CASE STUDY FOR ROSA
Rosa Case Study – Part 1
It is day shift on a 38 bed acute medical unit of a general hospital. A new admission arrives at 10:30; the patient is Rosa, a 58 year old, Spanish speaking only woman with a cc: “Something poisonous splashed on my ankles and I can’t stop scratching.”
The Emergency Room nurse’s handoff communication report included that the patient has been scratching at her legs constantly, Benadryl 50 mg. IM has been administered with little relief. There appeared to be no obvious dermatological problem, skin was free from any potential cause for the itch. The patient also seemed anxious; we gave her Ativan 5 po. Her son reported that she has been acting “strange” for approximately a week. She has a medical history of diabetes, hypertension, and cardiac disease. A review of the list of current medications for this patient included: Clonidine, Glucorol and Protonix and Xanax, the son said she ran out of the Xanax about a week ago.
You approach the patient at her bedside when she sits up, appearing startled, loudly and seemingly angrily speaks a succession of Spanish words and begins to pull at her IV tubing and her urinary catheter, the patient is clearly anxious and agitated. A nurse’s aide nearby is called in to “sit” as a constant observer with the patient while you leave to call the physician. Haldol 5 mgs and Ativan 2 mgs are ordered for the patient’s anxiety, an order to maintain the constant observer is obtained. The patient’s blood pressure and pulse are elevated and her respirations are rapid and shallow.
The patient continues to disrupt her catheter and IV lines, an EKG was ordered but the patient was uncooperative and she would not stay in bed. The physician was told and he ordered the patient to be restrained. The RN applies a soft waist belt conscientiously avoiding the most restrictive device.
Rosa Case Study – Part 2
The patient’s condition seems to get worse, she is thrashing about in the bed, the constant observer who is with her and does speak Spanish tells the nurse that she is not making any sense nor does she seem calmed by any of her words. The nurse calls the physician again, asking for the patient to be seen stat and when she returns to the room the patient has gotten out of her roll belt, pulled her IV line out and is striking out at the constant observer. The nurse immediately calls for a Code, and she and the constant observer attempt to hold the patients arms, using crisis communication in a soft gentle voice. The code call is responded to within moments, 2 nurses from other units and 2 nursing aides respond along with a security officer. The patient is out of bed, agitated, threatening, kicking and throwing punches towards the staff. The nursing staff works together as a team; the patient’s nurse indicates that she will be the team leader. While continuing to calm the patient verbally, the nurse directs the team with her body language and a few verbal commands to contain the patient, place her gently but firmly in a supine position on the bed and applies wrist and ankle restraints which were brought to the room by the security officer.
Summary table of elements to be addressed in the face-to-face assessment
Element / Detail1. Physical risks of loss of life
2. Physical dangers and discomforts
3. Psychological status and mental status
4. Legal and ethical considerations
Assessment Guide for Rosa – Key Element #1: Physical risks of loss of life
Name of Client: Rosa
Date and Time:
Element / Component / Assessment / Action/comment1. Physical risks of loss of life
a) Asphyxia
b) Agitated delirium
c) Cardiac failure
OTHER
Assessment Guide for Rosa – Key Element #2: Physical dangers and discomforts
2. Physical dangers and discomforts / Component / Assessment / Action/commenta) Positioning
b) Restraints
c) Clothing/bedclothes
d) Obesity
e) Nerve damage
f) Head Trauma
g) Pressure ulcers
h) Medical problems
i) Vital signs
j) Review medical record
k) Lab tests
l) Environment (seclusion)
m) Safety hazards
OTHER / Self inflicted wounds
Assessment Guide for Rosa – Key Element #3: Psychological status and mental status
3.Psychological status and mental status / Component / Assessment / Action/commenta) Situation leading to restraint
b) Psychological state
c) Psychiatric condition
d) Current symptoms
e) Reaction to restraint
f) Review medical record
g) Consider termination of restraint
h) Staff safety
i) Discuss event with staff
j) Assess stability of client
k) Debrief client
l) Client expectations regarding behavior
m) Need for ongoing restraint and assessment
OTHER / History of sexual abuse
Assessment Guide for Rosa – Key Element #4: Legal and ethical considerations
4. Legal and ethical considerations / Component / Assessment / Action/commentOTHER
Completion of the Assessment Guide
Summary: Rosa
Recommendation: Rosa
Signature of RN: X