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Name- Connor
Age- 68 years old
Illness- AKI

To protect patient confidentiality in line with the NMC Code (NMC, 2018), the patients name has been changed. Connor lives in a caravan with his girlfriend, he is a 68 year old male who is alcohol dependent and has a history with drug abuse. He was found in his caravan after having a fall 3 days ago. Connor was brought in to A&E via ambulance and appears to be extremely confused, dehydrated and has a temperate of 39.1C. Connor appeared to be easily agitated on arrival. Vital signs showed Connor to be hypertensive and have a blood pressure of 100 over 64. Connor expressed on entry that he cannot remember the last time he had passed urine.

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Connor came in to A&E with symptoms of an AKI, throughout the case study there will be discussions on therapeutic relationships and the importance of them with our patients and their families, there will be demonstrations of evidence base that is required to care and support patients with acute health conditions. There will also be examples of a variety of health assessments and points of care and the positive risk taking that goes with these and the legal and ethical issues when delivery care for adults with health difficulties.

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LO1- Discuss therapeutic relationships that places adults at the centre of their own decision making wherever possible

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LO1- Discuss therapeutic relationships that places adults at the centre of their own decision making wherever possible

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To promote patient involvement in treatment decisions, shared decision-making (SDM) models have been created in recent years (Joosten, 2008) this helps with creating those therapeutic relationships. Creating therapeutic relationships with patients and family members is vital in the health care setting, It's essential to establish solid therapeutic relationships with patients in order to deliver effective therapy. This has long been recognised as an important component of nursing. Delivering good person centred care is becoming more and more challenging due to a number of difficulties in clinical practise. For patients, families, carers, and nurses to have a pleasant experience receiving care, it is essential to recognise and address these issues (Feo et al, 2017). A therapeutic nurse-patient relationship must be positive and marked by mutual respect and trust in order to deliver individualised care. (Kaur, 2020). Having that therapeutic relationship also helps with shared decision making the patient put trust in their clinician, shared decision-making should assist people in making decisions that are best for them. Through a collaborative process, a clinician collaborates with a patient to assist them in determining their course of therapy (NHS, 2019). The patient-clinician interaction has evolved into more of a partnership or collaboration in recent years (Charles Et al 1999), Clinicians now treat patients more from a "we" perspective rather than a "me" perspective (Fuertes et al, 2007), which then helps develop that patient clinician relationship. The three key components of shared decision-making: recognising and admitting the need for a decision, being aware of and comprehending the best available data, and taking into account the patient's beliefs and preferences (Légaré & Witteman, 2013).

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LO2- Demonstrate the evidence base required to care for and support adults with acute health conditions

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LO2- Demonstrate the evidence base required to care for and support adults with acute health conditions

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Patient-centred teamwork in nursing is focused on shared goals among nurses. The idea draws on the unique skills and attributes of each nursing team member in order to provide excellent, efficient nursing care and to support positive healthcare outcomes for all patients (Faubion, 2022). Evidence-based practise utilises the best available data, clinical knowledge, patient values, and environmental considerations when making judgements regarding patients and clients, practises, and health policy..(American Physical Therapy Association, 2020).

Connor came in to A&E after being found at home after having a fall with long lie, he was found to be severely dehydrated which then caused low blood pressure and high heart rate, and a high temperature. To report the findings the nurse bleeped the doctor and handed over the patient through a system called SBAR. Information may be accurately shared between people because to the straightforward nature of SBAR (NHS, England, 2021). SBAR stands for Situation, Background, Assessment and Recommendation. Situation is to explain what is going on, Background is to deliver a basic history of the patient, Assessment is to describe the findings and Recommendations is for what needs to happen next.
In Connors case his SBAR would look like this-
S- Suspected AKI, severely dehydrated, low blood pressure, high heart rate and high temperature, scoring 6 on NEWS2 chart
B- Patient known to be alcohol dependent and history of drug abuse. Patient came in with fall with long lie, confusion and agitation.
A- NEWS 6, blood pressure 100/64, heart rate 112, and temp 39.1C
R- Prescribe 500ml bolus 0.9% sodium chloride, IV paracetamol, and take bloods U+E, CRP and full blood count to see if any infection and if AKI is present.
Using the most recent research, patient-centered care techniques are developed and supported to promote evidence-based practise in nursing. This makes it easier to build a questioning strategy that incorporates the beneficence, non-maleficence, autonomy, and justice tenets of healthcare ethics (Nursing Times, 2011).

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(Clinical Digital Resource Collaboration, 2023)

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LO3- Examine a range of health assessment strategies and tools in order to apply them in relevant adult practise settings

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LO3- Examine a range of health assessment strategies and tools in order to apply them in relevant adult practise settings

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When a patient presents in the emergency department it is vital for the nurse looking after the patient to complete an A-E assessment, this is made up of five different assessments these include airway, breathing, circulation, disability and exposure (Resuscitation Council UK, 2021). An untreated airway obstruction can cause hypoxia and can cause damage to multiple organs including the kidneys which would cause more issues for Connor and his ongoing AKI. Hypoxia is a condition where there is not enough oxygen present in the tissues to sustain proper homeostasis (Bhutta et al, 2022). A simply way to see if the patients airways are obstructed are to simply get them to talk, in Connors case his airways were clear and there appeared to be no obstruction. Other signs of airway obstruction can be indicated by breath sounds or lack of and abdominal movements (Resuscitation Council UK, 2021).
The next step would be to check Connors breathing, this would be done by checking his chest movements to see if they are uneven and listening to the sounds for example wheezing and crackles, at this point the oxygen saturations were also taken, Connor had oxygen levels of 96%, therefore didn't warrant oxygen being put in place as the normal oxygen saturation levels are between 95% and 100%.
The third step of the A-E assessment would be to check circulation, this is done by checking Connors capillary refill time and heart rate. Connors heart rate was raised on arrival was 112, which would score him a NEWS of 2. Connors BP was also extremely low, and was 100 over 64, which would also score him a 2 on the NEWS chart, this then helps explains the high heart rate, when a patients blood pressure falls the heart rate increases and the blood vessels in other regions of the body contract to try and help maintain the blood pressure (British Heart Foundation, 2020). Connor came in to A&E extremely dehydrated, this will have caused him to have low blood pressure, 500ml bolus of sodium chloride was prescribed to Connor in order to help his fluid intake, this was given via intravenous access.
The fourth step in the A-E assessment is disability, here the nurse looking after Connor checked his GCS, which stands for Glasgow Coma Scale. GCS assesses three things, these are eye opening, the scores are between 1-4, 1 being that the patient doesn't open their eyes at all and 4 being that the patient opens their eyes spontaneously, then there is verbal response to a command, 1 means no response and 5 is if the patient is talking and alert, and the final assessment is voluntary movements in response to a command, again 1 means the patient is unresponsive and 6 means the patient is able to follow commands (NHS, 2018). Connor was in fact scoring full marks of 15 for his GCS, and no concerns were raised during this time.
The final stage of the A-E is exposure, here the nurse took Connors temperate and due to the AKI his temp was 39.2C, paracetamol was prescribed and also given through IV, meaning that two canula sites were needed.

On arrival in to A&E Connor had his observations taken by one of the health care assistants, he was scoring for a low blood pressure of 100 over 64, a heart rate of 112 and a temperature of 39.1C, these means Connor was scoring a 6 on the NEWS2 chart. The NEWS is built on a simple aggregate scoring system, where physiological data collected when patients arrive at or are being followed in a hospital are given a score. Six fundamental physiological signs form the basis of the scoring system. (Royal College of Physicians, 2017).  These indicators are-
1. Respiration rate
2. Oxygen saturations
3. Systolic blood pressure
4. Pulse rate
5. level of consciousness or new confusion
6. Temperature
With Connor scoring a 6 on the NEWS2 chart the guidelines state that his score needs to be escalated to the nurse and medial team looking after him and placed on hourly observations. In the box at the top is an example of of the physiological indicators and what they would score on. To help with Connors low blood pressure and heart rate a 500ml bolus of 0/9% sodium chloride was prescribed to help with his fluid intake and dehydration. He was also prescribed and given IV paracetamol to help with his dehydration.

Connors fluid in put and out put was also being monitored whilst on A&E and he had passed very little urine for a prolonged period of time, this could be because he was dehydrated or gone in to bladder retention due to the AKI. The doctor ordered a bladder scan and if the bladder held more than 400ml of urine then the nurse had the go ahead to catheterise. If possible the nurse will have taken a urine sample to test for any infection before placing the catheter, it is important to check for this in case there is an infection there is a risk that placing a catheter could push the infection further up towards the kidneys which can create even more damage especially when Connor has an AKI.

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LO4- Apply the principles of risk assessment and management that reflect positive risk taking in adult care

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LO4- Apply the principles of risk assessment and management that reflect positive risk taking in adult care

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Risk assessments are part of the process of risk management which aim to identify analyse and evaluate risks that may have a negative impact on the safety and quality of care given to each patient (Kaya, Ward, Clarkson 2019). Risk management is recognising the situations and opportunities that put patients at risk of damage and then taking steps to mitigate or control those risks (WHO, 2008).

The dilemma of what to do when a potentially non-autonomous patient tries to depart or is observed to have left the ED regularly confronts emergency physicians. The MCA 2005 or MHA 1983 may allow for the detention of these non-autonomous patients if they pose a risk to themselves or others. 1 These patients might be psychotic, suicidal, delirious, or inebriated, for instance (Royal College of Emergency Medicine, 2020). Connor is at risk of absconding due to his confusion, agitation and alcohol withdrawal, the health care team have a duty to uphold once every patient is booked in, this means active risk management for any problem is required.

Whilst Connor was threatening to leave, to prevent this risk from him getting any worse, the nurse and medical team looking after him assessed him whilst attempting to defuse the situation, talking with Connor about why he wanted to leave, and quickly determining the patient's autonomy and capacity, whilst this is happening the nurse and medical team are creating that therapeutic relationship with Connor, to allow him to put his trust in the health care staff. Due to Connors confusion and agitation an MCA was put in place. The purpose of the Mental Capacity Act (MCA) is to safeguard and empower individuals who may not have the mental capacity to make their own decisions regarding their care and treatment (NHS, 2021)

Positive risk taking is vital in the health care sector, and staff are constantly weighing up the pros and cons. Making preparations and executing measures to support the service user's stated positive potentials and priorities while minimising risks to the service user or others is referred to as positive risk taking (Great Britain, Department of Health, 2009, P.10). The Department of Health also describe positive risk taking as 'risk management that improves the service user's quality of life and plans for recovery, while remaining aware of the safety needs of the service user, their carer and the public (Department of Health, 2009, P.9).

In Connors case he was given two cannulas in order to get him the fluids he needed to help with his dehydration and low blood pressure and paracetamol for his high temp, paracetamol could have been given orally, however is it proven to work faster through IV which Connor desperately needed to treat his high temp. The risks with cannulating Connor would be that it is a painful procedure to put him through and in line with the NMC code we are to cause no harm to our patients (NMC, 2018), however Connor desperately needed the fluids to help with his dehydration as his AKI was only going to get worse if not treated as soon as possible, and at this point it was in fact treatable. For cannulas there are risk assessments in place to make sure that the site of the cannula is healthy and to prevent any infection, this is called the Visual Infusion Phlebitis score also known as VIP score, this is done daily and scored between zero to five. Zero being that the IV site appears healthy and to remain for observation, 1 being that there is slight pain and redness at the IV site which can indicate the first possible signs of phlebitis and to observe the cannula. From 2-4 the symptoms go from early stages of phlebitis to finally number 5 which would be advanced stage of thrombophlebitis (VIP Score, 2022). This score chart is put in place for daily checks from the nurse and should prevent the canula from any harm if acted upon quickly. For each cannula site you would have a different VIP score chart. Attached at the top is an example of the VIP score.

To help diagnose the AKI, bloods would be taken through the canula, the blood waste creatinine is the most significant blood test to detect AKI. If the amount of this waste has doubled, kidney function has decreased by 50%, and AKI is present (National Kidney Federation, 2022). The bloods came back and confirmed an AKI present and it was staged at stage 1. Stage One is where the current creatinine is at least 1.5 times the baseline value or has increased by at least 26 m/L in the previous 48 hours (NICE, 2021). In response to this Connor will be moved to the medical assessment unit for repeat bloods of U+E in 5-7 days whilst continuing his fluids and IV paracetamol until the temperature comes down.

Connors AKI was caused by his alcohol/ drug in take and the fall with long lie, this all resulted in him being severely dehydrated which then caused damage to his kidneys.

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LO5- Consider the relevant legal, and ethical issues when delivering and evaluating care for adults with health and difficulties

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LO5- Consider the relevant legal, and ethical issues when delivering and evaluating care for adults with health and difficulties

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There are four major ethical principles in nursing, these are autonomy, beneficence, justice, and non-maleficence. Every patient has the freedom to make their own choices in accordance with their personal values and views, this is what we call Autonomy. The urge for autonomy by a patient may be at odds with the standards of care or recommendations that nurses or other healthcare professionals deem to be ideal (Haddad and Geiger, 2021).

A procedure known as intravenous cannulation involves inserting a small, flexible hollow tube with a retractable needle within a peripheral vein. This is the most often used invasive technique worldwide (Boyd, 2013). Connor required two cannulas in order to give him his fluids, and paracetamol through IV and take bloods from. The need for these cannulas were vital as the patient needed fluids urgently due to his server dehydration and needed to be given paracetamol through the most affective route to help bring his temperature down at a faster rate. In line with the NMC code section 4 (NMC, 2018) is to 'act in the best interests of people at all times', to achieve this 4.1 and 4.2 of the code must be completed. In regards to cannulation an informed consent should be acquired wherever possible. This will entail making sure that patients are aware of (Dougherty and Lister, 2015) the rationale behind cannula insertion, locations where it might be found, the dangers involved, potential complications, and information on the insertion process and aftercare. In Connors case he had an MCA put in place, however it is still vital to explain the steps and the process of the cannulation to help put him at ease, the therapeutic relationship the nurse had created with him also helped the process to go more smoothly as he trusted them fully. Cannulation would not complete non-maleficence as nurses must do no harm intentionally, nurses must deliver a level of care that minimises or avoids risk. Avoiding providing a patient with irresponsible treatment is one way that nurses can show this idea in action (Rosenburg, 2021). Cannulation unfortunately there are risks with cannulation and it can in fact cause pain to the patient.
An ethical principle that in this case the nurse would work in line with is beneficence, According to popular definitions, "beneficence" refers to acts of compassion, charitable giving, and active good promotion and with the patients best interest in mind (Munyaradzi, 2012). In regards to cannulating the patient the nurse had the patients best interest in mind as this was the only way they were able to provide Connor with emergency fluids, medication and take bloods. If a cannula was not in place bloods would still need to be taken however this could agitated him more if they were not able to get the bloods the first time.

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In conclusion throughout has been shown the important of therapeutic relationships with the health care team and how it influences a patients experience in hospital and their road to recovery, working as a team also helps this. Throughout has also been shown different health assessments that would be used in an A&E setting and the ethical assessments and positive risk taking behind these, and what sort of risk assessments and management would need to be in place to keep the patient from harm.

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