Case Study: Mrs Nguyen
Mrs Nguyen has been on the ward for 5 days. After being admitted with falls for investigation. You cared for her on her first day and then had 4 days off. Today she is allocated to you again. You read her notes and check her charts and recall that her blood pressure has been unstable and that her antihypertensive medication was ceased on the chart by the medical officer on her admission day. You check the vital signs and note BP has varied between 80/60 and 130/86. You note on the drug chart that despite the diltiazem being ceased on day 1 it has been given every day since. Two ANUMs have signed for this medication as well as 2 other RNs who work on the ward. One of the ANUMs is in charge today. What will you do to manage all aspects of this situation?
As the nurse responsible for Mrs Nguyen’s care, you have a duty to ensure that her care is safe and appropriate. In this situation, you have identified a potential issue with her medication management and her unstable blood pressure. To manage all aspects of this situation, you should take the following steps:
- Verify the accuracy of the information: Review the medication chart and blood pressure recordings to ensure that your observations are accurate. Confirm with the other RNs who administered the medication that they were aware of the cessation order for diltiazem.
- Notify the ANUM in charge: Inform the ANUM in charge of the situation and provide them with the relevant information. Seek their support and guidance on how to proceed.
- Notify the medical officer: Inform the medical officer responsible for Mrs Nguyen’s care of the situation and ask for their advice on how to manage her medication and blood pressure.
- Monitor Mrs Nguyen closely: Check Mrs Nguyen’s blood pressure regularly and document your findings. Report any significant changes to the medical officer or ANUM.
- Stop administering the medication: If the medical officer confirms that the diltiazem should be ceased, inform the other RNs that they should not administer it anymore.
- Document the incident: Record the details of the situation in Mrs Nguyen’s medical notes, including your actions, the response of the ANUM and medical officer, and any other relevant information.
- Follow up: Follow up with Mrs Nguyen’s care plan to ensure that it is appropriate, and monitor her blood pressure and symptoms closely. Report any concerns to the medical officer or ANUM in charge.
Overall, it’s important to communicate clearly and seek guidance and support from the ANUM and medical officer in charge. Documenting the incident and following up with Mrs Nguyen’s care plan can help prevent similar incidents from occurring in the future.