Nursing care is duty and professionalism of the nurses to work in such a way that the changes in the physiology of the patient can be monitored continuously and these changes can help in the interpretation of the condition in such a way that the clinical deterioration can be managed (Benner, 2019). The early warning system is present nationally which help the escalation of the problem and help the patient in revert and have positive health outcome. The present case given is of Mr. John Kendrick who is 48-years-old and during a bicycle accident where he was hit by a car.
He sustained injuries to his chest, leg and his abdomen, the impact was from the right side and he was conscious during impact. On a 10-point pain scale, he reported his pain as a seven in his right leg and a 4 in his chest which was radiating to his axilla. He has difficulty in breathing with elevated respiratory rate, heart rate and reduced blood pressure. The present academic paper aims to recognize the pathophysiological aspect of the clinical deterioration concerning the respiratory and cardiovascular systems due to the injury faced by him. The paper also discusses the escalation based on graded assertiveness and how communication could be improved and the measures of management for the nurses could have taken.
Recognize is the phase in which the pathophysiology is recognised so that the clinical signs and symptoms are in accordance to the pathophysiology. Mr. John Kendrick suffered an impact to his chest and his abdomen as a car hit him and from the impact it can be seen that he could have suffered a direct injury to his respiratory system leading to the respiratory depressive symptoms. In the case study, it is mentioned that he is given a spine board along with a C-collar as a precaution so that his spine is stabilized and his spine does not incur any movement during the transportation. The pain and the swelling which is present in his right leg are suggestive of fracture for which he has been given analgesics and the limb is stabilized.
In the present case, there could be three main causes for the respiratory symptoms that are seen first one is the injury to the brainstem which can cause the depression in the respiratory system because in humans, brainstem is the location for the respiratory centre. The second cause is that his right leg is suggestive of fracture and it is one of the most common causes of a fat embolism which can get lodged in the respiratory system which can lead to blocking of the blood supply and causing the symptoms. The third cause is that the patient had direct chest trauma during his accident.
Due to the impact which is seen to the chest cavity, there can be the formation of pleural edema which can be attributed to rupture of blood vessels or lymphatic drainage which has occurred during the accident (Clark & Soos, 2020). This is the non-cardiogenic source of pulmonary edema where the epithelial integrity is compromised and the anatomic continuity between the interstitial spaces is reduced and it is the site of filtration which occurs due to the existing pressure difference. When this pressure difference is more in interstitial space, the pressure on the lungs is increased and makes the airflow to the lungs difficult. In normal physiology, the pressure in the interalveolar space is higher compared to peribronchovascular interstitial space and it is closer to pleural pressure (Shahmohammadi et al., 2018).
Due to the accident, the vascular permeability of the endothelium is increased leading to pooling of blood and interstitial fluid around the lungs causing the pressure to increase and making the patient difficult to breathe (Sharara et al., 2017). There can be no conclusive report from the initial assessment that whether there is any kind of fracture to the ribs and therefore penetrating wound cannot be ruled out and it is another cause of increased pressure around the lungs in Mr. John Kendrick.
In humans, the respiratory centre is present in the region of pons and medulla which is located in the brain stem and any changes in the structural and functional integrity of the brain stem can cause the changes in the systems which are regulated by the region (Pedersen et al., 2017). The brain consists of midbrain, pons and medulla and it regulates the respiratory system and blood pressure. In case of injury to the brain stem like in Mr. John, the medulla can fail to sense the change in the level of carbon-di-oxide and respiratory rate to control the same which could fails and lead to respiratory problems (Pedersen et al., 2017). The cardiovascular system is also regulated by the medulla which regulates the heart rate and blood pressure (Tahsili-Fahadan1 & Geocadin, 2017). The depression of cardiovascular system can result in the reduction of blood pressure.
The patient is suspected of leg fracture and it is a most common cause for the inclusion of fat embolism in the blood circulation which is the presence of fat globules in the microcirculation and most commonly it gets lodged in the pulmonary system (Kosova et al., 2015). If the blood vessel is small, it can get lodged and obstruct the blood flow to the lungs which can lead to interstitial hemorrhage, edema and alveolar collapse and vasoconstriction can occur in such cases. Due to the presence of the fat, there can be the generation of high concentration of free fatty acid and lead to toxicity to the pneumocytes which can cause edema and hemorrhage (Kosova et al., 2015).
The respiratory system is regulated by multiple factors and the symptoms include that there is an increase in the level of circulating carbon-di-oxide and the oxygen saturation is reduced which was seen in the case of Mr. John. There is also alveolar collapse which makes the exchange of gases difficult which raises the respiratory rate as seen in Mr. John and his respiratory rate was 30 breaths per minute. This is compensation for decreased oxygen saturation. His circulatory system is depressed where the blood pressure is reduced and it is 115/70 mmHg which shows that the cardiac output is reduced. In order to compensate for the reduced cardiac output, the heart rate is often increased so that more blood reaches the lung for exchange of gases and his heart rate is 110 beats per minute and it is not regular (Graham et al., 2018).
Communication is a very important part in the healthcare and can change the health outcome for the patient and it is the way in which escalation of a particular case scenario can be done (Shahid& Thomas, 2018). ISBAR technique is one of the most commonly used communication technique in handover which is a simple way for planning and structuring of the communication in a patient care (Shahid& Thomas, 2018).
Identify: It involves the identification of the patient for whom the care and escalation are required and also it should be identified that the required person is actually reached. The person who is calling should identify themself as well (Shahid& Thomas, 2018). In the present case, the nurse introduces herself and then asks if the required person is reached and also she tells the person on the receiving end in this case the resident, the name of the patient.
Situation: In this, the situation of the patient is stated and the reason why is the escalation required (Shahid& Thomas, 2018). The strength is that the healthcare professional can escalate the problem being escalated to have better understanding but the weakness is that the information obtained is subjective, not objective and the understanding of the situation will vary accordingly. The registered nurse explains the case of Mr. John to the resident over the call.
Background: In this section, any laboratory or other tests that have been conducted is relayed for the person to whom the case is being escalated to (Shahid& Thomas, 2018). In the present case, the registered nurse relays that she has been monitoring his circulation and respiration and for further transfusion, she would like to conduct some blood tests. The resident says that he would not mind her taking the blood for further tests.
Assessment and action: This involves the current assessment of patient condition including the recording of early warning signs (Shahid& Thomas, 2018). The registered nurse says that physiological signs categorize the patient in clinical review category and requires urgent assessment by the concerned doctor.
Response and rationale: This is related to the action that is taken (Shahid& Thomas, 2018). In the present case, since the patient was not attended in the next 30 minutes the nurse escalated the case to a rapid response team which is the right course of action.
In the present scenario, since the resident is not taking the situation seriously and as there is the option of electronic communication, the nurse could send the chart of the patient by the means of the system. The effective communication should be present in the form of verbal as well as electronic communication (WH&S, 2016). Healthcare system is the one in which patient safety is the utmost importance and graded assertiveness is the way of communication which challenges unsafe practice and it involves structured thinking, communication, advocating and crisis management (Hanson et al., 2020).
In the present case of Mr. John, the nurse after informing the resident about the patient situation urges immediate action and upon reluctance, the nurse reminds him of the clinical review. The nurse finishes the conversation with the fact that as a matter of patient safety, she will escalate the case to the rapid response team. The suggestion made by the nurse was direct but in a non-confrontational manner which is the right use of graded assertiveness (Hanson et al., 2020).
In the retrospective study that was conducted by the Cignarella et al. (2019), it was seen that there was the various reason for the success and failure of the organ donations that have been conducted by the in the intensive care unit. The factors that were influencing the decision of the family members for the organ donation of the patient were the approach, conversations, family dynamics, and consent and organ suitability. The main ethical consideration that can be seen in the study is that family members cannot be forced or coerced for the organ donation and it has legal implications. The conversation regarding the organ donation should be done after the adequate time is given to the family members and after explaining the complete implication of the organ donations.
The religious consideration should be given appropriate importance in case of organ donation and it should be made sure that the person is a donor. In another study conducted by Milross et al. (2020), it is seen that the personal perceptions of nurses affect the conversation with the family members regarding the organ donations. The ethics in the healthcare dictates that the healthcare professional should have an objective stance rather than a subjective stance when dealing with the patients. Nurses are a source of emotional support to the patients and family members and they are the ones with whom the family spends more time.
The first opportunity is when the healthcare team is having the conversation with the family members regarding the donation the nurse can be present but not let her personal perceptions influence the decision. The second opportunity is when the nurse can advocate for the family with the healthcare team and team for organ harvesting so that they can allow adequate time for the family to spend with the patient as this is an emotionally challenging situation.
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. The pathophysiology is that the brain stem injury can cause these symptoms as it is the location of respiratory and circulatory centres. The nurse in the present scenario has done graded assertiveness properly for the escalation of case. The nurses should work within the ethical and legal boundaries to make sure that the organ donation is a smooth process and the family is not coerced towards the organ donation. Patient safety is important and all the work should be done towards one goal that is to obtain a better health outcome for the patient.
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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
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Shahid, S., & Thomas, S. (2018). Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care–a narrative review. Safety in Health, 4(1), 7.https://doi.org/10.1186/s40886-018-0073-1.
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Sharara, R. S., Hattab, Y., Patel, K., DiSilvio, B., Singh, A. C., & Malik, K. (2017).Introduction to the anatomy and physiology of pulmonary circulation. Critical Care Nursing Quarterly, 40(3), 181-190.
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