RTs Case Study: Online Case Study Nursing Assessment

RTs Case Study

Introduction:

My current role is as a community nurse running a community-based nursing clinic, caring for clients with acute and chronic wounds.  Our main assessment tool apart from wound assessment is taking a thorough vital sign assessment.  Vital sign assessment is a common nursing tool used to monitor and assess the client’s overall health.  Ongoing surveillance, assessment, and interpretation of data will lead to positive client outcomes (Watkins, Whisman& Booker 2016).  This case study introduces Marty (a pseudo-name) a client of the community clinic.  It is my aim to highlight the importance of regular vital sign observation in order to prevent a failure to rescue, as well using skills learnt through clinical reasoning and the importance of effective communication with community clients and appropriate health staff. 

Case study:

Marty is a 76-year-old man, who attends our community-based wounds clinic three times per week for wound care of bilateral lower leg venous ulcers.  Marty lives alone, has never married nor has any children.  Marty’s closest living relative is his sister who lives 5 hours away. Marty is a retired headmaster and currently tutors students where English is their second language.

On a routine visit to the clinic on a Friday afternoon, Marty’s initial presentation was not his normal bright, chatty self.  Marty was tired and lethargic.  On removal of previous wound dressings, Marty’s wounds presented with signs of infection.  Wounds were malodorous, cloudy exudate with a green-tinged appearance.  Surrounding skin was red, inflamed and warm to touch. Wound presented with clinical signs of infection present.  Vital signs were taken for Marty.  All vital signs were within normal range apart from temperature.  Temperature slightly elevated at 37.5.  Suspected infection in the wound, discussed concerns with the client.  Wound swab attended to, with a letter written to local GP explaining my findings. Advised Marty to attend his GP after his clinic visit to obtain pathology results.  My recommendation to the GP was to commence a broad-spectrum antibiotic (AB) until results are confirmed.  Marty agreed to this plan.

Marty did not attend his local GP that afternoon, Marty continued to deteriorate over the weekend.  Marty took a fall down his unit stairs on his way to his scheduled clinic appointment on Monday.  Marty’s neighbour found him and called an ambulance, Marty was taken to the hospital and commenced on the sepsis pathway.

Discussion:

The development of chronic wounds is caused when an acute wound fails to heal, this is usually in the inflammatory stages of healing (Carville 2007, p. 82).  Chronic wounds significantly impact the quality of life of the client and is a huge cost to the healthcare system (Carville 2007, p. 82: Rutter 2018).  Identifying infection of a chronic wound can be difficult and will often rely on the knowledge and skills of the nurse (Rutter 2018).  The role of the nurse is vital when detecting wound infection and therefore appropriate skills are required to detect and identify wound infection to prevent a failure to rescue (Rutter 2018: Levett-Jones 2010).

The importance of taking accurate vital signs, as well as the ability to interpret the data is a skill that nurses are taught during their years of training (Rose & Clarke 2010).  Although vital signs are not the only indicating factor of infection, they are often used as a useful tool to detect a deteriorating client (Watkins, Whisman& Booker 2016).  Although Marty’s vital signs presented within normal range apart from a slightly elevated temperature, this assessment is a requirement to rule out sepsis (NSW health 2018). 

Reflection:

On reflection on this case, I have gained a much clearer insight on the importance of detecting client deterioration (Levett-Jones et al. 2010).  I aim to improve my clinical assessment, documentation and communication skills in order to deliver the best care possible for my clients.  Since undertaking this case study and reviewing the appropriate literature, I feel I have gained new and re-enforced existing knowledge in my practice.  While I understand the importance of vital sign monitoring, I can now see other cues informing me of the severity of infection present for Marty on this day (Levett-Jones et al. 2010).  Apart from the clinical signs presenting in the wound, Marty was tired less and responsive than usual.  If using the clinical reasoning cycle in collecting cues and information, I would have encouraged Marty to attend his local emergency department or physically phoned Marty’s GP to ensure a complete and accurate handover could have been given prior to Marty leaving the clinic (Levett-Jones 2010).  This may have led to a better health outcome for Marty, as he spent the next week in hospital having IV antibiotics being treated as part of the sepsis pathway.

The importance of having good clinical reasoning skills as a nurse is detrimental for safe and effective client care (Campos de Carvalho et al. 2017: Levett-Jones et al. 2010).  From this case study, I will ensure I action the clinical reasoning cycle during client assessments and pay particular attention to subtle cues when collecting vital information (Levett-Jones 2010).  This will improve client outcomes and reduce hospital admissions. By using effective communication, clients will be well informed of areas of concern, ensuring medical attention is sought due to the severity of the situation (Levett-Jones 2010).

Reference:

Campos De Carvalho, E, Railka De Souza Oliveira-Kumakura, A, & Coelho Ramalho Vasconcelos Morais, S 2017, 'Clinical reasoning in nursing: teaching strategies and assessment tools', Revista Brasileira De Enfermagem, 70, 3, pp. 662-668, CINAHL Complete, EBSCOhost, viewed 29 July 2018.

Carville, K 2007, Wound care manual, 5thed. Silver Chain Foundation, Western Australia.

NSW Government 2018, Sepsis Tools, state of NSW, viewed 28 July 2018, http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools

Levett-Jones T, Hoffman, K, Dempsey, J, Jeong, S, Noble, D, Norton, C, Roche J & Hickey, N 2010. ‘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, vol 30, no. 6, pp. 515 – 520, viewed 28 July 2018.

Louise, R, & Sean P., C 2010, 'VIEWPOINT: Vital Signs,' The American Journal of Nursing, 5, p. 11, JSTOR Journals, EBSCOhost, viewed 28 July 2018.

Rutter, L 2018, 'Identifying and managing wound infection in the community,' British Journal of Community Nursing, 23, pp. S6-S14, CINAHL Complete, EBSCOhost, viewed 28 July 2018.

Watkins, T, Whisman, L., and Booker, P. (2016), Nursing assessment of continuous vital sign surveillance to improve patient safety in the medical/surgical unit. Journal of Clinical Nursing, 25: 278-281. doi:10.1111/jocn.13102

Example of a Students Response to Online Nursing Case Study Assessment

EWs response:

Thank you for your thorough and honest case scenario involving Marty’s care.  I have developed some helpful insights from examining both your case and the literature regarding health assessment relating to infection and sepsis.

You are correct in stating that vital signs can form a significant aspect of identifying infection in patients (Watkins, Whisman& Booker 2016).  The presentation of hypotension, tachycardia, tachypnoea, hypoxia or an increased temperature can all be indicative of the development of sepsis (Nouriel et al. 2018).  When utilising the clinical reasoning cycle as part of focused health assessment, it is imperative to adequately collect cues and information (Levett-Jones et al. 2010; Levett-Jones & Hoffman 2013).  The presence of a low-grade temperature should act as a prompt to nurses to perform further health assessment to rule out infection (Sloane et al. 2018). 

Identifying sepsis in its early stages requires a holistic and detailed health assessment, as early signs can be subtle and easy to miss (Shashikumar et al. 2017).  As evidenced by the literature, health interview forms an integral part of health assessment and the collection of cues (Erikkson et al. 2017; Levett-Jones & Hoffman 2013).  It is clear from your discussion that you noted Marty did not seem like his usual self that day.  Upon this observation, combined with the discovery of signs of wound infection, I would suggest the implementation of health assessment questions as part of further cue collection.  I would recommend asking open-ended questions regarding tiredness/lethargy as well as any presence of muscle aching or shivering (Dorsett et al. 2017).  I would also suggest asking the patient if they have experienced any oliguria, nausea, vomiting or gastrointestinal issues, as well as perform a Glasgow Coma Scale assessment to identify any confusion (Sloane et al. 2018; Dorsett et al. 2017).  In addition to these health interview questions, I would also assess global skin appearance to rule out any skin mottling or delayed capillary refill (Shashikumar et al. 2017). 

These recommended aspects of focussed health assessment can allude to possible infection or impending sepsis, allowing nurses to identify problems and take action early, permitting more positive outcomes (Levett-Jones et al. 2010; Shashikumar et al. 2017). 

References:

Dorsett, M, Kroll, M, Smith, C, Asaro, P, Liang, S & Moy, H 2017, ‘qSOFA has poor sensitivity for prehospital identification of severe sepsis and septic shock,’ Prehospital Emergency Care, vol. 21, no. 4, pp. 489-497, viewed 3 August 2018, CINAHL Complete, EBSCOhost.

Erikkson, I, Lindblad, M, Moller, U &Gillsjo, C 2017, ‘Holistic health care: patients’ experiences of health care provided by an advanced practice nurse,’ International Journal of Nursing Practice, vol. 6, no. 1, pp. 1-7, viewed 3 August 2018, Wiley Online Library.

Levett-Jones, T & Hoffman, K 2013, ‘Clinical reasoning: what is it and why it matters,’ in Levett-Jones, T (ed.), Clinical reasoning: Learning to think like a nurse, Pearson Australia, New South Wales, pp. 2-16.

Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, S.Y.S, Noble, D, Norton, C.A, Roche, J & Hickey, N 2010, ‘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, vol. 30, no. 6, pp. 515-530, viewed 3 August 2018, Elsevier Health.

Nouriel, J, Millis, S, Ottolini, J, Wilburn, J, Sherwin, R & Paxton, J 2018, ‘Blood pressure variability as an indicator of sepsis severity in adult emergency department patients,’ American Journal of Emergency Medicine, vol. 36, no. 12, pp. 560-566, viewed 3 August 2018, Elsevier Health.

Shashikumar, S, Stanley, M, Sadiq, I, Li, Qiao, Holder, A, Clifford, G &Nemati, S 2017, ‘Early sepsis detection in critical care patients using multiscale blood pressure and heart rate dynamics,’ Journal of Electrocardiology, vol. 50, no. 5, pp. 739-743, viewed 3 August 2018, Science Direct.

Sloane, P, Ward, K, Weber, D, Kistler, C, Brown, B, Davis, K & Zimmerman, S 2018, ‘Can sepsis be detected in the nursing home prior to the need for hospital transfer?’, Journal of the American Medical Directors Association, vol. 19, no. 6, pp. 492-496, CINAHL Complete, EBSCOhost.

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