SOLUTION: Managing the Deteriorating Patient | My Assignment Tutor

iNRS312 Essential Nursing Care:Managing the Deteriorating PatientMr Jason SwanNRS312 Assessment Item 2 // Case Scenario (Jason Swan)ii Disclaimer (please read before reviewing the scenario):The following scenario has been developed to support completion of theAssessment Item 2 for NRS312 in the 202130 session.In this scenario, a patient is admitted to hospital for chemotherapy and contracts abacterial infection in his intestines. He experiences abdominal pain and vomiting,and he eventually dies as the result of organ failure and cardiac arrest, secondaryto acute peritonitis and severe sepsis. The scenario has been based on aspects ofreal cases and has been reviewed by academics and clinicians to ensure that it isauthentic to the clinical context portrayed.This scenario includes elements that you may find confronting. In particular, youmay have been involved in similar events in your personal, professional or studyexperiences. If you are distressed by the scenario, please contact the SubjectCoordinator to discuss and consider contacting the CSU Student Counsellingservice (free and confidential) – https://student.csu.edu.au/services-support/healthwellbeing/counselling Written by Evan Plowman – 2020, updated 2021Reviewed by: Sue Slater, Renee McGill, Patience Moyo, Krishna Lambert, Keden Montgomery, MaryannePodham© Charles Sturt UniversityNRS312 Assessment Item 2 // Case Scenario (Jason Swan)1Scenario: Mr Jason Swan BackgroundMr Jason Swan is a 37 year old man, admitted to the Acute Medical Unit of a large ruralhospital in NSW for chemotherapy. Jason is a truck driver who lives with his wife Sarah andhis three young children.Twelve months prior to his admission, Jason was diagnosed with Acute Myeloid Leukaemia(AML) and commenced on chemotherapy.16/05/2020 – 1000The intravenous (IV) chemotherapy has concluded and Jason remains in hospital for furthermonitoring and observation.Michelle, the registered nurse (RN) caring for Jason enters the room to assess his vitalobservations. Michelle is a ‘Transitional Registered Nurse’, completing a 12 month programimmediately post gaining her registration as an RN.Vital Observations:• BP 118 / 80 mmHg• HR 95 bpm• RR 12 bpm• Temp 36.7°C• SpO2 99% (RA)• Alert16/05/2020 – 1015Sarah arrives and sits beside Jason while Michelle continues to enter the observations intothe computer (close to the bed). Sarah asks her husband if had slept well and had a goodnight. Jason explains that the food at the hospital was not agreeing with him.Shortly after this conversation Jason reaches for an emesis bag and vomits a small amountof vomitus. Michelle checks the volume (100mls) and records this in the medical record.Michelle discards the vomit into the clinical waste (outside of the room) and returns to offerJason an anti-emetic that is charted (ondansetron, intravenous, 4mg) and also ensuresthere is another emesis bag within reach.Jason agrees to the anti-emetic, and Michelle leaves to collect the medication and the InCharge nurse, Priscilla to assist with a two-person IV check. While the two nurses are in themedication room, they notice Dr Wong walking towards Jason’s room.16/05/2020 – 1030Dr Wong enters Jason’s room with her medical team (including Tina, an Oncology Fellow,Jillian a Medical Registrar and Justin a Medical Resident). Following close behind areMichelle and Priscilla, carrying the anti-emetic. NRS312 Assessment Item 2 // Case Scenario (Jason Swan)2 Dr Wong greets Jason and Sarah and asks how he is feeling. Jason explains he hasvomited twice this morning, holding a second emesis bag with a small amount of bile in it.Michelle mentions that they have brought an anti-emetic and Dr Wong asks the nurses toadminister this while the conversation continues.Dr Wong explains the current blood pathology levels are ‘looking good’ and that he shouldbe well enough to be discharged the following day. Michelle and Priscilla confirm Jason’sidentity, confirm that he has no allergies, check the ‘five rights’ of safe medicationadministration and administer the ondansetron.The medical team review the current vital observations, renew the medication order for antiemetics to include prochlorperazine and assure Jason that they will review him prior todischarge tomorrow.16/05/2020 – 1240Lunch arrives and Sarah presses the nurse call button for assistance. Michelle returns fromher lunch break and realises the call bell is on and heads for Jason’s room.Sarah meets Michelle at the door of the room and explains ‘I am a bit worried about Jason.He doesn’t seem himself. He has vomited again since you left and he is uncomfortable inthe chest’. Michelle assures Sarah that she will ‘have a look at him’ and consider giving himsome further medications.Michelle asks Jason to explain where his chest discomfort is located and he points acrossthe bottom of his ribs, from one side to the other. She asks if he has ever had this sort ofdiscomfort before and he says no. Michelle asks if Jason is still nauseous to which heconfirms that he is. Jason volunteers that the pain feels like ‘really bad stomach cramps’.Michelle explains that she needs some assistance and will return with Priscilla. Both nursesreturn within 5 minutes with a dose of IV prochlorperazine, 5mg, and a 12-leadelectrocardiogram (ECG) machine.The nurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’of safe medication administration and administer the prochlorperazine.Priscilla leaves and Michelle applies the electrodes to perform a 12-lead ECG. Michelle hasdifficulty getting the electrodes to stick to Jason’s chest as he is diaphoretic. Michelle wipesJason’s skin, uses tape to hold the electrodes on, and performs the 12-lead ECG.16/05/2020 – 1255Priscilla returns to the room to collect the 12-lead ECG. She explains to Michelle that shepaged the Resident on the medical team and wants to show her the ECG report before sheleaves the ward.Michelle mentions to Priscilla that she has noticed Jason is sweaty. Priscilla asks Michelleto stay with him and assures her that she will return after she shows the Medical Residentthe ECG. Priscilla leaves with the ECG.When Michelle returns to the bedside, Sarah mentions she is becoming increasing worriedabout Jason. She explains that he had been ‘constipated for a couple of days now’ and hadbeen straining to open his bowels earlier in the day and had not been able to. NRS312 Assessment Item 2 // Case Scenario (Jason Swan)3 Jason repositions himself and is unable to get comfortable in the bed. He is fidgeting withthe bed every few seconds and is visibly distressed.Sarah asks ‘Can he have anything for the pain? He is normally quite reluctant to tell me heis in pain and I have not seen him like this with his previous Chemo visits’. Michelle notesthat there is an order for IV morphine. She asks Jason if he has had this before and heconfirms that he has on several occasions. While he is worried the nausea will get worse,he explains the pain is becoming unbearable.16/05/2020 – 1330After getting caught up with other patients for a while, Michelle asks Priscilla to retrievesome morphine from the Schedule 8 (S8) cupboard. While getting this out of the cupboard,Priscilla confirms that Justin had reviewed the ECG and it was determined that there wereno detectable abnormalities. She also mentions that Justin is not concerned about Jason’spain as this is a ‘normal problem with repeated vomiting’.The nurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’of safe medication administration and administer IV morphine, 5mg. Priscilla assures Jasonthat they will be able to administer another dose of morphine if the first dose does notadequately reduce his pain. Michelle comments that he should feel some relief in just a fewminutes.Both nurses leave to care for other patients.16/05/2020 – 1400Michelle enters the room to perform another set of vital observations. When she brings theobservation equipment over, Sarah explains that the pain is not any better and he has been‘panting like a dog’.Vital Observations:• BP 105 / 70 mmHg• HR 110 bpm• RR 18 bpm• Temp 36.9°C• SpO2 95% (RA)• Alert• Pain 6/10Michelle explains to Jason and Sarah that the observations are within acceptable limits andthat she will get some additional morphine shortly.Michelle leaves again to catch up on work that she has been unable to get to as her shift isalmost over. NRS312 Assessment Item 2 // Case Scenario (Jason Swan)4 16/05/2020 – 1515Michelle provides shift-to-shift handover to Cathy, an RN on the evening shift: ‘This is JasonSwan. He is a 37 year old male admitted five days ago for IV chemo. He is expected to bedischarged tomorrow but has had some nausea and vomiting and some chest pain today.We conducted an ECG and it was normal. I have given him some ondansetron and Stemitilbut he is still nauseous. He had some vomiting this morning but that seems to havestopped. His observations have been within normal limits, next due at 1800, but he doeshave ongoing pain. I can check some morphine out with you before I head off’Michelle and Cathy collect the morphine from the S8 cupboard and enter Jason’s room.Michelle introduces Jason to Cathy and apologises for the delay with the morphine. Thenurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’ ofsafe medication administration and administer IV morphine, 5mg.Michelle thanks Cathy and leaves at the end of her shift.Cathy explains that she would like to perform another set of vital observations as Jason isstill uncomfortable and she is quite concerned that his breathing seems shallow anddifficult.Vital Observations:• BP 101 / 68 mmHg• HR 125 bpm• RR 20 bpm• Temp 36.6°C• SpO2 95% (RA)• Alert• Pain 8/10Cathy palpates Jason’s abdomen and is startled when Jason cries out in pain. Sarah askswhy the doctor has not arrived and explains that she has never seen her husband in thismuch pain. She is visibly distraught and concerned about her husband.Cathy explains that nausea, cramping and vomiting are all common side effects ofchemotherapy and that this often causes anxiety for patients experiencing these symptoms.Cathy reassures that she will call the doctor now, but his observations are stable, with theexception of pain, which should settle with the second dose of morphine.16/05/2020 – 1530Cathy leaves the room to call Justin on the medical team. NRS312 Assessment Item 2 // Case Scenario (Jason Swan)5 Hi Justin, this is Cathy. I have taken over care of Mr Jason Swan, a 37year old man admitted for Chemotherapy. I believe you are familiar withJason (confirmed). I am calling because his pain has not subsided withthe two morphine doses we have given him. He remains nauseous andhe is now tachycardic. He is taking shallow breaths and while hisoxygen levels and resp rate are o.k., I am worried about his breathing. Ithink it would be helpful if you could come and review him and I willinitiate a clinical review. Can you get here within the next 30 minutes?Thanks Cathy. I did check his ECG but I have not checked in on him. I willcome down shortly. If I am not able to get there in time, I will send the afterhours Resident who is starting work now.Thanks Justin. I appreciate it.16/05/2020 – 1550Cathy repeats another set of vital observations.Vital Observations:• BP 85 / 55 mmHg• HR 150 bpm (weak pulse)• RR 30 bpm• Temp 36.6°C• SpO2 80% (RA)• Verbal• Pain – unable to rateCathy presses the ‘urgent assist’ button on the wall and two other nurses from the AcuteMedical Unit arrive within one minute to provide assistance.Cathy initiates a rapid response for the After-Hours Medical Registrar to attend. NRS312 Assessment Item 2 // Case Scenario (Jason Swan)6 Cathy describes the current observations to the In-Charge of the evening shift, whoexplains that they have not been informed about the situation.Jason calls out ‘Please make it stop, just knock me out or something. I can’t take thisanymore’. Sarah is very distressed.As the Medical Registrar arrives, Jason becomes unresponsive16/05/2020 – 1555The nurses and the Medical Registrar commence basic life support and bring the arresttrolley. A cardiac arrest alarm is raised.A defibrillator is attached and CPR is commenced.16/05/2020 – 1557The Advanced Life Support team arrives and assist with the resuscitation. Despite aprolonged resuscitation effort, the team are unable to achieve a return of spontaneouscirculation and Jason is declared deceased at 1640.End of scenarioThis scenario includes elements that you may find confronting. Inparticular, you may have been involved in similar events in yourpersonal, professional or study experiences. If you are distressed by thescenario, please contact the Subject Coordinator to discuss and considercontacting the CSU Student Counselling service (free and confidential) –https://student.csu.edu.au/services-support/health-wellbeing/counselling NRS312 Assessment Item 2 // Case Scenario (Jason Swan)7Notes Page____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________