NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

Disclaimer (please read before reviewing the scenario):
The following scenario has been developed to support completion of the
Assessment Item 2 for NRS312 in the 202130 session.
In this scenario, a patient is admitted to hospital for chemotherapy and contracts a bacterial infection in his intestines. He experiences abdominal pain and vomiting,and he eventually dies as the result of organ failure and cardiac arrest, secondary to acute peritonitis and severe sepsis. The scenario has been based on aspects of real cases and has been reviewed by academics and clinicians to ensure that it is authentic to the clinical context portrayed.This scenario includes elements that you may find confronting. In particular, you may have been involved in similar events in your personal, professional or study experiences. If you are distressed by the scenario, please contact the Subject Coordinator to discuss and consider contacting the CSU Student Counselling service
NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

Scenario: Mr Jason Swan
Background
Mr Jason Swan is a 37 year old man, admitted to the Acute Medical Unit of a large rural hospital in NSW for chemotherapy. Jason is a truck driver who lives with his wife Sarah and his three young children.Twelve months prior to his admission, Jason was diagnosed with Acute Myeloid Leukaemia
(AML) and commenced on chemotherapy.

16/05/2020 – 1000
The intravenous (IV) chemotherapy has concluded and Jason remains in hospital for further monitoring and observation.

Michelle, the registered nurse (RN) caring for Jason enters the room to assess his vital observations. Michelle is a ‘Transitional Registered Nurse’, completing a 12 month program immediately post gaining her registration as an RN.

Vital Observations:
• BP 118 / 80 mmHg
• HR 95 bpm
• RR 12 bpm
• Temp 36.7°C
• SpO2 99% (RA)
• Alert

16/05/2020 – 1015
Sarah arrives and sits beside Jason while Michelle continues to enter the observations into the computer (close to the bed). Sarah asks her husband if had slept well and had a good night. Jason explains that the food at the hospital was not agreeing with him.

NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

Shortly after this conversation Jason reaches for an emesis bag and vomits a small amount of vomit us. Michelle checks the volume (100 mls) and records this in the medical record.Michelle discards the vomit into the clinical waste (outside of the room) and returns to offer Jason an anti-emetic that is charted (ondansetron, intravenous, 4 mg) and also ensures
there is another emesis bag within reach.

Jason agrees to the anti-emetic, and Michelle leaves to collect the medication and the In-Charge nurse, Priscilla to assist with a two-person IV check. While the two nurses are in the medication room, they notice Dr Wong walking towards Jason’s room.

16/05/2020 – 1030
Dr Wong enters Jason’s room with her medical team (including Tina, an Oncology Fellow,Jillian a Medical Registrar and Justin a Medical Resident). Following close behind are Michelle and Priscilla, carrying the anti-emetic.

Dr Wong greets Jason and Sarah and asks how he is feeling. Jason explains he has vomited twice this morning, holding a second emesis bag with a small amount of bile in it.Michelle mentions that they have brought an anti-emetic and Dr Wong asks the nurses to administer this while the conversation continues.

Dr Wong explains the current blood pathology levels are ‘looking good’ and that he should be well enough to be discharged the following day. Michelle and Priscilla confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’ of safe medication administration and administer the ondansetron.

The medical team review the current vital observations, renew the medication order for anti-emetics to include prochlorperazine and assure Jason that they will review him prior to discharge tomorrow.

16/05/2020 – 1240
Lunch arrives and Sarah presses the nurse call button for assistance. Michelle returns from her lunch break and realises the call bell is on and heads for Jason’s room.

Sarah meets Michelle at the door of the room and explains ‘I am a bit worried about Jason.He doesn’t seem himself. He has vomited again since you left and he is uncomfortable in the chest’. Michelle assures Sarah that she will ‘have a look at him’ and consider giving him some further medications.

NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

Michelle asks Jason to explain where his chest discomfort is located and he points across the bottom of his ribs, from one side to the other. She asks if he has ever had this sort of discomfort before and he says no. Michelle asks if Jason is still nauseous to which he confirms that he is. Jason volunteers that the pain feels like ‘really bad stomach cramps’.

Michelle explains that she needs some assistance and will return with Priscilla. Both nurses return within 5 minutes with a dose of IV prochlorperazine, 5mg, and a 12-lead electrocardiogram (ECG) machine.

The nurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’ of safe medication administration and administer the prochlorperazine.

Priscilla leaves and Michelle applies the electrodes to perform a 12-lead ECG. Michelle has difficulty getting the electrodes to stick to Jason’s chest as he is diaphoretic. Michelle wipes Jason’s skin, uses tape to hold the electrodes on, and performs the 12-lead ECG.

16/05/2020 – 1255
Priscilla returns to the room to collect the 12-lead ECG. She explains to Michelle that she paged the Resident on the medical team and wants to show her the ECG report before she leaves the ward.

Michelle mentions to Priscilla that she has noticed Jason is sweaty. Priscilla asks Michelle to stay with him and assures her that she will return after she shows the Medical Resident the ECG. Priscilla leaves with the ECG.

When Michelle returns to the bedside, Sarah mentions she is becoming increasing worried about Jason. She explains that he had been ‘constipated for a couple of days now’ and had been straining to open his bowels earlier in the day and had not been able to.

Jason repositions himself and is unable to get comfortable in the bed. He is fidgeting with the bed every few seconds and is visibly distressed.

Sarah asks ‘Can he have anything for the pain? He is normally quite reluctant to tell me he is in pain and I have not seen him like this with his previous Chemo visits’. Michelle notes that there is an order for IV morphine. She asks Jason if he has had this before and he confirms that he has on several occasions. While he is worried the nausea will get worse,
he explains the pain is becoming unbearable.

16/05/2020 – 1330
After getting caught up with other patients for a while, Michelle asks Priscilla to retrieve some morphine from the Schedule 8 (S8) cupboard. While getting this out of the cupboard, Priscilla confirms that Justin had reviewed the ECG and it was determined that there were no detectable abnormalities. She also mentions that Justin is not concerned about Jason’s
pain as this is a ‘normal problem with repeated vomiting’.

The nurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’ of safe medication administration and administer IV morphine, 5mg. Priscilla assures Jason that they will be able to administer another dose of morphine if the first dose does not adequately reduce his pain. Michelle comments that he should feel some relief in just a few
minutes.

Both nurses leave to care for other patients.

16/05/2020 – 1400
Michelle enters the room to perform another set of vital observations. When she brings the observation equipment over, Sarah explains that the pain is not any better and he has been‘panting like a dog’.

NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

Vital Observations:
• BP 105 / 70 mmHg
• HR 110 bpm
• RR 18 bpm
• Temp 36.9°C
• SpO2 95% (RA)
• Alert
• Pain 6/10

Michelle explains to Jason and Sarah that the observations are within acceptable limits and that she will get some additional morphine shortly.

Michelle leaves again to catch up on work that she has been unable to get to as her shift is almost over.

16/05/2020 – 1515
Michelle provides shift-to-shift handover to Cathy, an RN on the evening shift: ‘This is Jason Swan. He is a 37 year old male admitted five days ago for IV chemo. He is expected to be discharged tomorrow but has had some nausea and vomiting and some chest pain today.We conducted an ECG and it was normal. I have given him some ondan setron and Stemitil but he is still nauseous. He had some vomiting this morning but that seems to have
stopped. His observations have been within normal limits, next due at 1800, but he does have ongoing pain. I can check some morphine out with you before I head off’

Michelle and Cathy collect the morphine from the S8 cupboard and enter Jason’s room.Michelle introduces Jason to Cathy and apologises for the delay with the morphine. The nurses confirm Jason’s identity, confirm that he has no allergies, check the ‘five rights’ of safe medication administration and administer IV morphine, 5 mg.

Michelle thanks Cathy and leaves at the end of her shift.

Cathy explains that she would like to perform another set of vital observations as Jason is still uncomfortable and she is quite concerned that his breathing seems shallow and difficult.
• BP 101 / 68 mmHg
• HR 125 bpm
• RR 20 bpm
• Temp 36.6°C
• SpO2 95% (RA)
• Alert
• Pain 8/10

Cathy explains that nausea, cramping and vomiting are all common side effects of chemotherapy and that this often causes anxiety for patients experiencing these symptoms.Cathy reassures that she will call the doctor now, but his observations are stable, with the exception of pain, which should settle with the second dose of morphine.

16/05/2020 – 1530
Cathy leaves the room to call Justin on the medical team.

Hi Justin, this is Cathy. I have taken over care of Mr Jason Swan, a 37 year old man admitted for Chemotherapy. I believe you are familiar with Jason (confirmed). I am calling because his pain has not subsided with the two morphine doses we have given him. He remains nauseous and he is now tachycardic. He is taking shallow breaths and while his oxygen levels and resp rate are o.k., I am worried about his breathing. I think it would be helpful if you could come and review him and I will initiate a clinical review. Can you get here within the next 30 minutes?

Thanks Cathy. I did check his ECG but I have not checked in on him. I will come down shortly. If I am not able to get there in time, I will send the after-
hours Resident who is starting work now.

Thanks Justin. I appreciate it.

16/05/2020 – 1550
Cathy repeats another set of vital observations.

Vital Observations:
• BP 85 / 55 mmHg
• HR 150 bpm (weak pulse)
• RR 30 bpm
• Temp 36.6°C
• SpO2 80% (RA)
• Verbal
• Pain – unable to rate

Cathy presses the ‘urgent assist’ button on the wall and two other nurses from the Acute Medical Unit arrive within one minute to provide assistance.

Cathy initiates a rapid response for the After-Hours Medical Registrar to attend.

Cathy describes the current observations to the In-Charge of the evening shift, who explains that they have not been informed about the situation.

Jason calls out ‘Please make it stop, just knock me out or something. I can’t take this anymore’. Sarah is very distressed.

As the Medical Registrar arrives, Jason becomes unresponsive

NRS312 Essential Nursing Care Assignment-Charles Sturt University Australia.

16/05/2020 – 1555
The nurses and the Medical Registrar commence basic life support and bring the arrest trolley. A cardiac arrest alarm is raised.

A defibrillator is attached and CPR is commenced.

16/05/2020 – 1557
The Advanced Life Support team arrives and assist with the resuscitation. Despite a prolonged resuscitation effort, the team are unable to achieve a return of spontaneous circulation and Jason is declared deceased at 1640.