NRS387 - Accurate and Timely Support Case Scenario: Eligh

Scenario Overview

Patient: Eligh, 14-year-old male
Event: High-impact motorbike accident on a rural trail
Initial Presentation:

• Severe left-sided chest pain

• Difficulty breathing

• Bruising across the left chest wall

• Diagnosed with pneumothorax and rib fractures (left 4th and 5th)

Immediate Actions Taken:

• Trauma alert issued, ATS Category 2

• Chest tube (ICC) inserted with 10cm H₂O suction

• Patient monitored for oscillation, air entry, and drainage

• Administered patient-controlled analgesia (PCA) – 1 mg morphine/5 min lockout

Vital Signs Timeline & Progress

Monday, 1730 – Emergency Department

• HR: 110 bpm | RR: 24 | SpO₂: 98% (2L NP)

• BP: 110/66 mmHg | Temp: 36.8°C | Pain: 6/10

• Drain Output: 0 mL | Air Entry: L < R>Surgical Emphysema: No

Monday, 2215 – Paediatric Ward Admission

• HR: 108 bpm | RR: 24 | SpO₂: 98% (2L NP)

• Pain: 3/10 | Drain Output: 0 mL

• Parents present and actively involved in care

Tuesday, 0735 – Deterioration Begins

• Parents raise concern about discomfort and restlessness

• Pain managed with regular analgesics

• PCA usage noted to increase

Tuesday, 0753 – Neurological & Respiratory Decline

• GCS: 13 (E3, V4, M6) – indicates mild confusion

• HR: 135 bpm | RR: 32 | SpO₂: 94% (2L NP)

• Increased work of breathing, accessory muscle use

• Surgical Emphysema: Yes | Oscillation: Absent

• Air Entry: Still reduced on left side | Drain Output: 0 mL

Clinical Red Flags

• Absent oscillation: Indicates potential chest tube blockage or lung collapse

• Surgical emphysema development

• Increased PCA use + grimacing = Inadequate pain control

• Neurological changes (↓ GCS) = Possible hypoxia or opioid side effects

• Elevated RR and HR = Physiological distress

Recommended Nursing Focus Areas

• Close monitoring of chest tube function

• Reassessment of analgesic strategy (PCA effectiveness)

• Continuous GCS monitoring

• Escalate care immediately if deterioration continues

• Support and reassure distressed family members