Nicolas Noble:

In your shift plan did you consider:

• As this patient has had a ? TIA it is important that the patient is assessed by speech pathology prior to any oral medications being given. In this case, a tablet with a small sip of water is still dangerous as it may result in aspiration of the tablet and water into the patient’s lungs. All medications that are oral should be administered after the sip test only
• the patient is charted for nebulisers – did you consider that this patient needs to have nebulisers given with air not oxygen at this patient is a CO2 retainer?
• has repeat CTB in 2 days been ordered? Confirm this has occurred
• frequency of vital signs – as this patient has recently had a neurological change this should be assessed 15minutely for an hour, then hourly for 12-24hours. This should be in combination with neurological assessments
• Physiotherapy referral and review prior to mobilisation in context of cognitive change
• Speech pathology referral in context of possible dysphagia from cerebral change. Ensure patient is NBM until this happens, ensure no diet is ordered in eMR and NBM sign visible/alert in eMR. Ensure patient is aware
• Respiratory assessment to consider possible aspiration when eating dinner last night (time of cognitive change). Patient should have at least daily respiratory assessments until aspiration risk is eliminated. Hourly deep breathing and coughing (patient can do this on their own, but RN needs to ensure it is being done)
• Referral to endocrinology team/diabetic review – hbA1c blood test
• Wash, shave, teeth brush, teds
• DVT risk – anticoagulation, early mobilisation with physiotherapy and hourly foot and ankle exercises. At least once per shift assessment of deep veins to ensure no DVT developing
• VIP score for P.IVC • Falls prevention strategies. This patient is moderate risk. What could you do to reduce risk of falls specifically for this patient?
• Stroke guidelines recommend the following blood tests be conducted: full blood count, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein and glucose. Which of these are done and which need to be ordered?
• Have you done the ECG requested?
• Pantoprazole should be reconsidered in context of renal history – flag this with the medical team
• NSAIDS are also not recommended for patients with renal impairment, however aspirin is recommended for patients with cardiac history (PVD and IHD). Aspirin is also recommended for stroke. Which would take priority for this patient? Should this be reviewed? Apsirin should be continued – we need to monitor renal function then so urine outputs should be measured and EUCs should be ordered for follow up during his admission
• Did you update the FBC?
• Patient’s blood pressure is high. This is not a CR or a RR but still needs to be addressed. If he cannot have his oral antihypertensives, we need to discuss this with the medical team and perhaps get a transdermal patch or sublingual option until his oral medications can resume

CASE 2:

Thi Minh Tran: In your shift plan did you consider:

• ongoing IPS
• vital signs on right arm with alert placed in notes and on patient armband of no BP and IV on left side do to nodal clearance (lymphoedema risk)
• vital signs hourly as patient has had acute deterioration from NH for at least 4 hours then 4/24 if no changes (though remains at risk of sepsis)
• Patient is hypotensive, and in CR zone so alert nursing team leader. Possibly will not need a CR as has IV fluid charted and IVABs, encourage oral intake of fluids to reduce dehydration. If pt BP does not improve or continues to decline then call CR. If you wish to call CR anyway that is also not wrong
• Serum lactate needs to be checked (as per sepsis guidelines)
• administration of charted medications, especially antibiotics at due time, withhold metoprolol due to low BP, withhold temazepam due to delirium (benzodiazepine contraindicated). First antibiotics should be commenced within 1 hour.
• IV fluid charted in context of low BP and low Urine output is less than the requirements of 30mls/kg as a bolus if that patients lactate level comes back elevated – this needs to be discussed with the medical team. Sepsis guidelines state that this patient needs a bolus of 1470mls if lactate is high.
• pain assessments with vitals (increase pain will increase delirium)
• Falls risk assessment and falls prevention strategies (patient is high falls risk) • transfer to room close to nurses station for closer supervision
• physiotherapy review and application of mobility aids recommended by physiotherapy
• 2nd hourly toileting due to high falls risk and IV hydration, urine output needs to be measured after IV bolus if BP is improved
• encouraging oral fluids with toilet rounds (not on the toilet, but after toileting is finished)
• suggest walk around the ward after toileting (at toileting rounds) to promote early mobilisation and decrease delirium (with assistance and supervision, after IV bolus if BP is improved)
• Delirium assessment (likely the CAM) at least once per shift (delirium is not confusion)
• dietician referral due to malnourishment, if patient not eating then oral assessment is indicated – is this patient in pain/have dental problems impairing mastication? Does speech pathology need to review patient eating?
• assistance with mealtimes to optimise dietary intake, starting a food chart • mouth care prior to bedtime
• skin care (high risk of pressure ulcers and tears due to age, malnutrition, dehydration) this should include repositioning the patient, ensuring not to dry, assessment and treatment of incontinence associated dermatitis
• FBC and measuring urine output due to risk of kidney injury from sepsis and dehydration
• activities to cognitive stimulate and interest the patient (reading, TV, chatting to people, doing puzzles/word games, in cases of dementia folding washing/towels, rolling bandages or other activities to interest the patient).
• Ensure CXR (already ordered) is attended and follow up results
• Many recent falls and fractures – suggest gerontology review, consider bone density scan for ? osteoporosis
• Patient should have admission ECG – also should have ECG for ? causation of previous falls and current delirium (though delirium is most likely due to UTI and urosepsis, this could also be a contributing factor)
• DVT risk – anticoagulation, early mobilisation with physiotherapy and hourly foot and ankle exercises. At least once per shift assessment of deep veins to ensure no DVT developing
• Wash or shower with assistance, particularly groin and vulva area due to urinary incontinence