Case Study of Diagnosis of Neutropenia Patient

A 45 year old physically fit patient was admitted to hospital following several visits to his General Practitioner (GP) where is was complaining of decreased appetite, constipation, fever, chills, headaches, cramping, vertigo and respiratory problems after experiencing some hay fever like symptoms one week ago. He was commenced on Roxithromycin 150mg b.d and his GP ordered blood tests that showed his had neutropenia (low white cell count) (Harris et al 2006, p 1185) and thrombocytopenia (low platelet count) (Harris et al 2006, p. 1704). Two days later he was not feeling any better and the GP ordered a chest x-ray (CXR) which the patient to have bilateral pneumonia he was than admitted to the hospital. This essay will identify important events that took place during the patient’s admission to hospital and discuss three of these events in detail with contemporary evidence to support the writer’s discussion. The essay will than look what has been learnt through this case study in relation to future professional practice as a new graduate registered nurse in accordance with the Australian Nursing & Midwifery Council (ANMC) competency standards.

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Day 2 Why did the patient not received oxygen until his saturation got to 70% there is no mention of the treatment plan to or from nursing staff. Later that day the patient was transferred to main ward, the nursing staff raised the issue that the patient needed to be in the intensive care unit (ICU), the patient was reviewed by Respiratory Physician and was decided to not to transfer patient to ICU. This patient required close monitoring due to saturation decrease and as a newly registered nurse we do not have the experience or the time to monitor this patient in a ward environment (ANMC 2006) competency Professional Practice. Patient safety, patient advocacy.

Day 5 The patient was noted to be still febrile and was ordered another CXR as the Computed Tomography Scan (CT scan) was not preformed, why had this patient not had the CT scan that was ordered (ANMC 2006) competency Professional Practice. Team communication strategies, chain of command. Later that day it was also noted that the patient had a PR Bleed and a referral was made to the gastroenterologist. No mention of cause or any investigation taken place to assess the PR bleed no blood tests were ordered to determine patient’s status. Patient advocacy, patient safety.

Day 6 Respiratory Physician saw the patient and noted he had severe bilateral pneumonia, possible bone marrow suppression and anaemia of an unknown cause, no communication between medical officers as the patient had a PR bleed the day before and is neutropenic and thrombocytopenic. The Respiratory Physician requested an infectious diseases review. Patient advocacy, conflict management, documentation.

Day 7 It was documented again that the patient had low saturations and was febrile. He was seen by the Infectious Diseases Specialist and was ordered more tests and a lung biopsy. The lung biopsy was considered to be of high risk due to the patient’s condition by a Thoracic Surgeon. If this patient was a high risk why was he not in ICU as requested by the nursing staff? Conflict management, chain of command, patient advocacy.

Day 8 The nursing documentation states patient remains very breathless and low saturation is on 12L oxygen via a non-rebreather mask and is still febrile. A BiPAP (bilevel positive airway pressure) was requested to be used the next day but patient was not alive the next day, why was it not used immediately he is on high level oxygen and should have CO2 levels checked by having blood gases taken, a CT scan was ordered of the abdomen as a splenic infarction was suspected. Later that evening the patient was found out of bed with his oxygen mask still insitu but disconnected from the oxygen outlet, why was he trying to get out of bed?, Why was the tubing disconnected was he disoriented due to high oxygen saturations, did he fall out of bed ?, did the tubing need replacing ? This was not documented in the patients notes just handed over to night staff verbally. Patient safety, documentation, team communication strategies.

Early Day 9 The night duty staff stated they did not monitor oxygen saturation due to patients request, staff should have explained how important it is for the nursing staff to monitor his oxygen levels, the patient was buzzing several times during night for a urine bottle and to check his oxygen levels, staff gave the patient a urine bottle but left the curtain open, did the patient get up to close the curtains for privacy?. The patient was found on the floor ten minutes later in cardiac arrest, Cardiopulmonary Resuscitation (CPR) was commenced, the arrest team was called and resuscitation continues for 20 and ceased with authority from the respiratory physician. Policy and procedures, Patient safety.

First event was that the patient was not placed in ICU as requested by nursing staff. (Patient advocacy) ANMC Competency Standards (2006) Professional practice 1.2 clarifies responsibility for aspects of care with other members of the health care team, recognizes the responsibility to prevent harm. 2.4 Identifies when resources are insufficient to meet care needs of individuals/groups. 2.5 raises concerns about inappropriate delegation with the appropriate registered nurse.

The patient has been transferred to the ward after arrangements were made by his GP for admission to hospital following an illness of unknown origin. Tests reveal that the patient has.

Bilateral pneumonia.

Neutropenia.

Thrombocytopenia.

Upon presentation it was noted that the patient’s saturations where low and required 6L oxygen via a Hudson mask and the new graduate registered nurse felt this patient needed to be placed in ICU to receive appropriate care. The newly graduate nurse should have consulted with the with the unit manger about her concerns when the Respiratory Physician refused to place the patient in the ICU this is related to 1.2 of the competency standards by clarifying her concerns and recognizing to preventing of harm to the patient. Patient advocacy is not new to nurses, nurses assume they have an ethical obligation to advocate for their patients (Negarandeh et al 2006). Advocacy can be defined as the act of arguing in favor of something. In terms of nursing, advocacy can be seen as the process we engage in when we speak on behalf of our patients when they are incapable of doing so themselves (Spenceley et al 2006). Advocacy has been described in ethical and legal frameworks and, more recently, as a philosophical foundation for practice (Negarandeh et al 2006). It has also been described in terms of specific actions such as helping the patient to obtain needed healthcare, defending the patient’s rights, assuring quality of care, and serving as a liaison between the patient and medical officer (ANMC 2005,Code of Ethics), (Spenceley et al 2006). When nurses and new graduate nurses advocate for patients, they face certain risks and barriers associated with the settings within which they work (Negarandeh et al 2006). Therefore, there is always the possibility that attempts to advocate for a patient can fail, and that nurses can experience many barriers when addressing choices, the rights, or welfare of their patients (Negarandeh et al 2006). As a new graduate nurse this was an important event to advocate for their patient as it was quite evident that this patient needed extensive nursing care that is not available in the ward situation, the nurse needed to gather evidence to support their concerns and present it to the Physician and nurse unit manager (Spenceley et al 2006).

The second event was why did the patient not attend the requested CT scan (negligence, communication). ANMC Competency Standards (2006) Provision and Coordination of Care 7.1 Effectively manages the nursing care of individuals/groups. It is the registered nurses responsibility to make sure that all tests and orders by the medical officer are carried out. The registered nurse could be seen to be negligent of her duty by not making sure the patient had received his CT scan according to the treatment plan.

The legal definition of negligence means breach of duty. Standards of care in nursing generally mean those practices that “a reasonably average nurse would use.” So a good nurse knows and understands ethics in the medical field and strives to provide excellent quality of care in order to avoid negligence. However, mistakes, which will happen, do not necessarily mean negligence has occurred (Staunton & Chiarella 2008). Examples of breach of duty, which may be considered negligent under certain circumstances may include “doing something which a reasonably average person would not do, or the failure to do something which a reasonably average person would do, under circumstances similar to those shown by the evidence. It is the failure to use ordinary or reasonable care,” (Staunton & Chiarella 2008). Inadequate nursing skills or attention to tasks may result in a suit of negligence against a nurse who habitually fails to provide approved standards of care. Such incidents include, but are not limited to, constant medication errors, failure to follow policy or orders and improper use of equipment (Hughes 2008). The legal review of a nursing negligence requires proof that injury was done, and that it was the result of the nurse’s care or lack of. Negligence refers to the act of doing something or refraining from doing something that any other reasonable medical professional would do or refrain from doing in a similar situation (Staunton & Chiarella 2008). It goes without saying that every situation is different, and that is where the law becomes somewhat cloudy. However, when reviewing a nursing negligence case, assumptions and circumstantial evidence are taken into account to determine if there was negligence (Staunton & Chiarella 2008). There are five main elements in a nursing negligence, and all elements must be proven in order for a case to be valid. If one or more of the elements is not present, the case may be hard to prove, (1) the nurse had a duty to perform, (2) the appropriate care was apparent in the situation, (3) there was a breach or violation of care, (4) there was an injury proven to result from the nurse’s negligence, and (5) there is proof that damages occurred as a direct result of the situation (Staunton & Chiarella 2008).

New graduate nurse should know and practice the professional code of conduct for nurses in Australia, this standard cover all standards by the ANMC (ANMC 2005, Code of Professional Conduct for Nurses in Australia).

The third event was why was there no documentation on the patient’s incident on the 13th February day 8. (Legal documentation, communication) ANMC Competency Standards. Collaborative and Therapeutic Practice 10.1 Recognizes that the membership and roles of health care teams and service providers will vary depending on an individual/group needs and health care setting, 10.2 Communicates nursing assessments and decisions to the interdisciplinary health care team and other relevant service providers. Professional Practice 1.1 Complies with relevant legislation affecting nursing practice and health care.

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In today’s health care system, delivery processes involve numerous patient handovers among multidisciplinary team members with varying levels of educational and training (Hughes 2008). Changes to the nursing models of care have resulted in alteration to communications between health professionals for example patient allocation, all patient care remains the nurses responsibility, in team nursing the responsibility is shifted to the team manager (Fernandez et al 2010). During the course of a 3-day hospital stay, a patient may interact with 30 different employees, including physicians, nurses, technicians, and others (Hughes 2008). Effective clinical practice involves many instances where critical information must be accurately communicated, patient handovers, medication orders, follow up tests are some exapmles (Hughes 2008). When health care professionals are not communicating effectively, patient safety is at risk for several reasons: lack of critical information, misinterpretation of information, unclear orders over the telephone, and overlooked changes in status (Hughes 2008). The transfer of essential information and the responsibility for care of the patient from one health care professional to another is an important component of communication in health care (Hughes 2008).

Introduction, Situation, Background, Assessment, Recommend (ISBAR) is good effective communication tool for handovers (Jacques et al 2009).An effective handover supports the transition of critical information and continuity of care and treatment (Hughes 2008). Ineffective communication is a leading cause of preventable patient injuries, wrong medication events and patient death (Fernandez et al 2010). Documentation is a legal requirement to nursing, it must show the patient’s condition, decisions made about nursing care, objective observation of patient and any events that have taken place during that nurses shift and documented as events occur (Jefferies et al 2009). Nursing documentation must comply with the legal requirements such as it must be legibly written, identify the patient, 24hr clock used to identify when the report was written, signed with name and designation, incorrect entries must have a single line through them and initialed next to entry with written in error, do not make entries for other nurses, use only approved abbreviations and leave no blank lines between entries (Jefferies et al 2009, p. 121). As a new graduate nurse it is extremely important to document all events that occur during your shift, it is also important as an experienced nurse. New graduates should always back up their decisions and document why they managed the patient care that way using evidence base practice and policy and procedures of the facility.

What the writer has learnt for their future practice is always document everything that is factual and relevant information as soon as possible, this is a legal requirement of nursing and if you need to go to court you will be able to defend yourself with full comprehensive nursing documentation. Documentation is a hard copy of the patient’s events and the whole multidisciplinary team can read them and there will be no confusion, misinterpretation. Advocating for patients is important as with this case if the nurse had advocated for the patient he may have had a better chance at survival and received the extensive nursing care he needed. If you are not happy with a result go further to resolve the situation to ensure a safe outcome for your patient. Do not operate outside your scope of practice this could lead to breach of duty of care and negligence, nursing today is considered to be a professional occupation and knowing the competency standards and follow policy and procedure is an expectation. Becoming a registered nurse is a huge responsibility, it is one that the writer will embrace and except whole heartedly. This is just the beginning and the writer is looking forward to the very exciting future and helping people thought difficult and challenging times of their lives.

Conclusion

There were many important events and communication errors thought out the patients care. The three main issues identified by the writer where patient advocacy, negligence of care, communication/documentation. Patient advocacy is an important role for nurses. New graduate nurses need to develop these skills and seek out assistance from more experienced nurses to help advocate with them. There are many issue with negligence and sometime hard to prove, but if the new graduate nurse follows policy and producers and the ANMC competency standards they should have confidence in their practice as a newly qualified registered nurse. Documentation is a requirement both legal and professional in nursing, accurate, comprehensive nursing documentation has the relevant information for all multidisciplinary members to comprehend. Communication with all members of staff can be difficult as there as many health care professional with varying levels of educational and training. Ineffective communication is a leading cause of preventable patient injuries, wrong medication events and patient death. This case study has displayed the importance of these events and has assisted the writer for future practice.

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