Case Scenario – Vanessa Anderson
Shift handover:
Establish: Miss Vanessa Anderson, HRN: 123456, DOB: 25/12/2004
State of affairs: Vanessa is a 16yo, wholesome energetic feminine residing in Darwin who was admitted after experiencing a traumatic head damage after being struck on the R) aspect of her head, behind her ear by a golf ball at approx 0825.
Paramedics attended and introduced her into ED. She was despatched for an pressing CT which identified depressed focal proper temporal cranium fracture. Bone fragments in mind matter and dural lacerations current.
She has been complaining of a headache and has a GCS of 14-15.
She has been transferred to the CDU Neurological ward for persevering with care, it’s now Sunday 1300.
Background: Vanessa lives together with her mother and father and has an older brother Jason. She performs golf Three-4x per week and is in yr11 at Excessive College.
Pmh – Bronchial asthma – Seretide and Ventolin
Allergic reactions – Shellfish and nuts
60kgs, regular BMI
Assessment: Airway: Personal, patent
Respiratory: RR 23, O2 Sats 98% on RA.
Circulation: HR 68bpm, BP 120/65 mmHg.
Incapacity: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 5.0mmol/L
Publicity: Temp 36.5 oC,
She has 1 x PIVC inserted to her R) ACF, it’s patent.
Suggestions/Learn again: Medical orders
• Routine ward assessments and observations
• four/24 full neuro observations
• Administer analgesia as prescribed
• Weight loss plan and fluids as tolerated
• TED stockings and DVT prophylaxis
Medicine 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 in your affected person
The next occasions transpired over the course of the subsequent few shifts.
Monday
0830 Medical assessment.
GCS 15.
Proceed with common Panadeine Forte
Oxycodone modified to 5-10mg 3hrly PRN
You come on Monday for the nightshift, and you’re allotted to take care of Vanessa.
2100hrs • handover at 2100hrs you’re instructed that Vanessa final had the next analgesia.
• – Panadeine Forte
• – PRN Oxycodone 10mg
You carry out your Assessment and be aware the next:
Airway: Personal, patent
Respiratory: RR 16, O2 Sats 96% on RA.
Circulation: HR 62bpm, BP 105/58 mmHg.
Incapacity: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 6.0mmol/L
Publicity: Temp 36.2 oC,
2300hrs Vanessa rings the bell and complains of a continuing headache, you administer:
2300 – PRN Oxycodone 10mg
0000hrs You assessment Vanessa, and he or she complains of no enchancment in her headache; ache is 9/10; you administer her scheduled Panadeine Forte.
0100hrs At 0100 Vanessa rings her bell for help; she tells you, in a distressed voice, that she can’t transfer.
You try to do a full set of neurological observations and ask Vanessa to elevate her arms, she can’t, she is frightened. There is no such thing as a shaking, no stiffness to her limbs and her respiration is regular. She feels heat to the touch and has a traditional pores and skin color. You don’t assess every other limbs nor do you assess her GCS.
You don’t consider she is in quick hazard and assume she has had a nasty dream. You supply reassurance and depart the room as you urgently have a brand new admission you could attend to.
Inside 10 minutes you come to Vanessa and carry out a full set of neurological observations, with no deficits famous, you’re joyful together with your authentic assumption that she had a nasty dream.
0200hrs Vanessa rang the bell to ask for help to make use of the bathroom, she is ready to mobilise with some help.
Her ache stays unresolved, you give her PRN Oxycodone 10mg.
0400hrs You will have routine and neurological observations to conduct however as she was okay if you walked her to the bathroom 2hrs you resolve to not conduct these.
Her Dad arrived on the ward at 0345 and he’s quick asleep within the chair in her room, you resolve to not disturb them as she is lastly settled after her analgesia.
0530hrs You go to test on Vanessa and discover her unresponsive.
You provoke a MET name.
0635hrs Vanessa is pronounced lifeless, regardless of all makes an attempt to resuscitate her.
Coroners assessment – reason for loss of life. Publish-mortem:
• Blunt head damage and mechanism of loss of life most definitely a seizure. Unable to be formally decided.
• Troublesome to find out whether or not analgesia contributed – might have induced respiratory melancholy.
• Formal discovering – Respiratory arrest on account of depressant impact of opioid treatment
Necessities:
Utilizing the handover you obtained at first of your shift at this time, the knowledge under, and Present, dependable proof for finest follow, handle the next duties.
Don’t make up or assume details about your affected person. Solely use the knowledge you obtained at this time from above handover.
Responses must be written in paragraphs. You don’t want to incorporate an introduction or conclusion.
Question Assignment 1. Primarily based on the case situation and utilizing the knowledge from the ISBAR handover solely, full stage 2 (accumulate cues/info) and stage 6 (take motion) of the Scientific Reasoning Cycle (CRC). (250 phrases) ( 2 reference apa7 with doi)
Question Assignment 2 Establish three (Three) precedence nursing assessments that you’d conduct on the graduation of your shift. For every Assessment you’ve recognized clarify the next: (250) phrases ( 2 reference apa7 with doi)
· Why is the Assessment vital for the affected person’s situation and nursing care? (Make sure you additionally discuss with the underlying pathophysiology across the issues you focus on)
· What penalties can happen if this Assessment just isn’t accomplished precisely?
· What chart or doc might you utilize to help with/report your assessments?
Question Assignment Three. Focus on your nursing actions. For every motion you’re taking clarify the next: (500 phrases) (Three reference apa7 with doi)
· Essentially the most acceptable plan of action to realize your targets of care.
· Your nursing diagnoses [at least 3] utilizing present evidenced-based follow.
· Who’s finest positioned to undertake the required interventions and why.
· Who must be notified and when if the affected person’s situation deteriorates.
Question Assignment four: brief reply responses (1000 phrases) (10 reference apa 7 with doi)
Step eight of the Scientific Reasoning Cycle requires a nurse to replicate on the method and any new studying that has taken place. These reflections exhibit how your pondering or assumptions have been challenged, and the deeper insights you’ve gained. Reflections must be knowledgeable by the newest analysis tips.
Primarily based in your case situation and utilizing the knowledge from the ISBAR handover and the shift occasions, critically replicate on the position and obligations of the registered nurse.
The next factors have to be mentioned:
· Critically analyse ache and medicine administration within the therapy of your affected person, together with related danger administration.
· Take into account culturally secure, age-appropriate methods for selling well being and wellness.
· Mirror in your position, obligations, and scope of follow and discuss with authorized and moral frameworks in managing affected person care in an acute care setting the place acceptable.
· Illustrate proficiency and understanding of the subject through the use of a minimal of 10 references from educational sources (journals, books, educational or skilled web sites) from the final 5 years.
Pointers
· 2000 phrases
· No introduction or conclusion is required.
· Use of heading and subheading to construction your writing is beneficial
· Format your Assessment with dimension 12 Arial/Calibri or comparable font, 1.5 spacing.
· Use APA 7 with doi
· Write within the third individual and keep away from using -I- and -My-.
·
Supplementary sources:
Australian Fee on Security and High quality in Well being Care Requirements https://www.safetyandquality.gov.au/requirements/nsqhs-standards
Nursing and Midwifery Board Skilled Requirements for Observe.
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
Nursing and Midwifery Board Skilled Code of Conduct
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
Worldwide Council of Nurses Code of Ethics for Nurses:
https://www.icn.ch/websites/default/information/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
