Question

A new graduate nurse is working in a surgical ward of the local hospital. She has been allocated to care for Mrs Beverly Smith, a 70-year-old woman admitted for a hemicolectomy for stage 2 bowel cancer. Mrs Smith has a history of hypertension and stage 2 Chronic Kidney Disease (CKD). Mrs Smith had her surgery yesterday and is reported to have been stable overnight. She has a midline incision closed with staples, one Belovac of with minimal haemo-serous drainage, IV 4% Dextrose in 1/5 Normal Saline running at 85mL/hr and a PCA of Morphine sulphate 100mg in 100mL Normal Saline set to deliver 1mg with each press. She has an indwelling urinary catheter draining an average of 60mL/hr.

When the nurse assesses Mrs Smith at the beginning of the shift, she appears distressed and complains of pain rated 7 out of 10 in her abdominal area. Her observations are blood pressure 140/85 mmHg, pulse 90 bpm, respiratory rate 12, oxygen saturation 92% and temperature 36.2 degree Celsius. She is unwilling to sit up in bed and has difficulty taking a deep breath.   

The nurse explains to Mrs Smith the importance of pressing the PCA button regularly. She then checks her medication chart for any orders for “breakthrough” medication. Mrs Smith has an order for oxycodone (Endone) 10mg oral PRN, so the RN asks the endorsed EN to accompany her to the locked medication cupboard, check out the dose of Endone, and administer it to Mrs Smith, checking all the “5 rights” of medication administration.

The RN continues to give care to her other patients. When she returns to the room, she notes that Mrs Smith is sleeping peacefully. Because she had a poor night, she decides not to wake her for observations and charts “sleeping” on her PCA chart. The nurse then goes to morning tea.

When she returns from morning tea, she notes that Mrs Smith is slumped down in the bed and looks very pale. She does a set of observations and notes the following:

Patient is semi-conscious, rousing to voice, unable to give a pain score, PCA history delivered dose 15 times in the last 2 hours, blood pressure 90/60mmHg, pulse 70 bpm, respiratory rate 4 breaths per minute and shallow, oxygen saturation 84%.

Question 16. Maximum word limit 50 words. (1 mark) (Reference not required for this question)

Express the immediate priority patient problem indicated by this situation as a Nursing Diagnosis with a ‘Related to’ and ‘Evidenced by’ statement.

Question 17. Maximum word limit 200 words.

List four immediate priority nursing actions that are required in this situation to address the identified problem and a rationale for each.

Questions 18. Maximum word limit 200 words.

Discuss what you believe were the main patient factors and nursing or system errors, that led to this occurrence.

Question 19. Maximum word limit 150 words.

Following treatment by the medical and nursing team, Mrs Smith is significantly improved by the time her daughter visits later.

Describe the actions required following this incident as part of NSW Health and hospital policy to address issues of patient safety and standards of care.

Question 20. Maximum word limit 200 words.

What are the legal requirements for a Tort of negligence? Do you believe that the new graduate RN was negligent in this situation? Justify your answer.

Answer 1

16) The immediate priority patient problem indicated by this situation as a Nursing Diagnosis :-

Impaired respiratory function related to excessive use of morphine as evidenced by low saturation and bradypanea.

17) The four immediate priority nursing actions that are required in this situation to address the identified problem and a rationale are :-

1. Administration of antidote ( naloxone / naltrexone ) of opiod to reverse the effect of morphine on respiratory center .

2. Oxygen therapy to relieve the respiratory distress and improve saturation level

3. Isotonic IV fluid adminstration to get the normal blood pressure and to make the patient hemodynamically stable .

4. Provide the patient upright semi - fowlers position to allow lungs to expand fully and helps in inspiration and exhalation of breath

18) I believe that the main patient factors is :-

- excessive use of morphine for pain

Nursing or system errors, that led to this occurrence is the improper guidance and teaching regarding the use , side effects of PCA . If the nurse must have monitored that how she is using the PCA and often she is using she might have not been in such situation.

19) The actions required following this incident as part of NSW Health and hospital policy to address issues of patient safety and standards of care is to report the incident by the nurse to the incharge , administration about the negligence caused by her and how it affected the patient . And actions against the nurse will be taken as per rules and norms of the hospital policy .