services was informed by the senior treating Dr that this was the sickest patient he had ever seen in his time at Broken Hill.
1347 A request was made to transfer Alex to the Royal Adelaide, the closest hospital.

The Royal Adelaide confirmed there were no beds available.
1405 RFDS were informed their service was needed, but they were unable to transport him due to the only available pilot having already reached their maximum flying hours and the night pilot had called in sick.
1432 A bed was found at the Royal Prince Alfred Hospital in Sydney.

As there was no way of flying Alex out asap the air ambulance left Sydney.

It is a 5hr round trip.
1730

Alex deteriorated suddenly whilst in ED and the decision was made to intubate him so that he could be stabilised on the flight to Sydney.
2130 Alex finally left the hospital via air ambulance with his Mum on board.

She reported that the paramedics struggled to stabilise him during the flight and had to frequently call doctors for advice on how best to manage his care.
Friday

1250
Alex arrived in Sydney. Upon arrive he went into cardiac arrest
0200 18yr old Alex Braes was pronounced dead.
The hospital now conducts vital observations on every patient.

The inquest remains ongoing, it is expected to reconvene in April 2022 when findings are expected to be delivered. Alex died on 22nd September 2017.

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