Nursing Episode of Care: Mr. X in Emergency Department

This assignment focuses on a patient named Mr. X who was admitted to the emergency department following loss of consciousness. It discusses the nursing standards and practices followed during his care.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Outline of the episode of care
During my professional placement in the emergency unit, I got a chance to get
involved in numerous events of care. But for the purpose of writing this assignment, I would
like to focus on a patient named Mr. X who was admitted to the emergency department (ED)
following loss of conscious or black out during the morning when he was about to leave the
bed to go to the bathroom. He was 79 years old and used to live in nursing home. Upon
admission in the ED, he was complaining about chest pain along with dizziness and nausea.
His extremely high blood pressure (170bpm) has led to his hospital admission through the
South Australia Ambulance Service (SAAS). Patient has a past medical history of hyper-
tension, angina, type 2 diabetes mellitus (T2DM) ischemic stroke, depression and dysphagia.
Upon admission in the ED, he was diagnosed with supraventrivular trachycardia. Upon his
admission to the ED, his vital signs were measured and doctors reported that he was suffering
from spraventricular tachycardia. The medication management use for Mr. X include
administration of adenosine ( for spraventricular tachycardia management) with rapid bolus
and metoprolol (blood pressure management) and aspirin for control of pain. Glasgow coma
scale (GCS) and ECG was used to ascertain the condition of the patients’ and the level of
patients’ progress. Decrease of the troponin level at the normal range was followed by
patients’ released with discharge report.
Standard 1
According to the standard 1 for the Nursing and Midwifery Board of Australia
(NMBA), it is the duty of a nursing professional to think critically and analyse the required
nursing practices in relation to the care plan of the patient or clinical priority identified to
the patient. According to NMBA, a registered nurse (RN) must employ a variety of critical
thinking strategies while relating with the best available evidences for the effective decision

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making process. This helps in procuring safe and quality nursing practice with person-centred
care plan. The NMBA recommends critically accessing, analysing and monitoring the
patients in order to understand the clinical priority. The identification of the clinical priority
helps to improve the overall quality of care. The first sub-class (1.1) of standard one is safe
practice. Thus in order to abide by the safe practice guidelines, I first performed the hand
hygiene before giving treatment to the patient. This practice coincides with the standard 3 of
the National Safety and Quality Health Service Standards (2012), Preventing and Controlling
Healthcare Associated Infections. Proper use of the hand hygiene by the nursing professional
helps to control chances of hospital acquired infection and thus helping to procure safe
nursing care (Luangasanatip et al., 2017). Seventh sub-class (1.7) highlights that it is the duty
of the nursing professional to maintain accurate, comprehensive and timely documentation in
order to aid proper planning and the decision makes process (NMBA, 2016). Thus, before the
installation of the defibrillator for treating Mr. X for his sudden cardiac arrest, I performed
the ECG and recorded a detailed documentation of the his vital signs. Novosad (2016) stated
that proper documentation of the vital signs of the patients like the respiratory rate, blood
pressure, oxygen saturation, flow of oxygen, pain score, pulse rate and body temperature is
important to order to access the cardio-vascular health of the patients. This proper
documentation of the vital signs of the patients helps to improve the overall quality of care
and increase the provision for the person-centred care plan. 1.4 sub-class states that nurses
must abide by the prevailing healthcare policies thus when I was asked to administered 300
mg aspirin by the physician, I followed eight rights of medication as per the South Australia
health legislation (SA health). Since I was a student at that time, I went through the policy
thoroughly and then implemented it accordingly by taking help from my mentor nurse.

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Standard 2
As per the standard 2 of NMBA professional code of conduct (2017), a nurse must
engage in a therapeutic relationship and professional relationship with the student. When I
first meet the patient, I introduced myself politely to the patient. As per the sub-class 2.2, it is
the duty of the nursing professional to communicate effectively with the patients by
maintaining patients’ dignity and keeping respect to the cultural and spiritual values of the
patients. Thus before initiation of the medication of aspirin for the pain management, I
enquired Mr. X about any previous reported cases of allergy. MacLean et al. (2017) are of the
opinion that the use of the effective communication skills by a nursing professionals helps in
the initiation of quality interaction and thereby helping in the development of the therapeutic
relationships. This effective communication with Mr. X in a polite tone helped me to
understand his status of allergy. This in turn helped me to increase the participation of
patients in the therapy. As per the Australian Government Department of Health, Therapeutic
Goods Administration, (2019) in the prime component of the medicine is written over the
label of the medicine. Thus before the administration of the medication, it is the duty of the
healthcare professional to enquire about the allergy sate of the concerned patient and tally the
same with the label of the medicine that is required to be administered. Giving patients’
knowledge importance is a reflection that I am recognizing my patients as experts and
valuing their experience in life and this is what being told by the sub-class, 2.3. Sub-class 2.6
states that as per the professional standards, it the duty of the nurses to make proper use of the
delegation, supervision, co-ordination followed by proper consultation and standard referrals
in their professional relationships in order to improve the outcome of care. As I was trainee
then, I was not authorized for referrals however, I ensured effective co-ordination my
working under supervision of my mentor and taking her opinion in order to handle the

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patients. I also conducted detailed supervision of the patients based on the vital signs and
reported the same to my mentor or the attending doctor.
Standard 3
As per the Standard 3 of NMBA (2017) professional code of conduct, a nurse must
always maintain the capability of practice. This signifies effective self-care of the nurses,
both mental and physical health in order to make themselves compatible to withstand the
pressure of the nursing profession. Sorenson et al. (2016) stated that a nurse who is physically
fit and is mentally strong is more like to recover from the compassion fatigue and burnout,
one of the important occupational treats in nursing. Overcoming compassion fatigue and
professional burnout helps to improve the level of patients’ safety by reducing the chances of
the medication error, fall injury and hospital acquired infection (Hamilton, Tran & Jamieson,
2016). During my placement in the emergency department, as a student, I initially
experienced fatigue ad stress as there were constant flow of patients in the hospital and
majority of them have critical condition. In order to keep myself rejuvenated, I used to
conduct yoga and to read books. This helped to reduce my chances of developing compassion
fatigue. While caring for Mr. X, I never made a medication error or documentation error. I
have all my concentration in work while on duty and regular practice of yoga helped me to
overcome my stress factor. As per the sub-class 3.3, it is the duty of the nursing professional
to employ a lifelong learning approach in order to promote continuous professional
development of self and others. During my placement, I always kept my eyes and ears open
so that I can learn the nature of work done under actual workplace settings. This help to
promote by professional development like improvement in the effective communication
skills. I also learnt from my seniors the importance of the clinical hand-over. ACSQHC
(2012) stated that clinical handover (standard 6) helps to avoid the chances of medication

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error. In case of Mr. X who was suffering from supraventricular trachycardia, the main mode
of treatment is medication management. Thus, proper use of the clinical handover will be was
helpful in avoiding the chances of medication error.
Standard 4
As per the standard 4 of NAMBE (2017), a nurse must comprehensive conducts all
the assessments. During my care process to Mr. X, I comprehensively conducted all the
required assessment in order to ascertain the health condition of Mr. X. The sub-class, 4.2
states that a nurse must conducts all the assessment by using proper assessment techniques in
order to collect all the relevant data systematically and accurately. The first assessment tool
used by me is pain assessment by the use of the pain assessment tool. Schofield & Abdulla,
(2018) are of the opinion that the proper assessment of the severity of the pain can be done
with a combination of different pain assessment tool. Mainly the nursing professional, make
use of the self-reported questionnaire in order to access the level of pain of the patients.
Another assessment method used by me during the course of treatment of Mr. X is the use of
the GCS (Glasgow Com Scale). It is the most common assessment tool. It is used for
detecting the level of consciousness for the patients who has encountered traumatic brain
injury. Mr. X lost consciousness while waking up from bed and going to bathroom, at the
time of ED admission, he was complaining about nausea and thus detection of the level of
consciousness was important. The report of GCS was 15 out of 15 thus indicating complete
sense of brain and no possible signs of brain injury (Reith et al., 2015). Numerous repetitive
assessment of heart was done by the use of ECG. ECG was important for Mr. X as he was
suffering from supraventricular tachycardia with high BP. Repetitive conduction of ECG
helped to ensure that the Central Venous Catheter Care was working properly with proper
distribution of the medications injected to Mr. X. Improvement in the EGC scale helped to

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identify the signs of improvement. NSW Agency for Clinical Innovation (2017) stated that
for conscious patients, a nurse must abide proper assessment of the Central Venous Catheter
with the help of the central venous access device in order to ensure the level of patients’
safety.
Standard 5
According to the NMBA (2017), professional code of conduct, it is the duty of the
nursing professional to develop proper nursing plan. Ulin et al. (2016) stated that
development of the nursing plan for the patient population must be done in a patient centered
manner by proper identification of the patients’ priority in order to improve the overall
outcome of care while improving the level of patients’ safety. A thorough treatment plan of a
patient is important at the time of patient’s release. Continue ECG upon the administration of
the medication like the troponin, aspirin helped to improve the health condition of the patient.
When Mr. X was responding well for the treatment, the concerned doctor said that there is no
need to the further cardiac follow-up or troponin or ECG test as his cardiac parameters have
improved upon administration of adenosine. Katzung (2017) stated that adenosine must be
injected through rapid bolus and is an important medication of supraventricular tachycardia.
The treatment plan indicated administration of metroprolol at a range of 25 mg twice daily
followed by visit to the doctor after a certain interval and request for further medication if any
further complications rise in the future. Troponin test was dis-continued. Sub-class 5.5 stated
that it is the duty of the nursing professional to conduct proper documentation while making
proper evaluation and modifications in the treatment planning against the agreed outcomes.
Thus following his recovery (as per the ECG reports), and stable concentration of troponin in
blood, further troponin test is discontinued. Metroprolol is continued as it an important
medication of blood pressure and Mr. X had previous reported cases of high blood pressure

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(Katzung, 2017). The discharge planning however, failed to highlight any special diabetic
assessment protocol or toll and continuation of diabetic diet as Mr, X has previous reported
cases of T2DM and thus it can be considered as an error.
Standard 6
It is the duty of the nursing professional to provide safe, appropriate and quality
nursing care to the healthcare service user. In order to provide safe and appropriate yet
quality nursing care, I abided by the eight rights of medication according to South Australia
health legislation (SA health) (2019). The eight rights for ensuring medication safety as per
the South Australian Guidelines include giving medication to the right person, giving right
medication to right person. The administration of the right medication must be done under
proper dosage, route and time. This will be followed by the documentation of the patients’
information like vital statistics upon administration of medication. Documentation also
include medicines that are already been charged. I documented all the patient’s details in a
periodic manner in order to ensure standardized documentation of the patient’s, information
as per standard 6. The documentation helps to ensure the 7th and the 8th right of medication
safety of South Australian (SA) government that is right reason and right response. I always
practice within my scope of practice (6.2) and also practiced in accordance to the prevailing
nursing standards, regulation and safety guidelines. Proper documentation of the patients’
information will help to improve the proper medication safety (Standard 4 of ACSQHC,
2012) and making or proper clinical handover (Standard 6 of ACSQHC, 2012). Hart et al.
(2015) stated that proper documentation of the medication related information as per the 8
different rights of patients’ safety help to avoid the chances of medication error and thereby
helping to improve the overall quality of care. I also abided by the proper hand hygiene
protocol before the initiation of the each treatment. This further helped to improve the

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patients’ safety by reducing the chances of getting affected with the hospital-acquired
infections. Hospital acquired infection like the surgical site infection (in case it will be
Central Venous Catheter for ventilation Mr. X), wound infection, ventilation associated
infection and catheter associated infection. Decrease in the chances of the hospital acquired
infection by the use of WHO’s five step of hand hygiene helps to improve patients’ safety
(Hart et al., 2015). However, in this particular case, apart from my self-initiative of getting
knowledge about the patients’ allergic symptoms, my supervisor nurses failed to guide me
with the relevant process for the risk assessment of the therapy given to Mr. X. However, use
of the adenosine and metoprolol are evidence-based practice for the treatment of
Supraventricular tachycardia (Katzung, 2017).
Standard 7
The last standard of the nursing professional code of conduct by the NMBA include
evaluation of the outcome in order to inform the nursing practice. As per the 7.1, it is the duty
of the nurses to evaluate and monitor the progress towards the expected goals and health-
related outcomes of the patient. In case of Mr. X, the main goal was to reduce the blood
pressure and the blood troponin level. In order to understand why the goal of care of Mr. X is
designed in such a way, I studied the basic pathology to increase by professional standards.
This reading helped me to understand that supraventricular tachycardia is defined as a
condition where the heart rhythm increases abnormally (Madias & Link, 2017). It mainly
occurs from improper electrical activity occurring in the upper part of the heart. This problem
in the heart rhythm leads to increased blood pressure and the same is evident in Mr. X. When
a person has a heart attack, the level of cardiac troponin increases abnormally within blood
(Schultz et al., 2016). Thus, using troponin as a marker for patients’ recovery is justified. As
per the 7.3 sub-class, it is the duty of the nursing professional to determine, document and

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communicates the priorities of the patients’ care, followed by goals and outcomes with
relevant person (NMBA, 2017). Here the relevant person is the doctor, who after checking
the troponin levels and the ECG report recommended the commencement of the metoprolol
25 mg stat and ruled out the requirement of the troponin test. The vital reports also showed
normal parameters like Respiratory Rate (RR)=20, Oxygen saturation=99%, Oxygen flow
rate=1 Litre oxygen through patient awake and responding, pain score = 5 out of 10.Nasal
specs , Blood pressure= 108/65mmHg, Pulse Rate= 143bpm, Temperature=36.8, sedation=
Nil. The follow-up request mentioned in the discharge is a sign of encouragement of the
patients to seek proper healthcare access at the time of need.

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Part 2
Cognitive Continuum theory as DMT
Decision making theory (DMT) is an important skills or an ability of the nursing
professionals that helps to increase the level of patients’ safety and quality of care (Johansen
& O'brien, 2016). During caring for the patient, Mr. X in the clinical placement in the ED, I
applied cognitive continuum theory. It is an amalgamation of intuitive and critical analysis
where the theoretical decision-making is used in the decision making process (Parker-Tomlin
et al., 2017). Intuition means quick action as directed by the sub-conscious mind and is driven
by experience in this kind of similar situation. The critical analysis is done with the help of
the evidence-based practice. My use of intuition and critical analysis is reflected when I
followed by basic hand hygiene protocol while going to check Mr. X in the ED and
introducing myself before the initiation of the treatment. As per my understanding, a basic
introductory conversation is the first stage for the therapeutic relationship.
Moreover, while I was asked to administer aspirin for the pain management of the
patient, I asked the patient about any previous reported cases of medication allergy. My
critical thinking skills inherited from my academic studies in nursing about the roles of the
nurses in ensuring patients’ safety. I also followed the eight rights of medication as per the
guidelines stated by the South Australia health legislation (SA health). This citation of the
legislative medication guidelines by the government was done from both critical thinking
skills and intuition.
The strength of this theory is that is ensures less degree of error my promoting clinical
judgment. One of the limitation of this theory is it is a slow process and it some cases, few

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stages are hard like finding the best evidence-based practice for that particular case (Parker-
Tomlin et al., 2017).
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