Kate's practice experience

Kate’s practice experience

Kate is a second-year adult student nurse. As part of her practice learning experience on a medical ward she is spending a day with the critical care outreach team (CCOT). She is specifically working on a learning outcome for this placement around identifying and assessing the deteriorating patient, aligned to proficiency:

4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound clinical decisions

Standardof proficiency for registered nurses

Kate’s practice supervisor while she is with this outreach is Adam, who is a staff nurse within the CCOT.

CCOT is called to see Margaret – 88 years old who has fallen at home and has been brought to the emergency department by ambulance. Margaret had spent the night on the floor at home until her daughter arrived and called an ambulance. Margaret has a fractured pubic rami, this is a fracture that does not need surgery but is painful and Margaret will need some help with her mobility. Margaret has been admitted to an orthopaedic ward for pain assessment.

CCOT are called to see Margaret as she has become increasingly confused, and this has triggered an increase in her NEWS 2 score.

What Kate did

Adam and Kate introduced themselves to Margaret and her daughter Pat. Pat informed them that her mother had been living independently at home, but her mobility had decreased over the last few months, and she has fallen twice in the last week. Pat also said that her mother is normally not confused, and this is really worrying for her.

Adam and Kate looked at Margarets observations and noted the following:

Physiological parameter		NEWS 2 Score
Respiratory rate	22	2
Sp02	98%	0
Air or 02	air	0
Systoli BP	124mmHg	0
Pulse	99	1
Consiousness	Confused	3
Temperature	37.1oc	0
Total NEWS2		6

As this score was 6 it triggered the potential for serious acute deterioration and a review by CCOT.

Adam and Kate repeated these vital signs, and the score remained at 6. They noted that a fluid balance chart had been commenced and that it was recorded that Margaret had vomited twice in the last two hours. They also spoke to Pat, and she reported that her mother appeared drowsy, and this was not usual. The staff nurse on the orthopaedic ward said that Margaret has a urinary tract infection (UTI), and this was being treated with a course of oral antibiotics and this is why they thought she was confused.

Margaret vomited again while Kate was taking her blood pressure, they changed her bed linen and disposed of the vomit, bowl and bedlinen in accordance with local infection prevention policy. They offered a mouthwash and updated the fluid balance chart. They made sure that Margaret felt clean and comfortable and had a fresh vomit bowl available.

Adam asked Kate to look at the results of Margaret's blood tests and to also look at the medication she had been taking at home. It was noted that Margaret had been taking amiloride for the last eight months as prescribed by her GP as treatment for her diagnosed hypertension. Pat also reported that Margaret had been taking ‘over the counter’ ibuprofen regularly for some months for headaches.

The blood results revealed a lower than normal level of sodium (Na) in the blood with a serum sodium concentration of 129 mmol/L.

This was discussed with the multidisciplinary team and a diagnosis of hyponatraemia was made. This prompted an urgent review of Margaret’s medication. An infusion of hypertonic saline solution (3%) was commenced, and regular frequent NEWS scores continued. Adam and Kate updated Margaret's care plan and discussed this with Margaret, Pat and the orthopaedic ward staff