Assessment 2: Nursing Case Study - Professional Conduct Review

This case study analyzes a clinical incident involving an 81-year-old patient admitted to a rural hospital with shortness of breath, ultimately leading to the patient's death from septicaemia. The assessment requires an evaluation of the professional conduct of the registered nurse (RN) John, focusing on his actions and decisions throughout the patient's deteriorating condition. The analysis involves addressing specific questions: the events of the incident, the required immediate actions, the impact of professional behaviors, and the lessons learned for personal professional preparedness. Students must support their responses by referencing the National Safety and Quality Health Service Standards and NMBA professional practice documents. The case highlights critical failures in patient assessment, timely intervention, and communication, emphasizing the importance of adherence to professional standards and the potential consequences of inadequate care. The student is required to critically reflect on the case, applying clinical reasoning to identify areas where the nurse's actions deviated from expected practice and how those deviations contributed to the patient's adverse outcome.

The aim of this assessment is to develop your understanding when evaluating the
professional conduct of a nurse/midwife in a case study provided. The case study is a
shortened version of a decision statement selected from Decisions of the Professional
Standards Committee from the Nursing and Midwifery Council New South Wales,
featuring a clinical incident. This assessment also develops individual skills for critical
reflection and the application of clinical reasoning in practical situations.
Details
Students are to draw on the National Safety and Quality Health Service Standards and
the NMBA professional practice documents to develop critical responses to the clinical
incident. The following questions are required to be answered for this assessment:
1. What happened in this clinical incident?
2. What activities did the nurse or midwife need to complete in the immediate situation?
3. What professional behaviours may have made a difference in this situation?
4. What do you learn from this case study about your own preparedness for professional
practice?
Support your answers with reference to the relevant clinical and professional standards
that apply to professional practice.
Assessment 2
Nursing Case Study On 5 January 2013, Patient A, who was 81 years old, presented to a GP
clinic complaining of two nights of breathlessness when lying flat and shortness of breath. On
examination, Patient A was found to have fine creps at the base of both lungs and slightly
elevated jugular venous pressure. Her renal function was normal. She was commenced on
oral Lasix and was recommended to have a clinical review two days later. On 6 January
2013, Patient A attended a local (rural) hospital again with shortness of breath. Patient A was
admitted to hospital as the oral Lasix had not improved her symptoms. On 9 January 2013,
Patient A reported dizziness. This coincided with an atrial fibrillation (AF) rate of 120/ min.
The VMO was called to review Patient A. Patient A was refusing food and liquid at this time
and was complaining of feeling very weak and having abdominal pain. At 0830 hours on 10
January 2013, the VMO again assessed Patient A. He concluded that Patient A was depressed
and anxious. He encouraged nursing staff to mobilise Patient A. The nursing notes that follow
the VMO attendance refer to discharge planning at 1021 hours, and then, at 1315 hours,
comment that Patient A felt unwell, had refused breakfast and lunch, had no energy and
required encouragement to mobilise. Patient A's respiratory rate was recorded as 28-30/
minute, but other vital signs were within normal limits. At 1820 hours, the progress notes
state that Patient A refused to tolerate her dinner. At 1910 hours, Patient A was observed to
have a respiratory rate of 40/min and she was tachycardic at 122/min. At 1930 hours, Patient
A was documented as feeling "woozy", her skin was cold and clammy and she was
complaining of severe back pain. Her BSL was 16.1mmmol/I. An ECG was conducted,
which showed a heart rate of 168/min. The VMO was again called. He stated that Patient A
should be administered Digoxin and Valium. At 2110 hours, showing Patient A's respiratory
rate was still at 40/min. At 0530 hours on 11 January 2013, nursing notes state that Patient A
was unable to void, was pale and grey, and had clammy skin and nausea. At 0830 hours on
11 January 2013, the VMO assessed Patient A and wrote "?Significant medical illness". An
abdominal x ray and pathology were ordered. The VMO returned at 1330 hours and noted
that Patient A "won't/ can't mobilise [because of] pain in back and abdo" and that her white
cell count had risen to 17.5, despite an absence of fever. A urinary tract infection was
subsequently diagnosed and intravenous antibiotics were commenced at approximately 1430
hours. Registered Nurse (RN) John* commenced his afternoon shift as the nurse in charge at
1430 hours on 11 January 2013. He read Patient A's progress notes at approximately 1445
hours. RN John was immediately concerned about Patient A's condition. At approximately
1720 hours, Patient A reported to nursing staff that she was feeling dizzy and had abdominal
pain (8/10). She was observed to have a respiratory rate of 40-44/min, very low blood

pressure of 89/53 and a heart rate of 88. Shortly before 1810 hours, RN John was advised of
Patient A's condition by an enrolled nurse. RN John said he would have Patient A reviewed
once the locum arrived. At around 1810 hours, Patient A had continual diarrhoea. RN John
again stated that Patient A would be reviewed when the locum arrived. RN John did assess
Patient A, but did not document the observations. At approximately 1910 hours, RN John
arranged for a further ECG to be undertaken for Patient A. 401021 Assessment 2 – Nursing
Case Study At approximately 2020 hours, RN John telephoned the Clinical Nurse Manager,
Ms Sophie Smith*, to arrange for medication to be obtained from the drug safe (for a patient
other than Patient A). At approximately 2030 hours, Ms Smith attended the hospital and
signed for the medication. RN John did not raise any issues concerning Patient A with Ms
Smith at this time. At approximately 2100 hours, RN John and another registered nurse
completed an ISBAR (Introduction Situation Background Assessment Recommendation)
form. In that form, the respondent described Patient A as "deteriorating", and recommended
that Patient A's condition be reviewed "ASAP''. He also stated that Patient A's family had
been contacted. The VMO, arrived at 2200 hours. By this time, Patient A was critically
unwell. The emergency on-call doctor, Dr Aboud*, arrived at approximately 2300 hours and
inserted a large bore IV cannula to treat Patient A's severe dehydration. Over the course of
the night, attempts were made to transport Patient A to referral hospital. The ability to
transfer Patient A was significantly complicated by Patient A's critical condition. Tragically,
Patient A died whilst she was being assessed by the air evacuation team the following
morning. The primary cause of death was stated to be septicaemia *All names have been
changed in this case study to provide confidentiality Citation: HCCC v Heather Conyard
[2015] NSWNMPSC 3