Ally is a 17 year old female with a two year history

Ally is a 17 year old female with a two year history of Crohn’s Disease, and currently studying Year 12. Ally arrived for admission to the Day Surgery Unit (DSU) at Lakewood Drive Medical Centre for a routine colonoscopy and biopsy scheduled for theatre at approximately 10.00 hrs.

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Ally was admitted to the DSU by the registered nurse (RN), Sharon. The consent was checked as part of the procedure, and Sharon noted that consent had been given by Ally’s father for colonoscopy and biopsy. Ally’s vital signs were recorded as: temperature: 37.2; pulse: 70 bpm; respirations: 16bpm; and blood pressure 110/75 mmHg.

Ally was transferred to theatre for the procedure at midday because an emergency surgical case earlier in the morning caused a significant delay for all elective procedures. Following the colonoscopy, Ally returned to the DSU ward at 1400hrs. Her condition was haemodynamically stable and she was fully conscious although complaining of mild abdominal pain (pain score 3/10). She also said she felt she was ‘leaking slightly’ from the bowel and thought it might be some diarrhoea. Routine (half hourly) observations were commenced.

The shift was chaotic due to the earlier disruption to the surgical list, and at 1450 hrs, Sharon realised that Ally’s observations were behind schedule. She quickly took Ally’s pulse and noted it was slightly tachycardic. She estimated the pulse rate as 108 and also noted some tachypnoea but did not chart this observation. Ally’s blood pressure was slightly lower than on admission at 90/50 mmHg and the abdominal pain had increased (pain score 7/10). She also stated she felt slightly light headed but Sharon suggested it was probably due to the fasting and bowel preparation (liquids only for 24 hours).