To emphasis the connection between theory and practice you’re required to complete the following documentation (this will also help you to establish what information you may need to research for your case analysis):
- Add vital signs on arrival
- Document Gray’s presentation in the progress note (SAMPLE Hx is a good method)
- Add post morphine vital signs (allows you to see & identify trends)
Once this has been completed – your ready to undertake the case analysis.
1: Identify a specific, systematic assessment framework you would utilise to assess this patient. Apply this framework to the case to demonstrate your ability to document a systematic health assessment. Complete the required documentation.
2: Identify the legal, ethical and professional issues related to this scenario. Your discussion should incorporate at least one form of specific legislation, one specific ethical principle and one specific Registered Nurse professional standard
3: Evaluate the in-service that was given by your ‘peer’ on IM injections using the evaluation criteria of adult learning.
The assessment layout / format has been created for you at the end of the assessment information.
Gary is a 56-year-old gentleman who is being brought in by ambulance with severe abdominal pain. On arrival, he appears to have severe cramp-like pain; he is guarding his abdomen and panics when staff members attempt to touch his abdomen. He appears restless and is difficult to calm down. Gary’s past medical history includes: laparoscopic resection of the descending colon due to colon cancer in 2004, mild hypertension, osteoarthritis in his left knee and coeliac disease. He quit smoking thirty years ago and drinks socially; he recently changed his diet and walks every day to keep himself ‘fit and healthy’; his BMI is 30.
Vital signs on arrival:
- T – 37.5°C
- HR – 136
- RR – 30
- BP – 191/89
- SaO2 – 98% RA
- Pain score – 10/10
Gary has an intravenous cannula inserted (venous bloods are taken on insertion and sent to pathology) while in the emergency department and is written up for morphine 2.5–10 mg IM PRN for pain relief by a medical officer. You administer 2.5 mg morphine IV with no effect; a further 2.5 mg morphine IV is administered, and Gary slowly begins to settle down and appears to relax. Gary’s pain is resolving after the pain relief and he is now able to provide you with further information. He informs you that his abdomen is ‘bigger than normal’ and his left upper and lower quadrants are tender on movement and it ‘really hurts when people push on my tummy’. He also confirms that he hasn’t used his bowels in over a week, which is not normal for him.
As you sign the medication chart for the administration of the pain relief you notice you have administered the morphine via the IV route instead of IM. You inform the senior RN and complete an incident form.
Post morphine vital signs:
- T – 37.5°C
- HR – 86
- RR – 18
- BP – 154/63
- SaO2 – 96% RA
- Pain score – 4/10 at rest
The surgeon confirmed that on abdominal X-rays Gary has a distal blockage of his small bowel most likely due to adhesion from the resection of his descending colon. The surgical team consider medical management of Gary’s SBO prior to considering a surgical option. The nurse develops the following action plan:
- routine abdominal assessment
- nil by mouth (NBM)
- insertion of a nasogastric tube
- intravenous therapy (IVT) (+/– potassium replacement)
- pain relief (Schmelzer & Morcom, 2008).
The SBO was located in the distal portion of the small bowel approximately 50 cm from the ileocecal valve. The position of the blockage allowed for Gary to be able to absorb some fluids and electrolytes preventing him from developing an imbalance. The surgeon removed the obstruction and anastomosed the healthy ends. The remaining bowel was healthy with no signs of ischaemia or necrosis; the formation of an ileostomy was not required. On returning to the ward from recovery, Gary is drowsy but easily rousable and is able to answer simple questions. Following his general anaesthetic, he is breathing spontaneously with good air entry to the bases. He is hemodynamically stable on IVT, which will remain in situ until his bowel sounds return and Gary can be started on an oral diet. The NGT remains in situ on free drainage and is draining well.
The oral mucosa will need to be monitored and regular mouth care provided for comfort and to prevent drying out of the oral mucosa as Gary remains NBM. Gary also has an indwelling catheter (IDC) in situ to assist with fluid status monitoring. Gary is able to move himself in bed without too much pain; however, pressure area care will need to be monitored initially post-operatively. Three days after surgery, the bowel sounds return and Gary is passing flatus. He is commenced on ice chips and sips of fluids. Gary soon tolerates the introduction of clear fluids into his diet. Following having his bowels open Gary is commenced on a full ward diet by the end of the week. The NGT and IVT have been removed as he has tolerated the oral diet. The IDC has also been removed as Gary is now ambulating well and is able to walk to the toilet unaided. Gary is due for discharge into the care of his wife, and will need to be educated about initial changes to his lifestyle and exercise to prevent complications postoperatively from heavy lifting or trauma. He is advised to watch out for excessive pain, weight loss or change in bowel function.
As a result of the medication error the NUM has arrange a peer in service to educate the ward on IM injections.
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