• Internal Code :
  • Subject Code :
  • University : La Trobe University
  • Subject Name : Nursing

Recognising and Responding to the Deteriorating Patient

Question 1

The condition of your patient Joanna Cleese described in the ISBAR handover, appears to be changing. (Please refer to the attached documentation)

Using the information that you have identified from the NOC and the ISBAR case study handover:

  1. Discuss the possible causes of Joanna's changing condition, supporting your response with contemporary literature and the associated significant cues, signs, and symptoms listed in the case study.

  2. Explain what possible further deterioration could occur for this patient, with a detailed evidenced -based response.


Ms. Joanna experienced pneumothorax fractures and this may lead to pneumothorax tension, where a disease occurs when air is trapped under positive pressure in the pleural cavity, which displaces the mediastinal structures affecting the cardiopulmonary function (Hsu, & Sun, 2014). For a few cases, a region of weakened tissue forms a one way valve, and the volume of air in the space between the chest wall and the lungs rises.

She also suffers from laceration of the head which may cause her haemorrhagic shock. It results from decreased blood volume (hypovolemia) caused by a lack of blood, leading to reduced cardiac production and perfusion of the heart. The arterial pressure gradually increases if the haemorrhage is stopped and the heart rate reduces as long-term compensatory mechanisms are enabled to restore natural arterial pressure (Klabunde, 2020). Such patients develop ischemic injury in vital organs and if left untreated, leads to the failure of multiple organs.

Question 2

There are many tools that can be utilised when assessing a patient. When assessing a deteriorating patient accurate assessment is essential. Compare and contrast the following methods of patient assessment and their appropriate applications for the deteriorating patient.

  1. Primary (ABCDE)

  2. Head to toe assessment


  1. The ABCDE approach, initial diagnosis, and care is performed concurrently and continuously. The cause is sometimes unknown even though a vital condition is evident; in these cases, life-saving care must be initiated before a conclusive diagnosis is made. Prompt detection and successful clinical care avoid damage and require time to make a conclusive diagnosis (Thim et al., 2012). The mnemonic "ABCDE" stands for Airway, Breathing, Circulation, Depression, and Exposure. In this approach, life-threatening issues with the airways are assessed and treated; second, life-threatening breathing problems are evaluated and treated; and so on others are performed one by one. Using the organized approach, the aim is to recognize life-threatening problems without wasting the time of the patient and to administer care to fix them. The approach extends to both patients, adults and children alike. Regardless of the underlying cause, the clinical symptoms of dangerous conditions are identical. It makes precise knowledge of the underlying cause of the patient’s condition when initial evaluation and the treatment is done (Olgers et al., 2017). The ABCDE technique should be used when allegations of serious illness or injury are identified. This is a valuable resource in everyday practice to recognize or rule out the vital conditions. The technique is also recommended as the first step in treatment after spontaneous circulation.

  2. Head to toe assessment- It is a comprehensive physical exam, covers head to toe, and typically takes about 30 minutes to complete. It tests essential vital signs like temperature, heart rate, and blood pressure and uses assessment, palpitation, rhythm, and auscultation to determine the body conditions. A comprehensive health assessment is a systematic review usually requiring a clear history of the health of the patient. Registered nurses may perform this form of assessment for the patients as soon as they get admitted to the hospital or in the community-based settings, such as the home visit (Toney-Butler & Unison-Pace, 2019). Advanced clinical nurses like the nurse practitioners often conduct full tests while conducting regular physical exams, or when the patient is transferred to ward or shift change. It usually begins with the less invasive followed by the most invasive, which allows the patient to become more comfortable with the nurse with time. This also raises the likelihood that nothing like no health conditions or cues or symptoms to be missed by the examiner during the test. The first thing that should be considered during an examination is the physical appearance or general state of the patient. This includes alertness level of patient, health conditions, distress or comfort state, and respiratory rate. This is done just before vital signs are taken.

Question 3

A change in a patient’s heart rate, blood pressure, temperature and respiratory rate can all be an indication of clinical deterioration. It has been suggested that a changing respiratory rate is the earliest indication of clinical deterioration and yet it is often not measured correctly, or not measured at all. Using evidence-based literature to support your arguments:

  1. Discuss why a changing respiratory rate is an important indicator of clinical deterioration.

  2. Explain how the respiratory rate can be measured reliably and accurately.


Respiratory rate (RR) is an essential component of clinical evaluation and follow-up. The RR is a patient's most sensitive sign, and the first finding to suggest a concern when a patient deteriorates (Philip et al., 2015). If the oxygen delivery to cells is affected the cells undergoes into anaerobic metabolism to maintain the cell metabolism leading to metabolic acidosis. The respiratory system is the body’s first and quickest response system to altered blood pH, which happens when the co2 is not effectively removed from the blood. There is pressure on the body to maintain the oxygen levels which effects the RR. The RR helps the body to cope up with the deteriorations without changing the other vitals.

In general, the rate of respiration is calculated while a person is relaxed and simply includes the counting of the number of breaths for one minute by measuring the times the chest rise in that time. There are two specific methods of tracking respiratory rates which are a continuous method, performed by equipment such as capnography, or discontinuous, by manually measuring the capacity of a person to use auscultation and/or inspection capabilities between 30 and 60 (Massaroni et al., 2019). Guidelines for best practice recommend measuring the breaths in full one minute, making note of any changes in breathing duration, speed, consistency, and efficacy. Ideally, the clinician would evaluate the respiratory rate surreptitiously to prevent an erroneous result due to the patients' knowledge of being observed.


Hsu, C. W., & Sun, S. F. (2014). Iatrogenic pneumothorax related to mechanical ventilation. World journal of critical care medicine, 3(1), 8–14. https://doi.org/10.5492/wjccm.v3.i1.8 Klabunde, R. E. (2020). Cardiovascular Physiology Concepts

Massaroni, C., Nicolò, A., Lo Presti, D., Sacchetti, M., Silvestri, S., & Schena, E. (2019). Contact-Based Methods for Measuring Respiratory Rate. Sensors (Basel, Switzerland), 19(4), 908. https://doi.org/10.3390/s19040908

Olgers, T. J., Dijkstra, R. S., Drost-de Klerck, A. M., & Ter Maaten, J. C. (2017). The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study. The Netherlands journal of medicine, 75(3), 106–111.

Philip, K. E., Pack, E., Cambiano, V., Rollmann, H., Weil, S., & O'Beirne, J. (2015). The accuracy of respiratory rate assessment by doctors in a London teaching hospital: a cross-sectional study. Journal of clinical monitoring and computing, 29(4), 455–460. https://doi.org/10.1007/s10877-014-9621-3

Thim, T., Krarup, N. H., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117–121. https://doi.org/10.2147/IJGM.S28478

Toney-Butler TJ, Unison-Pace WJ. Nursing Admission Assessment and Examination. [Updated 2019 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. 

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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