NURS3002 Advanced Decision Making and Practice

This assessment requires you to identify pertinent legislation and ethical issues using the attached case study. You are required to integrate theory, demonstrate analysis using evidence and include other pertinent literature to support your answers.

Case study:

Patient: Peter Marshall

32 year old DOB 31/01/1988

Admitted via ED yesterday morning at 07.00am.

ED Notes- Bought in by ambulance, following a fall off roof onto a concrete driveway. Peter grabbed the ladder to break his fall, but twisted his right shoulder awkwardly as he fell. No loss of consciousness, GCS 15 at scene and maintained throughout transfer to ED.

Complaints of pain to Right shoulder, ribs, and Right ankle. Pain score 9/10. Laceration to Right ankle - dressing soaked with blood on arrival to hospital. IV analgesia given en-route to hospital.

On arrival to ED, patient asked for his mother and father to be called to be informed of the situation but asked for them to be told to not attend the hospital. In ED primary and secondary surveys were performed. Results of Cervical, Thoracic and lumbar x-rays and MRI to Right Shoulder are as follows:

• High grade tear approximately 80% to rotator cuff tendon. Orthopaedic team consulted. Plan - theatre for Rotator cuff repair and acromial decompression. Postoperative swelling decreasing after approximately 5 days). Immobilisation sling and ice to shoulder help reduce swelling.

• Fractures to right ribs # 4,5,6 – no displacement noted. Plan - Conservative management, pain relief as required and rest in bed.
  
  
• Right Tibia and Fibula fractures. Orthopaedic team consulted. Plan – for Open reduction internal fixation (ORIF) of Right tibia and fibula fractures. Consent for theatre and blood transfusion if required obtained on Theatre consent form.

• HB – 103. Plan – repeat Hb in 24hrs. All other bloods noted as Nil abnormalities detected (NAD).
  
  
• IV ab’s commenced - QID Flucloxacillin 1g.

HDU notes:

Pt transferred to HDU at 11.30am. Admission paperwork completed – NOK noted as fiancée (David Rogers) who had arrived at ED after patient phoned him post-accident and accompanied patient to HDU. Patient did not identify as any religion. Theatre checklist completed and patient prepped for theatre. Parents arrived at HDU to see patient but patient already in theatre.

Patient returned from OT at 18.30pm post rotator cuff repair and acromial decompression and ORIF right Tibia/fibula fracture. Large blood loss noted in OT, blood pressure low (ranging between 89-102 systolic) post theatre. 1000mls fluid challenge ordered over 2 hrs when reviewed by Dr for ADDS score caused by low BP, modifications noted for BP.

Current situation:

You are caring for the below patient on this morning’s am shift.

Handover by RN- Pain has been hard to manage overnight, required review by Anaesthetist

– further IV and oral analgesia ordered. Given with good effect. Neurovascular status –some tingling noted in fingers of right hand (RN states that is from the nerve block used in theatre). NVS intact R leg, DP and PT pulses palpable. Right leg raised with pillows. Systolic BP remains low but within modifications. Bloods taken at 06.00am. Right arm remains immobilized in sling with ice to shoulder 15mins on/1 hour off (patient tolerating). Rib fractures are limiting patient’s movement in bed and pressure area care required every 2 hrs. Mother phoned overnight to check on patient – no information disclosed as not listed as next of kin (NOK), mother became upset and told nurse that patient should not be given any blood products as he is Jehovah’s Witness. RN questioned patient about the mother’s information and the patient stated that he no longer identifies with that religion and is estranged from his parents due to their beliefs. Fiancée arrived at 06.45am and is currently with the patient.

Following handover at 7.15am you introduce yourself to the patient he complains of intense pain in his right shoulder. Complains he is feeling short of breath and light headed and just generally ‘off’.

As you are about to take patient’s observations, the shift coordinator enters the room and informs you that the FBC is back and Haemoglobin is 78g/L. Consultant coming to review patient to gain consent for a blood transfusion. The coordinator also informs you that the patient’s mother and father are waiting at the nurse’s station. The patient immediately starts telling you that his parents are not to come into this room and especially when David (fiancée) is there. Whilst telling you this, the bedside monitor starts to alarm with a Sa02 of 92% on Room Air. David starts to comfort Peter who is now visibly upset. The alarm stops and Sa02 rises to 95%. Peter asks you to go and tell his parents to leave and not return until he requests them to do so.

You excuse yourself and go to the Nurses station where the shift coordinator introduces you to Peter’s parents. Immediately his mother informs you that Peter is going through a bit of a crisis and that he has left his faith (Jehovah’s Witness), moved out and become engaged to spite both his mother and father. She asks you to ensure that his religion is noted on his paperwork. She tells you that if he should receive any blood products then he will be ex-communicated by his family and they will never see him again. At this time you are called away by the coordinator as the consultant is here to review the patient. You try to excuse yourself from the patient’s parents and tell them that they are currently unable to see the patient. The mother ignores you and starts walking down the ward towards the patient’s room.