I was looking after Mr Jackson (pseudonym), a 76-year-old man, who was 2 days post-op following a right hip replacement. As I entered Mr Jackson’s room to take his 10 a.m. observations I noticed that he was restless [5.2 Uses a range of assessment techniques to collect relevant and accurate data]and when I spoke to him he did not seem to comprehend my questions, replying inappropriately. I did not recall his confusion being reported at handover. I introduced myself to Mr Jackson and his wife [9.1 Establishes therapeutic relationships that are goal directed]and asked whether Mr Jackson had been confused before his hospital admission [5.2 Uses a range of assessment techniques to collect relevant and accurate data]. His wife replied that she had never seen him like this before.

I reassured her and explained [9.2 Communicates effectively with individuals/groups to facilitate provision of care]that I would take his observations and then consult the RN [Registered Nurse]I was working with [7.3 Prioritises workload based on the individual’s/group’s needs, acuity and optimal time for intervention]. I realised that this situation was beyond my scope of practice [2.5 Understands and practises within own scope of practice].

I started to consider some of the possible causes for Mr Jackson’s confusion. I wondered whether he was in pain but he did not reply when I asked about his pain. I thought that he might have been hypoxic, and when I took his SaO2 it was 88 per cent and his respiratory rate 28. His BP [blood pressure]was elevated compared to his pre-op BP; his pulse was rapid, full and bounding. He was afebrile. I checked that his IV [intravenous]was running and his catheter draining. I also checked the wound dressing, which was dry and intact [5.2 Uses a range of assessment techniques to collect relevant and accurate data; 7.1 Effectively manages the nursing care of individual/groups].

I then documented my observations [1.1 Complies with relevant legislation and common law]. I reassured Mr Jackson and his wife that I would consult with the RN and return [9.2 Communicates effectively with individual/groups to facilitate provision of care]. I put the bed rails up [9.5 Facilitates a physical, psychosocial, cultural and spiritual environment that promotes individual/group safety and security]before I left the room, as I was concerned for Mr Jackson’s safety. I discussed my observations and concerns with the RN [2.5 Understands and practises within own scope of practice; 10.2 Communicates nursing assessment and decisions to the interdisciplinary healthcare team and other relevant service providers]who immediately returned with me to review Mr Jackson.

The RN asked Mr Jackson to point to anywhere it hurt and he touched his head. She checked the IV rate and found that it was running at 125 mL/h. When the RN compared the rate to the fluid orders chart, she found it was meant to be running at 84 mL/h. She calculated that the catheter had drained less than 40 mL in 4 hours. The RN asked Mr Jackson’s wife if he was normally so puffy around his eyes and she replied that he wasn’t. She listened to his chest with a stethoscope and rechecked his SaO2, this time with an ear probe as his hands were cold, which could give inaccurate results. The RN explained to Mr Jackson and his wife what she was doing and said that she would phone the doctor immediately.

Outside the room the RN explained to me that she suspected hypervolaemia, renal impairment and possibly electrolyte imbalance and that she was concerned that Mr Jackson would develop pulmonary oedema if he were not treated quickly. She thanked me for bringing Mr Jackson’s cognitive impairment and abnormal observations to her attention. Review by the doctor and follow-up pathology tests later confirmed the RN’s preliminary nursing diagnosis.

I feel that I undertook a good but very general assessment of Mr Jackson. However, I realised after watching the RN that I need to develop more focused and comprehensive assessment skills [4.4 Uses appropriate strategies to manage own responses to the professional work environment]. I also believe that a deeper knowledge base would allow me to analyse and interpret abnormal observations more accurately. In particular, I need an understanding of the potential causes of confusion in elderly patients, and skills and knowledge related to fluid status assessment so that I can provide a better standard of care to my patients [3.1 Identifies the relevance of research to improving individual/group health outcomes]. It was inspiring to observe a RN who had the experience and knowledge to thoroughly and efficiently assess Mr Jackson and establish an accurate nursing diagnosis.