Read the below scenario and reflect on what really happened. Answer the questions following the scenario:
(Levett-Jones & Newby 2012)
1. In this scenario the nursing student did every task she had been asked to do. Should anything else be expected of students?
2. What interpersonal and situational factors influenced how this scenario transpired?
3. How might the outcome of Mr Esposito have been different had Maddie had a requisite level of clinical reasoning skills?
4. What aspects of this adverse drug event were preventable?
5. Should this adverse drug event be documented and reported? If so, where, by whom, to whom and why?
6. The medical officer and nurse discussed whether Mr Esposito and his daughter should be told that he had experienced an adverse drug event. The nurse thought they should be told, but the doctor disagreed saying that telling Mr Esposito and his daughter would make them worry needlessly. What do you think and why?
7. Reflect on the scenario and outline some of the errors that occurred and that led to Mr Epsosito’s adverse drug event.
Mr Guiseppe Esposito, 81 years, was admitted to the medical ward of Griffith Community Hospital with dehydration as a result of suspect gastroenteritis. He had been vomiting and had diarrhoea for two days prior to admission. Intravenous fluids were commenced and his diarrhoea began to improve the following day, although some nausea persisted. Mr Esposito’s IV was not resited when it ‘tissued’ later that evening.
At 000 the next day (Guiseppe’s second day following admission) Maddie was asked to administer Guiseppe’s usual oral medications (frusemide 80 mg, digoxin 125 micrograms and enalapril 20 mg). It was a busy shift and the registered nurse (RN) supervising Maddie was interrupted and asked to attend to another r patient. She said, ‘Keep going – I’ll watch what you are doing from over here’. Maddie, although new to the ward and feeling quite intimidated, was conscious that this was outside of her scope of practice. She said, I’m sorry but I am not allowed to administer medications without direct supervision by a registered nurse’. The RUN looked surprised but said, ‘Oh … Okay, I’ll be there in a tick’. While she waited, Maddie checked that there was a valid order for the medications and reviewed the ‘Australian Medicines Handbook’, (Rossi 2011) to find out more about the medications following the ‘six rights’ (right patient, right drug, right dose, right time, right route, right documentation); she also checked to see if Giuseppe had any allergies. Maddie asked him to check his medications as she gave them to him, saying, ‘I’m giving you your Lanoxin, Lasix and Renitec, is that right? Do you know what they’re for, Giuseppe?’ He nodded and replied, ‘Yes, yes, they’re for my ticker and my water’.
Read the above continuation of the scenario about Mr Esposito and answer these questions about medication safety and administering medications.
What other ‘rights’ are essential to medication safety?
1. What does a valid medication order require?
2. What three checks are required when administering medications?
3. Should Maddie have taken Giuseppe’s vital signs prior to administering his medications?
1 CONSIDER THE PATIENT SITUATION
In the first stage of the clinical reasoning cycle the nurse begins to gain an initial impression. He or she takes notive of the patient’s concerns and begins to thing about the situation. Whilst Maddie interacts with Giuseppe, Giuseppe tells her ‘Geez, I’m a bit dizzy, girly’. Maddie was not sure of what to do, but decided to leave him sitting for a while as she was concerned that if she took him to the shower he might fall.
2 COLLECT CUES / INFORMATION
During the second stage of the clinical reasoning cycle the nurse begins to collect relevant information that is currently available in the patient’s clinical documentation, medical and nursing notes, handover report, or other available information.
As Maddie began to think about why Giuseppe was feeling dizzy, she reviewed his charts. The fluid balance chart was incomplete, as it had not been maintained since the IV tissued the previous day. Maddie noticed that on the previous day Giuseppe was in a positive balance (2400mL in – mostly IV fluids and small amounts of oral fluids; total output 700 mL – he had been voiding small amounts infrequently).
Giuseppe’s observations had been relatively stable, but his pulse rate seemed to have decreased in the days since admission. Maddie was not sure what this meant. Giuseppe’s blood pressure had been between 120/70 and 110/60. His temperature had been 38oC on admission but 36.4-37oC over the last 24 hours. Giuseppe’s respiratory rate had been 16-20 resps per minute. There was no mention in the progress notes of Giuseppe feeling dizzy previously.
a Gather new information
The next stage of the clinical reasoning cycle is to collect relevant cues and information. This requires the nurse to determine which cues are relevant for a particular person at a particular point in time. Maddie considered Giuseppe’s dizziness and decided to take his blood pressure sitting and standing before getting him up for the shower. She used the manual sphygmomanometer attached to the wall beside his bed.
1. Why did Maddie take a sitting and a standing BP?
2. Why do you think Maddie chose to use the manual sphygmomanometer instead of the electronic one?
3. Giuseppe’s blood pressure was 120/70 sitting and 110/60 standing. What might this reading indicate?
Maddie also checked Giuseppe’s pulse rate; it was 64, weak and thready, and irregular. She confirmed this finding by checking Giuseppe’s apical pulse for 60 seconds using a stethoscope. Taken apically Maddie thought his pulse rate was 68 and very irregular.
1. Why did Maddie check Giuseppe’s apical pulse?
2. From the list below, identify the other cues that you believe Maddie should have collected?
b Condition of oral mucosa
c Oral intake
e Cognitive state
g Skin condition
h Level of thirst
1. Are there any other cues that Maddie should have collected at this time?
2. Are there any questions you would have asked Giuseppe if you had been in this situation?
b. Recall knowledge (quick quiz)
While cue collection involves reviewing current information and gathering new information, it also requires you to recall related knowledge. This includes a broad and deep knowledge of physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics and law and so on, as well as an understanding of evidence-based practice.
3 PROCESS INFORMATION
The next step of the clinical reasoning cycle is to interpret the data (cues) collected through careful analysis and to identify aberrations from normal. Always ask the question: ‘Are these cues normal for this person at this time and in this place?’
Which of the following would be considered to be within normal parameters for Giuseppe?
b Apical rate:
d Respiratory rate:
e Blood pressure: 36.4 – 37°C
weak, thready and irregular
64 beats per minute
16-20 breaths per minute
120/70 sitting and 110/65 standing
At this stage the nurse narrows down the information to what is most important. Research shows that novice nurses tend to wait until they have identified a patient problem before they search for cues, whereas experts practice more proactively, collecting a wide range of relevant cues to identify and prevent possible patient complications (Hoffmann, Aitken & Duffield 2009).
From the list below, select eight cues that you believe would be most relevant to Giuseppe at this time.
a Blood pressure
b Respiratory rate
c Blurred vision
f Pulse rate
h Condition of oral mucosa
i Level of consciousness
j Lack of appetite
k Urine output
The next step for Maddie is to cluster together the cues that she had collected and try to make sense of them by looking for relationships or patterns. Some people call this stage ‘connecting the dots’ or ‘putting two and two together’.
Label the following ‘true’ or ‘false’.
• Giuseppe may have been hypotensive due to insensible fluid loss (vomiting and diarrhoea).
• Giuseppe’s blurred vision was most likely an indication of deteriorating eyesight due to his age.
• Giuseppe’s dizziness and nausea could have been a side effect of one of his medications.
• Giuseppe’s nausea and anorexia may have been caused by exacerbation of his gastroenteritis.
• Giuseppe’s irregular pulse may have been caused by his hypertension and negative fluid balance.
• Giuseppe’s hypotension may have been caused by his negative fluid balance, irregular pulse and moving from a lying to a standing position too quickly.
• Giuseppe’s tachycardia and hypotension may have been from anxiety and stress.
• Giuseppe’s negative fluid balance may have been caused by vomiting, diarrhoea and inadequate oral intake.
In this stage of the clinical reasoning cycle the nurse thinks about all the cues that have been collected and makes inferences based on the analysis and interpretation of those cues.
From what Maddie knew about Giuseppe’s history, signs and symptoms, as well as the information she had recalled, she considered the following potential inferences:
Giuseppe could have been experiencing which of the following? (Select the two that you think are most correct.)
a Signs and symptoms of dehydration
b An exacerbation of his gastroenteritis
c An allergic reaction to one of his medications
d An adverse drug event
Next the nurse must anticipate potential outcomes depending on a particular course of action (or inaction). Maddie was worried and not sure what course of action to take. Because of her inexperience and uncertainty she wanted to just ‘wait and see’, but she began to think about what could happen if she did nothing.
If Maddie did nothing, what might happen to Giuseppe? Select the two correct answers.
a He could have gone into septic shock.
b His condition would probably have improved over the next few days.
c He could experience serious complications once discharged.
d He could have developed a life-threatening arrhythmia.
e He could have developed pulmonary oedema.
4 IDENTIFYING THE PROBLEM / ISSUE
This stage of the clinical reasoning cycle is where the nurse synthesises all of the information that has been collected and processed in order to identify the most pressing patient problems or issues.
What do you think Maddie’s main concerns about Giuseppe were?
5 TAKE ACTION
The next stage of the clinical reasoning cycle requires knowledge, clinical skills, effective communication skills and clinical reasoning ability. The nurse has to decide which actions to take priority, and who should be notified and when.
Draw up a table like the one below and record how Maddie could communicate with the RN about Giuseppe:
I Identify Self: name, position, location.
Patient: name, age, gender.
S Situation Briefly explain the reason for the call.
B Background Patient’s diagnosis, relevant history, investigations, what has been done so far.
A Assessment Summarise the patient’s current condition or situation.
Explain your assessment of the problem.
R Request/recommendation State your request.
a What are three of the most important things that you have learned from this scenario?
b What actions will you take in clinical practice as a result of your learning from this scenario?
c How will you demonstrate person-centred care when administering medications?
d What have you learned from this scenario about communication, clinical leadership and teamwork that you can apply to your clinical practice?