Appendix N. 1: A Case Study

Introduction:

The scenario included in Appendix n.1 shows multiple errors consequently leading to a patient’s deterioration. There was poor communication and record-keeping leading to an incomplete Early Warning Score Chart (EWS) and Fluid Balance Chart, and lack of practical knowledge and skills of the nursing staff in recognizing signs of deterioration of the patient. Furthermore, there is failure to understand the life-saving importance of intravenous antibiotics and the necessity of intravenous access in the case of emergency in acutely ill patients, and failure of the regular review of the patient by the nurses and doctors alike. Identified as the primary issue is the lack of communication and secondary problem an incomplete fluid
A fluctuation in fluid volume of just 5-10 % can have an adverse effect on health (Sheppard et al, 2006). Scales and Pilsworth (2008) identified three elements for assessing fluid balance and hydration status: clinical assessment, review of fluid balance charts and review of blood chemistry.

The physical symptoms of fluid imbalance as present in Appendix n.2 are part of the clinical assessment and should be never omitted when drawing a picture of overall patient hydration status. McMillen (2011) described the fluid balance chart as a record of a patient’s fluid input and output in 24 hours (Appendix n.1.4, 1.5 and 1.6). Critically ill patients cannot maintain normal water and electrolyte balance due to stress and inflammatory responses, so hourly fluid input and output monitoring is absolutely essential in recognizing fluid balance disturbances (Leach, 2009). Patients falling into the group having fluid balance charts in place are consequently patients who are at risk of dehydration. More than one reason for the importance of the fluid balance chart has been indicated in our case scenario. These were Mr. Albert having intravenous fluids in place because of being ‘nil by mouth’ due to unclear cause of his abdominal pain
In addition, staff shortages, and service redesigns introduced in the face of budgetary pressures, are putting nurses under immense strain (Sprinks, 2012). It is therefore important to clarify why the fluid balance chart was started in the first place, and in which patients it is beneficial to continue. Everybody should be aware of these patients’ fluid charts and the reasons behind them (Scales et al, 2008). A large proportion of a healthcare professional's daily workload in hospital is devoted to documentation, and nurses can spend a considerable amount of time in recording fluid charts, but doctors seldom look at them due to the inaccurate estimation of the measurements (Chung et al., 2002). The accuracy of fluid intake and output recording is not a new issue. Boylan and Brown (1985) stated that fluid charts were poorly and inaccurately maintained. Eleven years later, Armstrong-Easther (1996) believed that fluid balance charts were the least accurate of all charts. Are the fluid balance charts necessary then? Some researchers go so far as to suggest that it is not possible to assess a patient's hydration state by using a fluid balance chart because of insensible water loss that cannot be measured (Chung et al, 2002), but if that were the case, they should have been perhaps banned years ago. The reason, why they are still important even at the present time, is more likely due to the fact that altered vital signs