What key information was already available to you and how did this influence your thinking?
What was the new information you gathered from additional assessment?
What was telling you that the encounter was presenting you with a problem that required resolution?
What could/would have happened in your encounter if you were to have taken NO action and why?
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.
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 though nasal cannula and an Electrocardiography 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, a registered nurse by profession into action.
Recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring before proceeding with the rest of the cycle.
Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion
Review: In response to the patient’s critical condition, the patient’s past medical records and the family history of cardiac details are taken into consideration. The ECG reports were available which were assessed for specific criteria. Shift nurses were assigned for the patient’s monitoring and diagnosis purpose. The clinical handover reports of the shift nurses were available for consideration. From the patient provided medical history records, the patient had allergy from aspirin so aspirin as analgesic was not administered; instead morphine was administered to relieve pain. The patient had reported continuous chest pain and discomfort for the last 24 hours; increase in severity of pain caused him to seek for emergency help. Prior cardiac occurences have been mentioned in the patient’s medical history. The patient’s past cardiac reports showed an administration of ticagrelor to prevent blood clotting. The medications and diagnosis have been provided according to the patient provided medical details.
Relevant medications (where relevant): (not included in word count
Additional assessment of the patient made certain revelations. Drug treatment was intended to minimize the patient discomfort; however, the patient responded with severity post drug treatment. The symptoms with which the patient was admitted were elevated, which was a concern for consideration. The patient’s medical records revealed that the patient had allergy due to aspirin. The patient had recurrent hypertensive episodes. The patient showed a significant drop in pulse rate of 40 beats per minute compared to normal pulse rate of 80-120 beats per minute. The blood pressure showed an elevation compared to before admission. Reddened and itchy rashes were found in certain areas of patient’s body; a mild swelling of the face was noticeable. On assessment, the patient reported that he suffered from constipation and did not have any appetite. A feeling of nausea and vomiting accompanied the patient’s symptoms. The patient showed an increased level of anxiety and impatience.
Recall: Administration of the drugs namely nitroglycerin, morphine, ticagrelor had been in accordance with the patient’s past medical reports. However, while assessing the diagnostic reports and test results, the dosage of the drugs may play a crucial role in worsening the conditions of the patient. According to research evidence, sublingual nitroglycerin may not pose any negative effect on the patient’s condition (Takx et al. 2015). Nitroglycerin promotes dilation of cardiac vessels and restores the cardiac requirement of oxygen. The therapeutic use of morphine as pain reliever in myocardial infarction has not gained promising results due to dosage errors. High dosage of morphine is associated with various side-effects when used as a pain reliever. The patient’s symptoms of increased dizziness and difficulty in breathing post administration of morphine suggest as possible signs of overdose of morphine (Parodi et al. 2015). Ticagrelor administration is associated with side-effects even in normal dosage administered. Severe nose bleeding observed in the patient was a negative response due to side-effects. Shallow breathing rates observed post administration may also be an effect of overdose of ticagrelor (Gaaubert et al. 2014). Monitoring the patient’s conditions and assessing the diagnostic reports, the dosage administration of morphine and ticagrelor required critical concern in the patient’s case. Severity of the patient condition post drug treatment was the turning point of my understanding.
Interpret, relate and infer from the information gathered to demonstrate an overall understanding of the clinical encounter to determine the two main nursing problems.
Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion Interpret, Relate and Infer:
In the emergency department, many nurses are involved in patient diagnosis, treatment, management and follow-up care provision. The handover responsibilities between nurses are main areas of concern during patient management. Communication plays a significant role between patient and nurse relation in providing better care and patient outcome. In the reported patient’s case, nurses involved in immediate care provision during admission in the emergency department were assigned with the diagnosis of the patient. Another group of nurses were involved in recording the diagnostic results. The medications for pain relieving and patient management were provided by the shift nurses. A new group of shift nurses were assigned with the follow-up care for the patient post drug treatment. In all these handover responsibilities, communication forms a significant part; communication failures and misunderstandings during clinical handover pose an unpredictable care and patient outcome. Several handovers at diverse time points created communication gap between nursing professionals in emergency department and the shift nurses. Exchange of clinical information between shift nurses and follow-up nurses could have been resulted in misunderstandings of bedside handover responsibilities. Time to time clinical follow-up required to be taken by the follow-up nurses post administration of morphine in order to check for the patient’s response to the treatment. This post treatment follow-up may not have been taken in timed manner; severity of the symptoms was a response to failure of follow-up care. Investigating the patient’s reports involved clear communication between shift nurses; conveying of important clinical information relative to the changes in patient’s conditions in follow-up procedure resulted in communication gap. Efficient monitoring was not provided during the two hours post drug administration. The nursing care did not involve the patient in decision making; as a result, the patient responded with allergic reactions even in mild dosage of aspirin administration. That the patient was allergic to aspirin was not known from the past medical records; there was a lack of awareness from the patient. The nurses lacked proper knowledge about the side-effects of morphine and ticagrelor; thus the side-effects were predominant as patient’s response after drug treatment. The nursing knowledge about the side-effects and dosage composition of drugs need to be a priority concern while attending to the patients.
Overdose of morphine without any nullifying medication would have resulted in mortality of the patient. The naloxone is a medication administered at frequent regular time intervals to mitigate the adverse effects of the morphine overuse. If the intravenous administration of naloxone was not given to the patient, the patient would have died due to increased difficulty of breathing (Kim and Nelson 2015). In case of nose bleeding, the patient is made to sit upright and supported so as to breathe through open mouth. Nasal tampons coated with bacitracin was provided to stop nose bleed. The patient was administered 2% oxymetazoline (Morgan and Kellerman 2014). Excessive nose bleeding for continued hours would have resulted in fatal outcomes, even leading to death.
Identify the Problem/s List in order of priority two key nursing problems that required resolution (not included in word count)
Problem 1 Communication problem and misunderstanding during verbal exchange during clinical handover responsibilities.
Absence of well-structured written documentation
Establish Goals & Take Action
Work through the two nursing problems identified and establish one goal and then rationalise with scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials the related nursing actions you did/would undertake (125 words for each rationale section). Other sections not included in word count. Problem 1 Goal Related nursing actions Rationale
Communication and incomplete verbal exchange of information between nurses
Improved communication between shift nurses and clinicians with improved patient safety and patient outcome. Implementing SBAR clinical handoff communication tool Evidence based nursing strategies show that the clinical handoff tool (SBAR communication tool) during clinical transfer of responsibilities provide an improved communication between shift nurses and clinicians (De Meester et al. 2013). SBAR communication tool provides the framework for a well structure communication between nurses and physicians. This tool provides a detailed information on Situation, Background, Assessment and Recommendation based on the patient condition. It provides a clear and succinct communication strategy. The mnemonics can be used to remember the critical steps of care provision. The well-structured format provides a logical and easy to follow process and minimizes communication gap during transfer of clinical responsibilities (Randmaa et al. 2014). This communication tool prevents the risk of missing any critical clinical information.
Problem 2 Goal Related nursing actions Rationale
Absence of written documentation between clinical handover responsibilities
Improved patient safety and efficient care provision. Training to nurses, involving more nurses increase the number of nursing staff. Evidence-based research shows that the clinical documentation forms an important part of patient care services. Training the nursing officials on standardised documentation formats would help to keep a record of the patient details (Munroe et al. 2013). Technological reliance for documentation purpose would save a lot of time, thereby the nurses could devote more time to patient centred quality care. Clinical documentation leads to accuracy of providing care services and intervention methods to patients (Kern et al.2013). As a result, the risk of faulty treatment or medications gets reduced. This impacts positively on the medical finances; unreasonable medical billing is prevented. Technological training and involvement of more number of nurses into documentation would maintain the patient records in a detailed and safe format which can be retrieved as and when required and thereby referred for future diagnosis (Khali et al. 2014).
Evaluate the outcomes of your clinical encounter including effectiveness of the care provided with supporting evidence-based literature
*Do not ‘reflect on new learning’ in this section. This will occur in your next assessment .
The patient showed an improvement in the health condition; the nauseatic feeling and vomiting tendencies have been cured. The nose bleeding stopped and the gasping breathlessness of the patient was improved. The heart rate was restored to normal threshold level; the itchy painful rashes due to allergic reactions of aspirin were dissolved and the patient discomfort was relieved comparatively. My frequent monitoring of the patient’s condition in response to naloxone administration. The patient gained stability in condition and consciousness was restored. A well-structured diagnostic plan and documented follow-up method would improve the patient care (Guerrasio and Aagaard 2014).
De Meester, K., Verspuy, M., Monsieurs, K.G. 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. and Maillard, 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.M., 2014. Methods and outcomes for the remediation of clinical reasoning. Journal of general internal medicine, 29(12), pp.1607-1614.
Kern, L.M., Malhotra, S., Barrón, Y., Quaresimo, J., Dhopeshwarkar, R., Pichardo, M., Edwards, A.M. and Kaushal, R., 2013. Accuracy of electronically reported “meaningful use” clinical quality measures: a cross-sectional study. Annals of internal medicine, 158(2), pp.77-83.
Khalil, H., Cullen, M., Chambers, H., Steers, N. and Walker, J., 2014. Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement. International wound journal, 11(3), pp.314-318.
Kim, H.K. and Nelson, L.S., 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.J. and Kellerman, R., 2014. Epistaxis: evaluation and treatment. Primary Care: Clinics in Office Practice, 41(1), pp.63-73.
Munroe, B., Curtis, K., Considine, J. and Buckley, T., 2013. The impact structured patient assessment frameworks have on patient care: an integrative review. Journal of Clinical Nursing, 22(21-22), pp.2991-3005.
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), p.e001593.
Randmaa, M., Mårtensson, G., Swenne, C.L. 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.C., 2014. The structured communication tool SBAR (Situation, Background, Assessment and Recommendation) improves communication in neonatology. SAMJ: South African Medical Journal, 104(12), pp.850-852.
Takx, R.A., 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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