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Image transcription text 2. Stage 6 (take action): Utilising stage 6 of the Clinical Reasoning Cycle, discuss your nursing actions. These must include; The most appropriate course of action to achieve your goals of care. Address your nursing diagnoses, using curre… Show more Identify: Miss Vanessa Anderson, HRN: 123456, DOB: 25/12/2004 Situation: Vanessa is a 16yo, healthy active female living in NSW who was admitted after experiencing a traumatic head injury after being struck on the R) side of her head, behind her ear, by a golf ball at approx 0825 Sunday morning. Paramedics attended and brought her into ED. She was sent for an urgent CT which diagnosed depressed focal right temporal skull fracture. Bone fragments in brain matter and dural lacerations present. She has been complaining of a headache and has a GCS of 14-15. She has been transferred to the CDU Neurological ward for continuing care, it is now 1300. Background: Vanessa lives with her parents and has an older brother Jason. She plays golf 3-4x a week and is in yr11 at High School. Pmh – Asthma – Seretide and Ventolin Allergies – Shellfish and nuts 60kgs, normal BMI Assessment: Airway: Own, patent Breathing: RR 23, O2 Sats 98% on RA. Circulation: HR 68bpm, BP 120/65 mmHg. Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 5.0mmol/L Exposure: Temp 36.5 oC, She has 1 x PIVC inserted to her R) ACF, it is patent. Recommendations/Read back: Medical orders · Routine ward assessments and observations · 4/24 full neuro observations · Administer analgesia as prescribed · Diet and fluids as tolerated · TED stockings and DVT prophylaxis Medication orders · Panadeine Forte 1000mg/60mg QID · Oxycodone 5mg PRN (Max dose 30mg in 24hrs) · Dilantin 100mg IV over 6hrs Nursing orders · Devise a plan of care for your patient The following events transpired over the course of the next few shifts. Monday 0830 Medical review. GCS 15. Continue with regular Panadeine Forte Oxycodone changed to 5-10mg 3hrly PRN You return on Monday for the nightshift, and you are allocated to care for Vanessa. 2100hrs On handover at 2100hrs you are told that Vanessa last had the following analgesia. 1900 – Panadeine Forte 2000 – PRN Oxycodone 10mg You perform your assessment and note the following: Airway: Own, patent Breathing: RR 16, O2 Sats 95% on RA. Circulation: HR 62bpm, BP 105/58 mmHg. Disability: GCS 14/15, she is intermittently confused, PEARL 3mm, BGL 6.0mmol/L Exposure: Temp 36.2 oC, 2300hrs Vanessa rings the bell and complains of a continual headache with 9/10 pain, you administer: 2300 – PRN Oxycodone 10mg 0000hrs You review Vanessa and she complains of no improvement in her headache, pain is 9/10, you administer her scheduled Panadeine Forte. 0100hrs At 0100 Vanessa rings her bell for assistance, she tells you, in a distressed voice that she cannot move. You attempt to do a full set of neurological observations and ask Vanessa to lift her arms, she cannot, she is frightened. There is no shaking, no stiffness to her limbs and her breathing is normal. She feels warm to touch and has a normal skin colour. You do not assess any other limbs nor do you assess her GCS. You do not believe she is in immediate danger and assume she has had a bad dream. You offer reassurance and leave the room as you have a new admission you must attend to urgently. Within 10 minutes you return to Vanessa and perform a full set of neurological observations, with no deficits noted, you are happy with your original assumption that she had a bad dream. 0200hrs Vanessa rang the bell to ask for assistance to use the toilet, she can mobilise with some assistance. Her pain remains unresolved, you give her PRN Oxycodone 10mg. 0400hrs You have routine and neurological observations to conduct but as she was ok when you walked her to the toilet 2hrs ago you decide to not conduct these. Her Dad arrived on the ward at 0345 and he is fast asleep in the chair in her room, you decide not to disturb them as she is finally settled after her analgesia. 0530hrs You go to check on Vanessa and find her unresponsive. You initiate a MET call. 0635hrs Vanessa is pronounced dead, despite all attempts to resuscitate her. Coroners review – cause of death. Post-mortem: • Blunt head injury and mechanism of death most likely a seizure. Unable to be formally determined. • Difficult to determine whether analgesia contributed – may have caused respiratory depression. Formal finding – Respiratory arrest due to depressant effect of opioid medication
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