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Essential Nursing Care: Managing the Deteriorating Patient

Introduction to Deteriorating Patient Scenario Critique

Deterioration in patients is a notable issue in care settings. Nursing care in the deteriorating patient helps to prevent, reduce, recognize and respond to clinical deterioration across the patient’s journey (Idrisu et al., 2018). A deteriorating patient who is clinically deteriorating without recognition is at high risk of care administration and high mortality and morbidity. ABCDE approach, i.e. Airway, breathing, circulation, disability, and exposure approach for deteriorating patient’s assessment, helps in responding and identifying the life-threatening condition. During ABCDE assessment, the patient’s most important signs are measured and recorded which enhances the recognition of deterioration and helps in optimising communication and escalating the deteriorating patients (Smith & Bowden, 2017). The patient in the given scenario is Mr John Kendrick who is 48 years of age and has met with an accident and is admitted to the hospital in a condition of clinical deterioration. He has sustained injuries on his chest, leg and abdomen on his right side along with difficulty in deep breathing. The patient has been observed with irregular pulse rate, high respiratory rate, and low blood pressure/flow. The content that will be included and explained in the given paper will be divided into three major approaches: recognition, escalation and management of the patient with clinical deterioration. First of all, the pathophysiological changes are recognised with the help of assessment and then the significant role of communication along with the applications of ISBAR clinical handover in escalating nursing care of the deteriorating patient followed by the management of the patient with consideration of ethical and legal aspects.

Question 1: Recognise

Recognition of pathophysiological changes is to be done first considering the life-threatening conditions. Mr Kendrick met with an accident has come in a clinical deteriorating condition. The patient is first diagnosed with primary survey i.e. with an ABCDE assessment. The assessment is done to identify the life-threatening condition, ensuring the opening of airways and adequate breathing and circulation. The patient has also shown worsening hypoxia during intubation despite the high flow of oxygen. By primary ABCDE assessment, it is shown that due to accident the patient has sustained injuries on chest, leg and abdomen; he has been detected with cervical injury due to which the cervical spine is protected with collar bones and supported by spine board. The patient’s leg has got splinted and is experiencing extreme pain and swelling and is suspected with a fracture. In terms of respiration, the patient is facing problem in taking deep breathing and intercostals recession, the primary reason for this recession and the respiratory issue is the sudden shock on the brainstem and spinal cord. According to Ikeda et al. (2017), the lower brainstem is responsible for the modulation in respiratory activities as well as the control of respiration. The reason is cervical and spine injury. Berlowitz, Wadsworth and Ross (2016) have suggested that spinal cord surgery is often subjected to respiratory impairment which is characterised by weakness in the respiratory muscle and low lung volume and it has also been mentioned in patient’s reports that there is reduced entry of air the right lung fields. This low lung volume is because of the pressure difference which is more in interstitial space that leads to the increase in pressure on the lungs and makes the airflow to the lungs difficult.

There is also alveolar collapse in Mr Kendrick’s lungs which makes the exchange of gases difficult and eventually raises the rate of respiration. The patient was also subjected to the chest injury which may also lead to difficulty in breathing. The circulatory system is affected as well, after the accident while doing ABCDE assessment it has been mentioned that the peripheries are cool, pale, diaphoretic, and thready and weak pulse with 4 seconds of capillary refill time which results in inadequate myocardial contractility and reduction in blood pressure and flow. According to MedicineNet (2020), high or low blood pressure leads to the fluctuation of pulse rate. In the given scenario, the patient is subjected to the low flow of blood which means the blood flow is too low to deliver the nutrients and oxygen to the essential organs of the body via veins and arteries. The flow of blood is determined by factors like the amount of blood pumped by the left ventricle into the arteries and resistance caused by the walls of the arterioles to the blood flow. Any type of injury and bleeding causes low blood pressure. As the patient is subjected to sustained injury on the chest and abdomen; it results in lowering the flow of blood. Blood pressure and pulse rate are inversely proportional to each other so, when the blood flow lowers it automatically tends to increase the pulse rate. When the patient was subjected to injury it made his circulatory system compromised which leads to the lowering of blood flow to 115/70 mmHg as the blood pressure decreased the heart tends to pump the blood at an increased rate which leads to increase the heart rate exponentially. On ECG, atrial fibrillation is shown which means irregular and quivering heartbeat which often refers to an arrhythmia that leads to blood clots, heart-related complications and strokes. Due to this injury on chest cavity during the accident, there is a chance of the formation of pleural edema which leads to the thready and weak pulses and draining lymph nodes during the accident (Clark & Soos, 2020).

In Mr Kendrick’s case, low blood pressure can also lead to edema and vasoconstriction. Thready and weak pulses have also been reported in the patient. Thready pulses are the fine network of pulses which looks like thread over the arteries of a person (Merriam Webster, 2020). The reason for thready and weak pulses is often the forceful heartbeat. Fast pulse rate leads to create a thready network of pulses over arteries (MedlinePlus, 2020). According to Hackett (2015), CRT i.e. capillary refill time helps in providing the information regarding the peripheral perfusion, assessing the patient’s blood volume and information about shock etiology with the help of conjugation with heart rate, the colour of mucous membrane and respiratory effort. Normal capillary refill time is 1-2 seconds following the normal blood perfusion and volume. The capillary refill time of the patient is observed to be 4 seconds. A capillary refill time more than 2 seconds refers to the poor perfusion due to the peripheral vasocontraction. This peripheral vasocontraction is the response to the low blood pressure of the patient and lesser oxygen delivery to the important tissues and organs.

Question 2: Escalate

Effective communication skill is considered to be the important aspect of the health care system and it directly increases the rapport with the client which led to better health status. Effective communication helps to improve the health care associates understanding concerning the issue faced by the patient (Vermeir et al., 2015). One of the communication tools that can be utilized to improve communication concerning patient health status is ISBAR. The method is considered to be a reliable communication tool that helps to improve the practice in the hospital (Shahid & Thomas, 2018).

Identity- the section includes different information regarding the nurse and patient concerning the first interaction of both of the individual (Shahid & Thomas, 2018). The nurse is the charge is Alicia who had interacted with the patient during administration. The patient name is Mr John and he is a 48 year he was administered to the emergency department due to his critical condition.

Situation- The situational aspect includes the reason for the escalation and it includes the current issue faced by the client (Shahid & Thomas, 2018). The reason behind the escalation in this case study includes patient blood loss in the chest and the hypovolemic state of the patient as he had met with an accident this morning.

Background: it should include the medical history and treatment procedures that are conducted are included concerning the patient condition (Shahid & Thomas, 2018). The patient has a medical history of atrial fibrillation that is managed by warfarin. In the emergency department, he had a chest drain inserted and during treatment, his blood pressure is decreasing and his heart rate was trending up. He was inserted with 16-gauge cannula followed by a litre of Hartman’s. The ABCDE assessment of the patient doesn’t reveal major fluctuation.

Assessment and action: this section involved the different assessment process concerning the patient current health status and identifying early warning sign (Shahid & Thomas, 2018). The nurse except to perform some blood test and evaluate the patient chest drains as they are the major concern for the patient.

Request: This section includes the different evaluation in which the nurse needs assistance and requires a senior supervisor to check upon the patient. The nurse has requested to the resident of the orthopaedic team to visit the patient to evaluate the chest drain and conduct the blood test. The weakness is the busy schedule of the resident that increase the need for the nurse to re escalate due to the critical condition of the patient

Question 3: Manage

In the given retrospective audit by Cignarella, Redley and Bucknall (2019), the authors aimed to explain characteristics of the patients who are suitable for their organ donation along with exploring the variables linked with the failure and success of the organ donations in the intensive care unit. The study offers insights into the organisational factors and the factors related to the patient and his family members that contribute to the success of the positive outcomes of organ donation. Apart from that, some more factors influence the success of organ donation. Firstly, on behalf of the patient, the family members did not consent to donation. In such case forcing family for giving their consent is not appropriate and will face some legal implications. Effective communication approach should be applied to manage this; while communicating with family, it should be the core duty of the nurse to explain the whole procedure, timings and outcome. Secondly, consent was given, but due to medical issues donation did not proceed. According to the Nova Scotia Health Ethics Network (2016), health ethics deals with considering the ethical issues in health and health care system. It includes the discussion regarding the treatment preferences and options of care services that the patient, his family and caregivers may face. The healthcare ethics addresses that the healthcare professional should have an objective stance instead of having only a subjective stance when dealing with the patients It ensures the positive and better outcomes of the health population by creating a relationship between patient and the health providers. It involves a critical, ethical, and political analysis of social determinants of health. The ethical issue that might be faced can be a critical examination of discrepancies in health status along with ethical consideration to achieve equity and access to health services and ensuring the appropriate ethical approach in health research.

The American Nurses Association (ANA) in 2016 has stated that the pillar of nursing is Advocacy; it is the key to advance nursing care. Nurses advocates for their patients, in their workplaces, and community; but advocacy based on legislative and political is no less crucial to patient care and enhancement and development of the patient. Role of nurse in such cases of organ donation is that the RNs are often the caregiver of the patient. The nurse facilitates the coping mechanism of patients and their family members. They address the process for organ donation by guiding and educating the donor families without doubt and heart-wrenching process. The nurses stay with the patients always and help the family to understand the organ donation process, which includes keeping the brain dead patient’s body functioning until the organ is been collected. Nurses should not be work on pre-assumed beliefs as it is seen that the personal perceptions of nurses affect the conversation with the family members regarding the organ donations.

The opportunities for the nurses in this scenario are the deep knowledge that nurse has got because of some of the aspects which include multiple questions regarding organ donation and the equity, access and advocacy of a nurse as it is the fundamental key to enhance the nursing care.

Conclusion on Deteriorating Patient Scenario Critique

The present case of Mr John Kendrick who met with an accident while riding a bicycle and he sustained an injury to his right side and was suspected of right leg fracture and spinal injury. After admission to the emergency department, it was seen that his physiological signs were deteriorating which was in accordance with respiratory depression and circulatory depression. Three major approaches that have been used effectively in the paper: recognition in which assessment of the risk is done, escalation including communication and ISBAR tool and management of the patient with clinical deterioration is done. The nurse in the given scenario has done graded assertiveness efficiently to achieve the escalation of the case with equity, access and advocacy and facilitates the coping mechanism of patients and their family effectively, However, it also concludes that effective communication between health providers and patient creates a healthy relationship between patient and the health providers along with the involvement of critical, ethical, and political analysis of social determinants of health which helps in the better health outcomes.

References for Deteriorating Patient Scenario Critique

Berlowitz, D. J., Wadsworth, B., & Ross, J. (2016). Respiratory problems and management in people with spinal cord injury. Breathe, 12(4), 328–340. https://doi.org/10.1183/20734735.012616

Cignarella, A., Redley, B., &Bucknall, T. (2020, Mar). Organ donation within the intensive care unit: A retrospective audit. Australian Critical Care, 33(2), 167-174. https://doi.org/10.1016/j.aucc.2018.12.006

Clark, S. B., & Soos, M. P. (2020). Noncardiogenic pulmonary edema. In StatPearls [Internet]. StatPearls Publishing.

Hackett, T. B. (2015). Chapter 2 – Physical examination and Daily Assessment of the Critically Ill Patient. https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/capillary-refill

Iddrisu, S. M., Hutchinson, A. F., Sungkar, Y. & Considine, J. (2018). Nurses' role in recognising and responding to clinical deterioration in surgical patients. Journal of Clinical Nursing. 27(9-10),1920‐1930. https://doi.org/10.1111/jocn.14331

Ikeda, K., Kawakami, K., Onimaru, H., Okada, Y., Yokota, S., Koshiya, N., Oku, Y., Iizuka, M., & Koizumi, H. (2017). The respiratory control mechanisms in the brainstem and spinal cord: integrative views of the neuroanatomy and neurophysiology. The Journal of Physiological Sciences, 67(1), 45–62. https://doi.org/10.1007/s12576-016-0475-y

MedicineNet. (2020). Low Blood Pressure (Hypotension). https://www.medicinenet.com/low_blood_pressure/article.htm

MedlinePlus. (2020). Pulse – bounding. https://medlineplus.gov/ency/article/003077.htm

Merriam webster. (2020). Thready Pulse. https://www.merriam-webster.com/medical/thready%20pulse

Scotia Health Ethics Network. (2016). What is health ethics. https://www.nshen.ca/index.php/what-is-health-ethics/

Shahid, S. & Thomas, S. (2018). Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care – a narrative review. Saf Health 4(7), 1-9. https://doi.org/10.1186/s40886-018-0073-1

Smith D & Bowden T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standards, 32(14), 51‐63. https://doi.org/10.7748/ns.2017.e11030

The American Nurses Association. (2016). Advocacy. https://www.nursingworld.org/practice-policy/advocacy/

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., Hallaert, G., Van Daele, S., Buylaert, W. & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International Journal of Clinical Practice, 69(11), 1257–1267. https://doi.org/10.1111/ijcp.12686

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