NURS1131 Complex Nursing Care Assessment Answer

Question 1

In nursing practice, the tragic example of 16-year-old Matt, who died following a simple appendectomy, highlights the mutual understanding, rational reasoning, and documentation. Matt's tale highlights the benefit of the A-E assessment and the relevance of identifying and responding to red-flag symptoms of deterioration (Forster & Scaini-Clarke, 2022). This section of evidence-based writing explores how Matt's death may have been prevented if the nursing team had adhered to the suggested guidelines. Patients, like Matthew who worsen without being noticing or receiving treatments run the risk of being admitted to critical care and having their increase of morbidity or death. The A-E method of rigorous patient evaluation ultimately allows health staff to identify and treat life-threatening illnesses. As part of the A-E assessment, the patient's vitals should be taken and documented to recognise physiological anomalies which indicate worsening. Heath professtionals should use a appropiate communication method to convey the results of A-E assessment in order to enhance communication and escalate the care of the deteriorating patients. “Don't normalise the abnormal”, acts as a reminder for medical staff to be alert for odd circumstances and to take action when required. It emphasises the value of identifying early signs of deterioration and stopping them from getting worse, making it a key concept in nursing practice. The A-E assessment is a method for identifying early signs of patient decline (Fragkandrea, Nixon & Panagopoulou, 2013). The acronym's letters stand for "airway, breathing, circulation, disability, and exposure". Each aspect of the A-E technique is essential to patient evaluation and must be monitored periodically to identify problems. The warning signs of Matt's circumstances deteriorating were frequently cited. Despite the fact that Matt had been vomiting and had a temperature, these symptoms were considered to be typical post-operative side effects and were recognised as normal. Also, Matt was breathing quickly, but this wasn't seen as a possible sign of oncoming deterioration. Documentation is an essential component of nursing practice when using the A-E assessment to ensure that all patient records are correctly and promptly recorded. The nurse attending to Matt during the night shift would also have needed to take note of his observations, including his physiological parameters, fluid intake, and output (Lorenzetti et al., 2018). The remainder of the medical team must be informed right once of any interventions or changes to his treatment plan. All health-related concerns about Matt were to be written down and forwarded to medical staff. Apart from that, it would have been essential for the nurse caring for Matt on the night shift to often check his vital signs and make sure he was comfortable and pain-free. The rest of the medical team should have been informed of any changes in Matt's health. If Matt's respiratory rate had continued, it would have been necessary to hand off Matt's care to a more experienced staff. It would have been essential to make sure Matt was well-hydrated and receiving the appropriate amount of pain medication. Any issues with his condition must be noted and reported to medical staff (Lorenzetti et al., 2018). Moreover, critical thinking is a crucial aspect of nursing practice and involves applying knowledge, abilities, and experience to arrive at wise conclusions and which may have been used in Matt's case to stop his deterioration and respiratory distress. The staff had seen early indicators of disease progression, such as Matt's rapid breathing and elevated body temperature. If that were the case, they may have stepped in sooner to stop his condition from getting worse. Critical thinking abilities may have also been used to spot any possible issues from Matt's operation and make sure the right safety measures were taken to prevent them.

Question 2.

Nursing records span a wide range of problems, subjects, and frameworks. Documentation is seen by practitioners, and hospital managers as a crucial component that promotes compliance, safety, quality treatment, and continuity of care. Documentation is an essential component of nursing practise because it ensures that all patient records is correctly and immediately recorded. Documentation enables data exchange with the other healthcare professionals, promotes therapeutic consistency, and provides a legal documentation of treatment (Bee et al., 2015). Remarkably little indication of a connection between documentation and all these results has been found in studies, nevertheless. Many advice pieces and case studies in the literature are intended to help nurses keep better records generally or for particular diseases. Also, the research indicates the conflicts related to nursing documentation. They include the time required for documentation, the number of mistakes in the records, the goal of making nursing role accessible, and the requirement that nursing notes be clear to other professions (Houben et al., 2014). There are several studies of the research on clinical decision systems. The most systematic and thorough study was conducted by Urquhart and Currell, who looked at the literature up to 2004. (Houben et al., 2014). As system differences have an impact on health care and patient consequences, they concentrate on nursing record systems. According to Currell and Urquhart, nurses must balance the requirements of patients with the documentation guidelines imposed by hospital management. Also, they discovered that there are conflicting results in the research about how people react to new systems and if the nursing documentation system in use has an effect on patient care. The absence of system uniformity was also highlighted. All health-related concerns about Matt were to be written down and forwarded to a senior nurse or medical staff. There are several studies of the research on clinical decision systems. The most systematic and thorough study was conducted by Urquhart and Currell, who looked at the literature up to 2004. (Houben et al., 2014). As system differences have an impact on health care and patient consequences, they concentrate on nursing record systems. According to Currell and Urquhart, nurses must balance the requirements of patients with the documentation guidelines imposed by hospital management (El Kassem et al., 2013). Also, they discovered that there are conflicting results in the research about how people react to new systems and if the nursing documentation system in use has an effect on patient care. The absence of system uniformity was also highlighted. After his operation, Matthew developed problems and ceased breathing. He was resuscitated despite coughing up pink foam and finally sent to the ward to heal. As none of the aforementioned observations were recorded, the case appeared to be a routine one. Langowski investigated the connection between point-of-care online nursing assessment systems and high-quality healthcare, notably safety (Nkechi, 2021). In contrast to Currell and Urquhart, Langowski discovered that an online "electronic health record (EHR)" increased overall reporting quality.

Question 3.

It would have been crucial for the department nurse caring for Matt on the night shift to often check his vital signs and make sure he was at ease and pain-free given the nursing demands. Any changes in Matt's health should have been communicated to the rest of the medical staff, and Matt's evaluations should have been accurately and immediately documented. It would have been required to transfer Matt's care to a nurse or medical staff member with higher experience if his respiration rate had persisted. In Matt's instance, critical thinking abilities may have been applied to halt his decline and respiratory difficulty. Early signs of illness development, such as Matt's rapid breathing and raised body temperature, had been seen by the nursing staff. If such were the case, they may have intervened sooner to prevent the deterioration of his health. Also, nurses able to do medication administration, attending wound dressing, and obtaining vital signs. Understanding any changes of the wound could impact BP and temperature and also, such changes would call for urgent medical attention demands critical thinking abilities. Throughout the shift, nurses tend to a lot of patients. To ensure that patient care and safety are not jeopardised when juggling many jobs, it is essential to possess strong critical thinking abilities (Molterer, Hoyer, & Steyaert, 2020). To choose which patient to see first, which drugs to administer first, and how to schedule their day of patient care, nurses must also use critical thinking. Because patient circumstances and environments are continuously changing, nurses must consistently review and revise the data they collect in order to keep their patients safe. Making sure Matt was well hydrated and receiving the right dosage of painkillers would have been crucial. A senior nurse or other member of the medical team must be informed of any problems with his condition (Lorenzetti et al., 2018).

Question 4.

Patient injury can result from a variety of factors, including medication mistakes, poor hand hygiene, surgical errors, and more (Hoffmann et al., 2020). Therefore, addressing concerns verbally and swiftly is referred to as "speaking up" and is regarded a crucial patient safety habit for healthcare practitioners. Speaking up is primarily done to advocate for patient safety, although studies have shown that this might backfire due to organisational culture. Prerequisites for enhancing patient safety and the safety culture include education and ongoing training to acquire safety competence. A patient safety curriculum guide for medical schools was created by the World Health Organisation (WHO) in 2009 (Hoffmann et al., 2020). Since then, a number of studies have revealed that there is still a need for improvement in the undergraduate curriculum's incorporation of patient safety teaching. According to the case study, Matt's fast breathing and raised body temperature were early signs of illness development that the nursing team had seen. If such were the case, they may have intervened sooner to prevent the deterioration of his health. The ability to think critically may have also been utilised to identify potential problems stemming from Matt's procedure and ensure that the proper safety precautions were taken to avert them.

References:

Bee, P., Price, O., Baker, J., & Lovell, K. (2015). Systematic synthesis of barriers and facilitators to service user-led care planning. The British Journal of Psychiatry , 207 (2), 104-114. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/systematic-synthesis-of-barriers-and-facilitators-to-service-userled-care-planning/73D0E76E2BE7206C2A80F2CC0BA5B097

Broderick, M. C., & Coffey, A. (2013). Person‐centred care in nursing documentation. International journal of older people nursing , 8 (4), 309-318. https://onlinelibrary.wiley.com/doi/abs/10.1111/opn.12012

El Kassem, W., Abdulrahman, A., Raghab, A., Pro, K. W., Elgaily, D. E., Sahal, A. O., ... & Con, K. J. W. (2013). Should clinical practitioners, as part of institutional or accreditation standards, be required to document their rationale when choosing to not adhere to widely accepted clinical practice guidelines?. Canadian Journal of Hospital Pharmacy , 66 (4). http://www.cjhp-online.ca/index.php/cjhp/article/view/1272

Forster, E., & Scaini-Clarke, L. (2022). Recognising and responding to the sick child. Paediatric Nursing in Australia and New Zealand , 293. https://books.google.com/books?hl=en&lr=&id=0A9NEAAAQBAJ&oi=fnd&pg=PA293&dq=A-E+systematic+method+and+the+significance+of+recognizing+and+reacting+to+red+flag+indicators+of+deterioration+&ots=_MHYjsATR-&sig=4cwaRY_xhWAmlf2Y7UeDcQorORk

Fragkandrea, I., Nixon, J. A., & Panagopoulou, P. (2013). Signs and symptoms of childhood cancer: a guide for early recognition. American family physician , 88 (3), 185-192. https://www.aafp.org/afp/2013/0801/p185.html

Hoffmann, M., Schwarz, C. M., Schwappach, D., Banfi, C., Palli, C., & Sendlhofer, G. (2022). Speaking up about patient safety concerns: view of nursing students. BMC health services research , 22 (1), 1-9. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08935-x

Houben, C. H., Spruit, M. A., Groenen, M. T., Wouters, E. F., & Janssen, D. J. (2014). Efficacy of advance care planning: a systematic review and meta-analysis. Journal of the American Medical Directors Association , 15 (7), 477-489. https://www.sciencedirect.com/science/article/pii/S1525861014000267

Lorenzetti, D. L., Quan, H., Lucyk, K., Cunningham, C., Hennessy, D., Jiang, J., & Beck, C. A. (2018). Strategies for improving physician documentation in the emergency department: a systematic review. BMC emergency medicine , 18 , 1-12. https://link.springer.com/article/10.1186/s12873-018-0188-z

Molterer, K., Hoyer, P., & Steyaert, C. (2020). A practical ethics of care: Tinkering with different ‘goods’ in residential nursing homes. Journal of business ethics , 165 , 95-111. https://link.springer.com/article/10.1007/s10551-018-04099-z

Nkechi, C. E. (2021). Inter-relationships of the components of documentation in nursing practice. Journal of Nursing Science Practice Research and Advancements , 3 (1), 7-12. https://www.researchgate.net/profile/Edith-Chiejina/publication/346489508_Inter-Relationships_of_the_Components_of_Documentation_in_Nursing_Practice/links/5fc4e3e1458515b7978a6c15/Inter-Relationships-of-the-Components-of-Documentation-in-Nursing-Practice.pdf

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