A patient was admitted to the emergency department with severe chest pain, sweating, body discomfort, palpitations, breathlessness and light-headedness. He was immediately put on supplemental oxygen therapy through nasal cannula and an Electrocardiography (ECG) was performed to monitor the patient’s heart conditions. The patient was administered with sublingual nitroglycerin in conjunction with morphine to relieve the severe chest pain. The patient was given ticagrelor, a platelet aggregation inhibitor to prevent any blood clotting. A mild dose of aspirin was administered along with ticagrelor. Two hours post administration, noticeable drop in blood pressure was observed followed by severe nose bleeding; difficulty in breathing was aggravated. Monitoring the ECG showed a significant drop in pulse rate or bradycardia. Severe nose bleeding, bradycardia, dizziness and breathing difficulties and worsening patient condition post administration of pain relievers and ticagrelor raised an alert signal which brought me, as a registered nurse by profession into action.
Provide an overview of the encounter. What happened, how it occurred, etc what was it that alerted you to that fact that you needed to take action in the encounter.
In this paper, the focus is on extending Your ‘evaluation’ phase of the cycle within that encounter and ‘reflect on new learning’ to close the cycle.
In critical care nursing, close attention must be paid to the patient’s present status Most errors in clinical reasoning are not due to inadequate or incompetent knowledge but to the weakness of human thinking when there are uncertainty, complexity and pressure of time. To minimize such perception error we need to understand its causes. Generally nurses use clinical decision making during patient care. These decisions may affect the actions of healthcare professionals favourably or adversely and also the health care that the patient gets (Google Books, 2019). It’s the responsibility of the nurse to make clinical decisions based on whatever knowledge and skills acquired so far. To make quick, instantaneous decisions, such as steps to be taken if the condition of the patient starts deteriorating at a rapid pace.. Nurses rely on sound decision-making skills to maintain positive outcomes and up to date care. According to Orme & Maggs (C, 2019), decision-making is part and parcel of clinical practice. If a number of nurses are involved and each has been given different roles, then proper co-ordination and understanding are required for successful treatment otherwise if there is lack of coordination between different nurses, there will be communication gap and the patient is going to suffer. This paper will discuss why the steps are taken did not go according to plan and discuss two critical reasoning errors.
A patient was admitted to the emergency ward of a clinic with symptoms of severe chest pain, sweating and other side effects. The necessary emergency measures were taken like supplemental oxygen therapy through a nasal cannula and ECG was done to monitor the heart condition of the patient. Sublingual nitroglycerin along with morphine was administered to the patient to give relief of chest pain. He was given ticagrelor (an oral antiplatelet drug used with a low dosage of aspirin generally applied to patients having acute coronary ), to prevent any blood clotting. Instead of improving, the condition of the patient took a serious turn with all sorts of complications like a substantial drop in blood pressure, severe nose bleeding, breathing problem aggravated and a noticeable drop in pulse rate was observed in ECG.
Because of the critical condition, earlier medical records of the patient and the history of cardiac data were considered. ECG report was available and clinical handover reports of shift nurses were available As per the reports the medications and diagnosis were in line with earlier records The medical records showed that the patient had allergy due to aspirin, administration of drugs like nitro-glycerin(Takx et al., 2015), morphine was in accordance with the patient’s past medical records. The dosage of the drugs might have some connection with the worsening condition of the patient.
While analysing the case a number of shortcomings on account of improper supervision, lack of communication and also lack of knowledge to deal with such critical case were observed.
In the emergency department, many nurses were engaged for management of diagnosis, treatment, medicine and follow up measures. The main concern was the communication gap between the nurses and their handover responsibilities during changeover routine at the change of shifts. The follow-up actions of the nurses were not well documented as a result next shift nurses were not well informed about the actions taken. For better care and patient outcome, communication plays an important role between patient and nurse relation (De Meester et al., 2013).
After drug administration during the two hours period when the situation worsened, monitoring of the patient’s condition was not done efficiently. The nurses should have involved the patient to get some information before taking a decision, as a result, the patient had allergic side effects in the form of body rash even with a mild dosage of aspirin. Due to dosage error the application of morphine as pain reliever in myocardial infarction has not yielded any improvement. High dosage of morphine may have a number side-effects when used as a pain killer. The increase of dizziness and aggravation of breathing problem after application of morphine is possibly due to an overdose of morphine (Parodi et al., 2015). The nurses were not well informed about the side-effects of ticagrelor (Gaubert et al., 2014). A morphine overdose without any compensating medicine could have been more fatal even it may lead to the death of the patient. The naloxone can overcome the ill effects of overuse of morphine. If the intravenous dose of naloxone was not applied in time, the patient might have succumbed because of the respiratory problem (Kim and Nelson, 2015). In case of bleeding from the nose, excessive bleeding could have been fatal. Necessary steps were taken to stop bleeding through the nose. The patient had to sit upright with support, to facilitate breathing through the mouth and nasal tampons coated with bacitracin were applied which arrested nose bleeding and saved the patient.
From the above analysis we can come to a conclusion that coordination among all nursing staffs working in shifts was lacking in some parts particularly important clinical information relating to changes in patient’s conditions were not properly communicated between nurses working in shifts (Raymond and Harrison, 2014) ,lapses on the part of nurses in applying drugs mechanically without going in depth of the problem were the causes for worsening of the patient’s condition.
Now I shall analyse the clinical errors mentioned using clinical reasoning. There are nine types of errors of clinical reasoning. Some of the reasoning errors are interdependent. The errors can be minimised if the proper communication system is used to improve communication among nurses, more training to be given to nurses to encounter efficiently such type of cases. From the case study, one of the error can be mapped to overconfidence bias. Overconfidence always drives to act on incomplete information and the patient has suffered because of the overconfidence on the part of nurses without collecting proper information. The second error according to me is ascertainment bias though to some extent other errors like anchoring or unpacking principle have also been observed. Ascertaining bias comes when a nurse thinks based on prior assumptions and preconceptions. This is very much evident in this case because of nurses administering drugs without properly going through old case history and what dosage to be applied at what situation and what precautionary actions to be taken.
However, the errors were eventually remedied by taking rearguard action by supporting evidence-based literature like the patient’s case history reports , the fact that the patient is having allergy to aspirin was known after the case history reports was scrutiny, intravenous administration of naloxone was given to offset overdose of morphine. To stop bleeding through the nose, the patient sat in an upright position with support so that he can breathe through the open mouth. Nasal tampons coated with bacitracin was applied as well as 2% oxymetazoline (Morgan and Kellerman, 2014) was administered. The patient gained stability in condition and his consciousness was restored.
I can arrive at the following conclusion that when a patient is admitted to an emergency ward instead of following the traditional approach of the health care process. a well structured and organized diagnostic plan is to be followed and follow up method with proper documentation would improve the patient care. (Guerrasio and Aagaard, 2014).For improving communication and incomplete verbal exchange of information between nurses. clinical handoff tool (SBAR) during clinical transfer of responsibilities provide improved communication between shift nurses and physicians (De Meester et al., 2013). SBAR communication tool (Randmaa et al., 2014) provides a framework for good structure communication between physicians and nurses. To improve patient safety and efficient care, more and more nurses should be trained in standardized documentation formats so that they can keep records of the past and present details of the patient (Munroe et al. 2013). Clinical documentation gives more accuracy and efficiency in providing better method of health care services and intervention to patients (Kern et al., 2013). This measure will definitely reduce the risk of faulty treatment and applying faulty medication. One of the learning points from this case study is that a lack of expertise and information can have serious consequences in dealing with this type of critical cases. Unless the knowledge level is improved with the latest technology to deal with difficult cases becomes a challenge. The nurses also should get specialized training and exposure in dealing different departments of medical science like heart, kidney, infectious diseases, cancer etc. so that they can be an expert in a particular department instead of dealing all departments without any value addition.
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C, O. (2019). Decision-making in clinical practice: how do expert nurses, midwives and health visitors make decisions? - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/8413127 [Accessed 21 Jan. 2019].
De Meester, K., Verspuy, M., Monsieurs, K. and Van Bogaert, P. (2013). SBAR improves nurse-physician communication and reduces unexpected death: A pre and post-intervention study. Resuscitation, 84(9), pp.1192-1196.
Gaubert, M., Laine, M., Richard, T., Fournier, N., Gramond, C., Bessereau, J., Mokrani, Z., Bultez, B., Chelini, V., Barnay, P., Maillard, L., Paganelli, F. and Bonello, L. (2014). Effect of ticagrelor-related dyspnea on compliance with therapy in acute coronary syndrome patients. International Journal of Cardiology, 173(1), pp.120-121.
Guerrasio, J. and Aagaard, E. (2014). Methods and Outcomes for the Remediation of Clinical Reasoning. Journal of General Internal Medicine, 29(12), pp.1607-1614.
Kern, L., Malhotra, S., Barrón, Y., Quaresimo, J., Dhopeshwarkar, R., Pichardo, M., Edwards, A. and Kaushal, R. (2013). Accuracy of Electronically Reported “Meaningful Use” Clinical Quality Measures. Annals of Internal Medicine, 158(2), p.77.
Kim, H. and Nelson, L. (2015). Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opinion on Drug Safety, 14(7), pp.1137-1146.
Morgan, D. and Kellerman, R. (2014). Epistaxis. Primary Care: Clinics in Office Practice, 41(1), pp.63-73.
Parodi, G., Bellandi, B., Xanthopoulou, I., Capranzano, P., Capodanno, D., Valenti, R., Stavrou, K., Migliorini, A., Antoniucci, D., Tamburino, C. and Alexopoulos, D. (2015). Morphine Is Associated With a Delayed Activity of Oral Antiplatelet Agents in Patients With ST-Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circulation: Cardiovascular Interventions, 8(1).
Randmaa, M., Mårtensson, G., Leo Swenne, C. and Engström, M. (2014). SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. BMJ Open, 4(1), p.e004268.
Raymond, M. and Harrison, M. (2014). The structured communication tool SBAR (Situation, Background, Assessment and Recommendation) improves communication in neonatology. South African Medical Journal, 104(12), p.850.
Takx, R., Suchá, D., Park, J., Leiner, T. and Hoffmann, U. (2015). Sublingual Nitroglycerin Administration in Coronary Computed Tomography Angiography: a Systematic Review. European Radiology, 25(12), pp.3536-3542.
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