As the RN you arrive at the remote clinic at Wilcannia for your fortnightly visit, the population here is mainly Indigenous Australians and there is a high percentage of children in this community. It is normally quite a busy day.
The next patient you see is Ashanti, a 3 year old indigenous girl. Ashanti presents in the arms of her Mother with her Grandmother present. When asked about Ashanti’s chief complaint, her mother explains she has ‘had the runs for a few days and whatever I give her just goes straight through’. Ashanti is lethargic and unable to walk. On examination you observe Ashanti to be speaking quietly to her Grandmother, you notice there is no accessory muscle usage but there is an increase in her work of breathing (WOB). She has normal breath sounds on auscultation, is pale and cool to touch, she has cracked lips, a dry tongue, sunken eyes and looks very unwell. There is no sign of any wounds or lesions which could indicate an infection as the cause of her deterioration. On further questioning Ashanti’s Mother tells you she has had about 2 cups of juice today you work this out to equate to approximately 400mls. You also ask about her urine output, Ashanti’s Mother is unsure about this as she just states that it is just her bowels that are working, as far as she knows she has not passed urine and has not noticed any urine in her nappies. You ask when she last passed urine and you are told ‘it has not been for a day or so’.
You take her observations and record the following
RR SpO2 BP HR AVPU Temp Pain BGL
56 93% 68/32 182 V 36.9 0 3.1
Ashanti is fully immunised and has no medical history she weighs 13kg.
Questions:
1. Discuss your assessments on this patient, identify signs of deterioration and clearly state if the patient requires a clinical review or rapid response as per Between the Flags (BTF). Justify your decision with data from the case and relevant support.
2. Document a succinct and accurate ISBAR handover in verbal script format (eg. Hello, my name is…)
3. Considering the assessment findings, prioritise and discuss the immediate nursing management of the patient
4. Succinctly discuss the ongoing management of this case and integrate the relevant members of the interdisciplinary team
Case Study 2 (Aged care facility)
Bruce Reynolds is a 84 year old man who is in a community nursing home, he has been a resident in the nursing home for the past 12 months. He was admitted due to his decreased mobility and heart failure. While you are showering Bruce this morning you notice swelling from his toes to his knees and you ask him how long they have like this for in which he replies a few days. You also notice he is short of breath and is only able to speak in short sentences. You assess Bruce and note an increased work of breathing, intercostal recession and crackles at the lung bases. Bruce is warm to touch, diaphoretic and pink with a capillary refill of less than 2 seconds. You finish showering Bruce and he passes urine while in the shower. You then settle him into his chair and read his notes from the past week to see if there is anything documented about his oedema. There is no documentation on this and there has been no recent observations taken, however he had a BGL yesterday of 6.4 mmol/L.
You decided to take a set of vital observations and the following is documented;
RR SpO2 BP HR Temp Pain
28 91% (on room air) 178/104 130 – irregular 36.8 1/10
You document and discuss your findings with the nurse in charge and the decision has been made to repeat the vitals after morning tea and see if there is any improvement. In the mean time you look at his medical history where in the past he has had acute kidney failure due to heart failure preceding his admission to the nursing home. You consider whether this could be happening again.
next set of observations are;
RR SpO2 BP HR Temp Pain
32
88% 182/102 134 36.6 1/10
You notice there to be an increase in his shortness of breath, you advise Bruce that you will call his doctor, Dr Polson. Bruce has an Advanced Care Directive which states he is not for active resuscitation or invasive airway management and ventilation, however he is for active treatment and non-invasive ventilation.
Questions:
1. Discuss your assessments on this patient and identify signs of deterioration. Discuss the escalation required for Bruce being in an aged care facility based on your understanding of the Between the Flags (BTF) program and the CERS. Justify your decision with data from the case and relevant support.
2. Document a succinct and accurate ISBAR handover in verbal script format (eg. Hello, my name is…)
3. Considering the assessment findings, prioritise and discuss the immediate nursing management of the patient
4. Succinctly discuss the ongoing management of this case and integrate the relevant members of the interdisciplinary team