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  • Subject Name : Nursing

Documentation and Care of The Deteriorating Patient

Airway obstruction

1.1, How would you recognize an airway obstruction a patient is experiencing is partial or complete?

When there is inability to talk, breath or cough, complete obstruction of upper airway happens. It is noted that cyanosis and apnea are present and paradoxical respiration may be present. When there is partial upper airway obstruction, it is termed as incomplete obstruction in which ability to breathe is continued. In this kind of airway obstruction, the patient is able to cough and breathe but there may be a noise of stridor when the air passes via a narrowed space (Sheldon, et al 2018). Generally, small foreign body is cleared by coughing but the breathing may be noisy, air can still pass and leave the lungs. 

1.2, How would you assess a patient’s airway?

For immediate assessment and treatment, the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is applicable.

Airway (A)

  • Examination of the mouth is done and obvious objects/dentures are removed.
  • Attention is paid to the stridor, gurgling, snoring which indicates airway compromise.

Breathing (B)

  • The cardiac arrest team is called if there is poor or absent respiratory effort
  • Chest expansion is observed (to ascertain that it is even between right and left)
  • Attention is paid to the entry of air into the lungs (to ascertain that it is even between right and left)
  • Percussion is performed where there is any concern, (to ensure that it is even between right and left- specifically if thinking of tension pneumothorax)

Circulation (C)

  • The cardiac arrest team is called if no pulse is found
  • Cyanosis, distended veins in the neck and pallor are observed
  • The rate and rhythm of a central pulse(carotid/femoral) is examined and capillary refill time is also checked

Disability (D)

  • AVPU is assessed and if there is time, also GCS.
  • Glucose is checked by pricking finger

Exposure (E)

  • Temperature is checked.
  • If the patient is hypothermic, he should be warmed.
  • The body including the groin and back is examined for rash or any injuries.
  • The patient is covered with a blanket and his dignity is respected.

This approach is useful for conducting an assessment of the patient suffering from airway obstruction and this allows for treatment procedures which helps in stabilizing the patient’s condition (Smith, & Bowden, 2017).

1.3, What are the causes of a compromised airway?

It can be due to a variety of causes which are bronchial secretions, blocked tracheostomy, pharyngeal swelling (e.g. oedema, infection), laryngospasm, epiglottis, foreign body (e.g. food, tooth), bronchospasm which leads to narrowing of the small airways in lungs.

1.4, How do you recognize a deteriorating patient?

The patient has to work harder and harder to exchange air due to the development of obstruction (Price, & Williams, 2020). As a result, exercise intolerance, dyspnea and noisy respiration are developed. But, a patient whose mental status is compromised may not be able to share that he is dyspneic or have difficulty in breathing. This makes it important that the clinical signs of developing obstruction are recognized.

1.5 What are the essential actions to be undertaken in managing a deteriorating patient?

The essential actions that have to be taken in the management of a deteriorating patient is discussed below:

To recognize a deteriorating patient, systematic assessment is essential and to decrease the incidence of further deterioration appropriate and timely action should be taken.

In identification of patients that are at the risk of becoming acutely sick, the ABCDE approach is applied so that appropriate assistance is called at the early stage.

The obtained physiological data should be reviewed by the practitioner for making an effective management plan and future investigations.

The obstruction of upper airway is a life threatening emergency which needs immediate attention. First step is to do the basics that is checking the air way of the patient. in a patient with altered consciousness, there is an obstruction due to the tongue lying close to the back wall of the oropharynx. So, the one of the following basic techniques are applied in all instances-

Head tilt-chin lift manoeuvre: one hand is placed on the patient’s forehead and the head is tilted backwards. The chin is lifted open the airway by using fingers on the pateint’s chin.

The Jaw thrust- for a patient with suspected C-spine injury, this is only option applicable. This is performed by moving the tongue forward with the help of mandible as it reduces the ability of tongue to obstruct the airway. The middle finger of the right hand is placed at the angle of the patients jaw on the right while standing at the head of the bed. The left hand’s middle finger is also placed like that on the right. The tongue will be lifted from the posterior pharynx when an upward pressure is applied to raise the mandible.

If the patient is still showing signs of incomplete or complete obstruction of airway, then this indicates that this manoeuvre is unsuccessful. Thus, the use of airway adjuncts should be the next step.

Airway Adjuncts

Depending on the assessment and background of the patient, there is a variety of airway adjuncts available to the healthcare workers-

  • To prevent the tongue from blocking the airway, oro-pharyngeal airways are used.
  • For semi-conscious patients who suffer from gag reflex and a variety of different circumstances, naso-pharyngeal airways are used.
  • An important device in the management of the difficult airway is a laryngeal mask which is a supraglottic airway device.
  • Another supraglottic airway device which is made up of medical grade thermoplastic elastomer is the Igel airway.
  • An orotracheal tube is placed under direct vision through the larynx into the trachea when endotracheal intubation is used which is a advanced airway procedure.

Clinical handovers

Question 2.1, Compare the two handovers and outline how you would structure the handover

In the two clinical handovers, the correct handover was done using systematic method. The patient was identified at first by using the code on the wrist band. The documents were prepared in a standard manner. There was verbal and face to face communication during the clinical handovers. The relevant history of the patient was discussed with the nurses. The observations for the vital signs of the patient were stated. At the end the healthcare professionals develop a care plan which was mutually agreed. The transfer of responsibility of the patient from one nurse to another occurred with acknowledgement of the patient as well (Mannix, Parry, & Roderick, 2017).

ISBAR (Introduction, Situation, Background, Assessment and Recommendation) format is utilised to structure the clinical handover. It consists of five elements which are focusing on a conversating in detail. This helps in focusing on the information and thereby eliminating the irrelevant information (Pang, 2017).

2.2 Complete the table below by using ISBAR outline the handover


RMO I am calling about a 76 year old patient


I am calling because he has become drowsy, rate of breathing has increased.

Heart rate- 65bpm to 100 bpm

Respiratory rate increased from 14 bpm to 22 bpm


This patient has been admitted three days ago due to pneumonia.


I think his pneumonia infection has deteriorated his condition. 95% oxygen has been given and saturation has been maintained via nasal 2L. patient is febrile at38OC and his BP has decreased to 90/60 from 110/60.


I would like you to monitor his fever and BP.

2.3, What is the recommended format for a clinical handover?

The recommended format for a clinical handover is the ISBAR format. This is used as it eliminates the unnecessary information and provides details of the patient in an objective manner. This helps in quick and effective decision making.

2.3, Outline the steps of a clinical handover.

When a handover is given, the nurse must ensure that

  • he/she has communicated with the patient and its carer.
  • It is essential that the receiving department and the clinician are prepared while accepting the patient and must be able to understand the estimated details and time of patient arrival.
  • Identification details of the patient should be confirmed and the patient should be assesses to make sure that he/she is stable and ready for a hanydover, tranyfers or discharge.
  • The documentbs required in the process should be updated and completed which includes updating progress reports and preparing handover forms. It also includes completion of any transfer or discharge forms related to the treating doctor, referrals, risk and prevention strategies, important events during admission, date of admission and diagnosis, discharge summary.

It is noteworthy that all the important documentation is kept with the patient.


3.1, Which criteria should nurse documentation fulfil?

The nurses are required to document the vital signs that assist in identification of the patient at risk and this is ‘between the flag’ observation chart. In chart there are different zones that are being standardized and this provides for specific calling criteria. This has to be notified by the nurses in the document.

3.2, The nurse recognizes that incorrect spelling in the patient’s records results in

Medical errors for instance incorrect spelling can lead to wrong identification of the patient or the symptoms or it can lead to administration of wrong medications and medical treatment.

3.3 What are the nurses legal and ethical obligations for the patient information obtained through examination, observation, conversation, or treatment?

The nurses have legal and ethical obligations for the information of the patient that is obtained through treatment, conversation, observation or examination. Confidentiality of the patient’s health data has to be maintained by the nurses all the time. The health information has only to be given to the healthcare professionals who are relevant in the healthcare of a patient.

What are the basic rules of documentation?

Good clinical documents are to be maintained by the nurses for improving their healhtcre delivery processes (Fencl, 2016). The basic rules of documentation are as follows-

  1. It should be factual which means that it contains descriptive and objective information provided by the nurse.
  2. It should be complete which means that it must have vital and appropriate information regarding the patient.
  3. It should have accurate data by employing exact measurements.
  4. The document is organized to communicate information in a logical order.
  5. The current condition of the patient should be mentioned in it.
  6. It should be in compliance with standards of NRMB registered nurse.

These rules ensure that right information is passed between the healthcare professionals and proper care is rendered at the required time.

References for COPD Diagnosis and Management

Fencl, J. L. (2016). Guideline implementation: patient information management. Aorn Journal104(6), 566-577.

Mannix, T., Parry, Y., & Roderick, A. (2017). Improving clinical handover in a paediatric ward: implications for nursing management. Journal of Nursing Management25(3), 215-222.

Pang, W. I. (2017). Promoting integrity of shift report by applying ISBAR principles among nursing students in clinical placement. In SHS Web of Conferences (Vol. 37, p. 01019). EDP Sciences.

Price, D., & Williams, N. (2020). Diagnosis and management of COPD: a case study. Nursing Times, 36-38.

Sheldon, G., Heaton, P. A., Palmer, S., & Paul, S. P. (2018). Nursing management of paediatric asthma in emergency departments. Emergency Nurse26(4).

Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard (2014+)32(14), 51.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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