Mrs Ballard Case Study - Electro Convulsive Therapy - Nursing Assignment Help

Assignment Task :

1. Introduction and cause of death 

1.1. Mrs Ballard was a 76 year old lady who was admitted to Glenside Hospital in November 2008 with Alzheimer’s dementia. She died on 2 January 2009 at Glenside Hospital. An autopsy was carried out by Drs Dodd and Chia who found the cause of death to be aspiration of gastro-intestinal contents as a result of small bowel obstruction due to small bowel torsion1, and I so find. It should be noted that Mrs Ballard was not detained at the time of her death and, accordingly, this was not a death in custody within the meaning of the Coroners Act 2003. 

2. Background 

2.1. Mrs Ballard had a past history of major depression requiring electro-convulsive therapy and she had been admitted on a number of times to various hospitals over the 3 years prior to her death. In the weeks prior to her death she was experiencing 1 See Exhibit C1a hallucinations which were difficult to control and a number of alterations in her medication were made towards the end of 2008 in an effort to address these symptoms. 

3. The circumstances leading to Mrs Ballard’s death 

3.1. On 1 January 2009 at approximately midnight, Mrs Ballard was found unconscious on the floor by her bed. She was examined by the duty doctor, Dr Buenviaje, who noted that she was hypotensive and clammy. She complained of right-sided abdominal pain and, after discussions with the emergency registrar at the Royal Adelaide Hospital, Dr Buenviaje transferred Mrs Ballard to the Royal Adelaide Hospital for assessment. Dr Buenviaje prepared a transfer letter stating that his impression was: 'Unconscious collapse, ? vaso vagal syncope, ?TIA, ?MI' 

3.2. Mrs Ballard arrived in the Emergency Department at 0141 hours and was triaged as a category 3. Her observations were recorded as BP 116/85, pulse 65, respiratory rate 18, temperature 36.2° and GCS 14, in that she was confused as to time and place. The triage nurse recorded that she had a soft abdomen with no pain. At this time an ECG was recorded that showed normal sinus rhythm with no acute changes. At 0307 hours she was reviewed by Dr Peter Bruce who was a resident medical officer and an emergency medicine trainee in the Emergency Department. 

3.3. Dr Bruce later recorded that2 Mrs Ballard was able to give a ‘clear history’ of feeling light headed and weak immediately prior to collapsing. During the fall she did not hit her head or sustain any other injuries. She denied any chest pain or shortness of breath and had no headache or neck stiffness. In the preceding 48 hours she told Dr Bruce that she had experienced some diahorrea and vomiting but no abdominal pain. She had not received any analgesia or antiemetics during this time and her regular laxatives had continued to be administered. 

3.4. Dr Bruce noted her past medical history to include Alzheimer’s dementia, hypothyroidism and hearing impairment. He noted her regular medications were listed as sorbitol, sodium valproate, venlafaxine, temazepam, quetiapine, stelazine, oxazepam, thyroxine, ostelin and coloxyl with senna. 

3.5. On examination Dr Bruce found that Mrs Ballard had heart sounds I and II with no audible murmurs. Her chest had good air entry bilaterally with no added sounds, her abdomen was not distended and was soft and non tender with normal bowel sounds. 2 Exhibit C14a 

The power in all four of her limbs was 5/5 with normal sensation and normal reflexes and cranial nerves II to XII were clinically intact. 

3.6. Intravenous access with a cannula was obtained and blood tests taken. These blood tests returned the following results: 

'Haemoglobin, white cell count and platelets within normal ranges; sodium 130 and chloride 95 both slightly below normal limits but with remaining electrolytes within the normal ranges; bicarbonate and anion gap within normal limits; normal liver function tests. Troponin at 3hrs post collapse was negative.' 3 

3.7. Dr Bruce said that his impression after taking a history and examining Mrs Ballard was that the transient bradycardia and hypotension recorded following her collapse, in the context of a normal ECG and essentially normal blood tests, were consistent with a vaso vagal syncopal episode. He said that he thought her recent symptoms of diarrhoea and vomiting without abdominal pain or distension were consistent with gastroenteritis and were likely to have resulted in mild dehydration and hypovolaemia which may have potentiated the vaso vagal collapse. 

3.8. Dr Bruce directed that she be given two litres of intravenous normal saline over the next 2 hours to rehydrate her. He directed that she be given an antiemetic in the form of 2mg of tropesitron IV and to resolve any vomiting associated gastritis, she was given 40mg IV pantoprazole. 

3.9. Mrs Ballard remained in the Emergency Department for 4 hours following her admission and did not complain of any abdominal pain and did not vomit. She was connected to an alarmed monitor that recorded ECG output, oxygen saturations and blood pressure and all of these remained within normal limits. Dr Bruce returned to review her and she stated that her light headedness had resolved and that she felt much improved. Mrs Ballard wished to use the commode to urinate and Dr Bruce assisted a nurse with her mobilisation which he reported as being satisfactory. 

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