Posted: October 14th, 2022

Case Scenario – Vanessa Anderson

Case Scenario – Vanessa Anderson

Shift handover:
Identify: Miss Vanessa Anderson, HRN: 123456, DOB: 25/12/2004
Situation: Vanessa is a 16yo, healthy active female living in Darwin who was admitted after experiencing a traumatic head injury after being struck on the R) side of her head, behind her ear by a golf ball at approx 0825.
Paramedics attended and brought her into ED. She was sent for an urgent CT which diagnosed depressed focal right temporal skull fracture. Bone fragments in brain matter and dural lacerations present.
She has been complaining of a headache and has a GCS of 14-15.
She has been transferred to the CDU Neurological ward for continuing care, it is now Sunday 1300.
Background: Vanessa lives with her parents and has an older brother Jason. She plays golf 3-4x a week and is in yr11 at High School.
Pmh – Asthma – Seretide and Ventolin
Allergies – Shellfish and nuts
60kgs, normal BMI
Assessment: Airway: Own, patent
Breathing: RR 23, O2 Sats 98% on RA.
Circulation: HR 68bpm, BP 120/65 mmHg.
Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 5.0mmol/L
Exposure: Temp 36.5 oC,
She has 1 x PIVC inserted to her R) ACF, it is patent.
Recommendations/Read back: Medical orders
• Routine ward assessments and observations
• 4/24 full neuro observations
• Administer analgesia as prescribed
• Diet and fluids as tolerated
• TED stockings and DVT prophylaxis
Medication 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 for your patient
The following events transpired over the course of the next few shifts.
Monday
0830 Medical review.
GCS 15.
Continue with regular Panadeine Forte
Oxycodone changed to 5-10mg 3hrly PRN
You return on Monday for the nightshift, and you are allocated to care for Vanessa.
2100hrs • handover at 2100hrs you are told that Vanessa last had the following analgesia.
• – Panadeine Forte
• – PRN Oxycodone 10mg
You perform your assessment and note the following:
Airway: Own, patent
Breathing: RR 16, O2 Sats 96% on RA.
Circulation: HR 62bpm, BP 105/58 mmHg.
Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 6.0mmol/L
Exposure: Temp 36.2 oC,
2300hrs Vanessa rings the bell and complains of a continual headache, you administer:
2300 – PRN Oxycodone 10mg
0000hrs You review Vanessa, and she complains of no improvement in her headache; pain is 9/10; you administer her scheduled Panadeine Forte.
0100hrs At 0100 Vanessa rings her bell for assistance; she tells you, in a distressed voice, that she cannot move.
You attempt to do a full set of neurological observations and ask Vanessa to lift her arms, she cannot, she is frightened. There is no shaking, no stiffness to her limbs and her breathing is normal. She feels warm to touch and has a normal skin colour. You do not assess any other limbs nor do you assess her GCS.
You do not believe she is in immediate danger and assume she has had a bad dream. You offer reassurance and leave the room as you urgently have a new admission you must attend to.
Within 10 minutes you return to Vanessa and perform a full set of neurological observations, with no deficits noted, you are happy with your original assumption that she had a bad dream.
0200hrs Vanessa rang the bell to ask for assistance to use the toilet, she is able to mobilise with some assistance.
Her pain remains unresolved, you give her PRN Oxycodone 10mg.
0400hrs You have routine and neurological observations to conduct but as she was ok when you walked her to the toilet 2hrs you decide to not conduct these.
Her Dad arrived on the ward at 0345 and he is fast asleep in the chair in her room, you decide not to disturb them as she is finally settled after her analgesia.
0530hrs You go to check on Vanessa and find her unresponsive.
You initiate a MET call.
0635hrs Vanessa is pronounced dead, despite all attempts to resuscitate her.
Coroners review – cause of death. Post-mortem:
• Blunt head injury and mechanism of death most likely a seizure. Unable to be formally determined.
• Difficult to determine whether analgesia contributed – may have caused respiratory depression.
• Formal finding – Respiratory arrest due to depressant effect of opioid medication

Requirements:
Using the handover you received at the beginning of your shift today, the information below, and Current, reliable evidence for best practice, address the following tasks.
Do not make up or assume information about your patient. Only use the information you received today from above handover.
Responses should be written in paragraphs. You do not need to include an introduction or conclusion.
Question 1. Based on the case scenario and using the information from the ISBAR handover only, complete stage 2 (collect cues/information) and stage 6 (take action) of the Clinical Reasoning Cycle (CRC). (250 words) ( 2 reference apa7 with doi)
Question 2 Identify three (3) priority nursing assessments that you would conduct at the commencement of your shift. For each assessment you have identified explain the following: (250) words ( 2 reference apa7 with doi)
· Why is the assessment necessary for the patient’s condition and nursing care? (Ensure you also refer to the underlying pathophysiology around the concerns you discuss)
· What consequences can occur if this assessment is not completed accurately?
· What chart or document could you use to assist with/record your assessments?
Question 3. Discuss your nursing actions. For each action you take explain the following: (500 words) (3 reference apa7 with doi)
· The most appropriate course of action to achieve your goals of care.
· Your nursing diagnoses [at least 3] using current evidenced-based practice.
· Who is best placed to undertake the required interventions and why.
· Who should be notified and when if the patient’s condition deteriorates.
Question 4: short answer responses (1000 words) (10 reference apa 7 with doi)
Step 8 of the Clinical Reasoning Cycle requires a nurse to reflect on the process and any new learning that has taken place. These reflections demonstrate how your thinking or assumptions have been challenged, and the deeper insights you have gained. Reflections should be informed by the latest research and professional guidelines.
Based on your case scenario and using the information from the ISBAR handover and the shift events, critically reflect on the role and responsibilities of the registered nurse.
The following points must be discussed:
· Critically analyse pain and medication management in the treatment of your patient, including associated risk management.
· Consider culturally safe, age-appropriate strategies for promoting health and wellness.
· Reflect on your role, responsibilities, and scope of practice and refer to legal and ethical frameworks in managing patient care in an acute care setting where appropriate.
· Illustrate proficiency and understanding of the topic by using a minimum of 10 references from academic resources (journals, books, academic or professional websites) from the last 5 years.
Guidelines
· 2000 words
· No introduction or conclusion is required.
· Use of heading and subheading to structure your writing is recommended
· Format your assessment with size 12 Arial/Calibri or similar font, 1.5 spacing.
· Use APA 7 with doi
· Write in the third person and avoid the use of -I- and -My-.
·
Supplementary resources:

Australian Commission on Safety and Quality in Health Care Standards https://www.safetyandquality.gov.au/standards/nsqhs-standards
Nursing and Midwifery Board Professional Standards for Practice.
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
Nursing and Midwifery Board Professional Code of Conduct
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
International Council of Nurses Code of Ethics for Nurses:
https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

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Answer Writing Guide Notes:
tages 2 and 6 of the Clinical Reasoning Cycle (CRC) for Vanessa Anderson’s case.
Stage 2: Collect cues/information
The following cues and information have been collected from the ISBAR handover:
Patient identification: Vanessa Anderson, a 16-year-old female, HRN: 123456, DOB: 25/12/2004.
Presenting condition: Traumatic head injury caused by a golf ball strike to the right side of her head behind the ear at approximately 0825.
Diagnosis: Depressed focal right temporal skull fracture with bone fragments in brain matter and dural lacerations, confirmed by CT scan.
Current status: Complaining of headache, GCS 14-15, transferred to CDU Neurological ward.
Medical history: Asthma (managed with Seretide and Ventolin), allergies to shellfish and nuts.
Physical assessment:

Airway: Own, patent
Breathing: RR 23, O2 Sats 98% on room air
Circulation: HR 68bpm, BP 120/65 mmHg
Disability: GCS 14/15, intermittently confused, PEARL 3mm, BGL 5.0mmol/L
Exposure: Temperature 36.5°C

Interventions: PIVC inserted in right ACF, patent.
Medical orders:

Routine ward assessments and observations
4/24 full neuro observations
Analgesia administration as prescribed
Diet and fluids as tolerated
TED stockings and DVT prophylaxis

Medication orders:

Panadeine Forte 1000mg/60mg QID
Oxycodone 5mg PRN (Max dose 30mg in 24hrs)
Phenytoin 100mg IV over 6hrs

Stage 6: Take action
Based on the collected information, the following actions should be taken:

Implement routine ward assessments and observations as ordered, with particular attention to neurological status due to the head injury.
Conduct full neurological observations every 4 hours, including GCS assessment, pupil reactivity, and limb strength and movement.
Administer prescribed medications, including analgesics and anticonvulsants, while monitoring for effectiveness and side effects.
Ensure proper positioning of the patient to maintain airway patency and promote comfort.
Monitor and record fluid intake and output to maintain adequate hydration.
Apply TED stockings and implement DVT prophylaxis measures as ordered.
Provide education to the patient and family regarding the nature of the injury, expected recovery process, and potential complications to watch for.
Assess pain levels regularly and administer analgesia as prescribed, evaluating its effectiveness.
Monitor for signs of increased intracranial pressure, such as changes in level of consciousness, pupil size or reactivity, or new onset of neurological deficits.
Ensure a safe environment to prevent falls or further injury, considering the patient’s intermittent confusion.
Collaborate with the multidisciplinary team, including neurosurgeons and physiotherapists, to optimise care and recovery.
Document all assessments, interventions, and patient responses accurately in the medical record.

These actions aim to provide comprehensive care for Vanessa, addressing her immediate needs related to the head injury while monitoring for potential complications and promoting recovery.
References:
Curtis, K., Ramsden, C. and Lord, B., 2020. Emergency and Trauma Care for Nurses and Paramedics. 3rd ed. Elsevier Health Sciences.
Hickey, J.V. and Strayer, A.L., 2019. The clinical practice of neurological and neurosurgical study pro essay nursing. 8th ed. Wolters Kluwer Health.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S.Y.S., Noble, D., Norton, C.A., Roche, J. and Hickey, N., 2018. The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 60, pp.40-46.

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