CLINICAL REASONING AND DETERIORATING PATIENT.

Running head: CLINICAL REASONING AND DETERIORATING PATIENT
CLINICAL REASONING AND DETERIORATING PATIENT
Name of the Student
Name of the University
Author note

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CLINICAL REASONING AND DETERIORATING PATIENT
Patient situation
82 years old, Mary Smith has been admitted in a general surgical department
following surgery for left total knee replacement under general anaesthesia 6 hours
ago.
Cues/information
Mary weighs 100 kilo -grams, she also has fatty liver disease with moderate
enlargement and essential hypertension. She has diabetic neuropathy in both feet
with intermittent mild neuropathic pain and no neurological deficit.
Mary is currently on beta blockers for her hypotension and one hour ago her BP
was 123/70 mmHg, radial pulse 55, RR 18, SpO2 96%, FiO2 0.21, T 36.2,
peripheral capillary refill 2 seconds, warm digits. She is fully alert with GCS of 15,
her surgical wound dressing is dry with no ooze and she has not accessed her PCA
in the past hour. Mary feels lightheaded and she stated she has 7/10 pain in her Left
knee. She has less appetite and has tried sips of water and she feels nauseated.
Upon checking Mary has an 18G IV catheter in her right hand and isotonic saline
running at 80mL per hour via a pump with 200mL remaining in the IV bag,. The
PCA circuit is attached to this line. Mary’s vital signs are now BP 105/56mmHg,
radial pulse 66 regular, RR20, SpO2 93%, FiO2 0.21, T36.4 tympanic.
BGL11.5mmol/L, Peripheral capillary refill is 3 seconds plus pale cool digits.

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CLINICAL REASONING AND DETERIORATING PATIENT
Mary is taking beta blocker which may have influenced her drop in blood pressure
because they cause vasodilation (Parati et al., 2013). Mary has not accessed her
PCA in the past hour and she has pain score of 7/10 which can result in stimulation
of stress response therefore an increase in heart rate and decrease in oxygen level.
Her capillary refill has just increase from 2 seconds to 3 seconds which in her case
may evidence Cold temperatures, Peripheral vasoconstriction, Shock, Dehydration
and may also be the cause of her decrease in oxygen level (Parati et al., 2013).
Processing information
For a person with a history of Hypertension Mary’s blood pressure is very low and
she is now showing signs of tachycardia and hypoxia (Parati et al., 2013). She is
afebrile and her BGL is within normal range for type 2 diabetic patients which
leaves the nurse more concerned about her hypotension, capillary refill, pain and
tachycardia.
Because Mary just had surgery her low blood pressure may be a result of blood
loss. Mary might be suffering internal bleeding which refers to bleeding that occurs
inside the body that is not seen from the outside (Mirkazemi, Bereznicki & Peterson,
2013). This is evidenced by her surgical wound dressing that is dry with no ooze.
She may also be dehydrated since she was nil by mouth before surgery and she

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CLINICAL REASONING AND DETERIORATING PATIENT
stated that she only managed sips of water but feels nauseated post-op ( Hooper et
al., 2015)
Internal bleeding (to some extent) is a common complication of a post-op knee
surgery (Mirkazemi, Bereznicki & Peterson, 2013). Internal bleeding may be because of
injury to the vessels in the incision area. If Mary does not get fluids she might go
into serious shock which is a medical emergency requiring immediate intervention
( Hooper et al., 2015). She may also go into an acute confusion state if her pain is
not manage or controlled and hypoxemia that leads to multisystem organ failure if
her oxygen levels are not increased (Mirkazemi, Bereznicki & Peterson, 2013).
Identifying the problem/issue
Decreased fluid volume reduces blood return to the heart resulting in a decline in
preload that leads to a drop in cardiac output ( Maas et al., 2013) Evidenced by
hypotension, capillary refill, pain and tachycardia Mary has reduced cardiac output
related to vasodilation and decreased intravascular volume ( Maas et al, 2013).
Vasodilation occurs naturally in a human body in response to triggers such as low
oxygen levels. It causes the widening of blood vessels, which in turn increases
blood flow and lowers blood pressure ( Maas et al, 2013). Additionally, factors
such as Mary’s age and weight can also negatively affect vasodilation ( Maas et al,
2013).

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CLINICAL REASONING AND DETERIORATING PATIENT
Goals
Nursing goals would be to manage Mary’s pain, restore circulating blood volume,
improve and preserve Mary’s hemodynamic status in order to prevent any damage
to vital organs and Monitor and improve Mary’s urine output over the next 45 min-
2 hours.
Nurse’s action
If a deteriorating trend in clinical observations is detected, even if the patient is not
yet in a coloured zone, a registered nurse may initiate either a Clinical Review or
Rapid Response (Mannix, Parry & Roderick, 2017). .The underlying principles of
managing patients with low cardiac output focuses on stopping the loss of fluid and
restoring the circulating volume (Mannix, Parry & Roderick, 2017). In Mary’s case
the registered nurse urgently need to consult promptly with the Nurse in-charge
and the medical officer for Clinical Review.
The Slippery Slope
The Slippery Slope diagram shows how the BTF system is designed to intervene in
the process of patient deterioration with two key interventions, which are Clinical
Review and Rapid Response. According to the slippery slope chart Mary is in the
yellow zone and early intervention is crucial to a positive outcome (Martin & Grocott,

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CLINICAL REASONING AND DETERIORATING PATIENT
2013). Mary’s BP of 105/56mmHg and SpO2 of 93% suggest deterioration and
that calls for urgent clinical review to initiate appropriate clinical care to avoid
further deterioration that is life threatening (Martin & Grocott, 2013).
Nursing interventions:
When nurses care for patients they follow the nursing process that includes
making a plan and setting goals for the patient. Nursing interventions involves
actual treatments and actions that are performed to assist the patient to reach the
goals that the nurse set for them (Zeller & Levin, 2013).
Managing Pain and discomfort
Pain and discomfort are also important factors in Mary’s postoperative period as
good pain management is essential for physical and psychological recovery
(Mannix, Parry, & Roderick, 2017). If pain is not well managed Mary will be unable
to move without excessive difficulty, thus increasing the risk of complications
associated with prolonged bedrest (Mannix, Parry & Roderick, 2017). In this case the
registered nurse should administer postoperative analgesics by accessing Mary’s
PCA or as ordered by the medical officer.
Related problems that Mary has such as nausea can often cause the patient further
distress and reduce the individual’s ability to cope with postoperative pain and
discomfort, and therefore should be addressed.

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CLINICAL REASONING AND DETERIORATING PATIENT
Positioning and Oxygen Therapy
Pulse oximetry is used in measuring oxygen saturation (Martin & Grocott, 2013).
Although, this cannot be solely relied on as the oximetry may not pick up Mary’s
inadequate tissue perfusion and accurate pulse rate, therefore An arterial blood gas
should be taken to provide information on adequacy of ventilation, acid base
balance and oxygen delivery to the tissues (Reed, & Card, 2016). Mary’s oxygen
saturation is currently 93% on FiO2 0.21 and should be increased. At this point
Mary’s oxygen saturation should be maintained at 95% or higher to avoid decrease
in aerobic metabolism and occurrence of lactic acidosis that may result in the
decrease in pH and increased carbon dioxide levels. Any reading less than 93%
puts Mary into the risk of entering the red zone indicating shock progresses (Martin
& Grocott, 2013). Although skin condition is not a high priority during fluid
resuscitation, Marys low perfusion put her at higher risk for developing pressure
ulcer (Martin & Grocott, 2013). To reduce pressure surface the nurse might obtain a
low air-loss mattress making sure she does not lie on hard surface for extended
periods
Continually monitor the patient’s vital signs and maintain the patient’s ABC’s
(airway, breathing, circulation).

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CLINICAL REASONING AND DETERIORATING PATIENT
Vital signs assist in monitoring patient’s physical and physiologic status ( Vaprio
et al., 2015). The Registered nurse must monitor vital signs every 15 minutes.
Gauging the capillary refill time ( Perry et al., 2013). may be useful in assessing
the circulatory status, it is important to pay attention to Mary’s skin colour when
assessing circulatory status( Quinn et al., 2014). When assessing the skin site
where pressure was applied the colour should return to the skin within two
seconds, Mary’s peripheral capillary refill is 3 seconds plus pale cool digits this
may indicate a reduced peripheral perfusion ( Quinn et al., 2014).
Because Mary is a surgical patient she is at risk of both hypothermia and pyrexia in
the immediate postoperative phase therefore her temperature should be monitored
frequently and assure that she is warm. It is also essential to take frequent blood
pressure because if the blood pressure continues to drop Mary may start to lose
perfusion to vital organs (Ramasubbu, Stewart & Spiritoso, 2017). To optimise blood
pressure Mary should be positioned in a semi fowler position or Trendelenburg’s
position to increase venous return from the legs ( Fernendas et al., 2016).
Whilst waiting on the medical officer to review Mary the registered nurse might
also conduct a bladder scan. Renal system holds back water to compensate for low
Blood Pressure ( Maas et al., 2013). When urine retention is present it impends on
urine flow causing destruction therefore this is necessary to identify any underlying

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CLINICAL REASONING AND DETERIORATING PATIENT
causes and contributory factors to avoid kidney damage, renal failure or bladder
rupture ( Maas et al., 2013) The airway should be assessed for patency assuring
Mary’s breathing is relaxed, effortless, and regular. Characteristics of a shock
include rapid, shallow respirations and adventitious breath sounds such as crackles
and wheezes ( Kable et al., 2013). The measurement of central venous pressure
(CVP) provides a useful insight into the circulatory system as it will indirectly
assesses Mary’s fluid status. This is helpful in identifying if she is at risk of
hypovolaemia following surgery ( Leonthevas, 2013)
Monitor LOC (Level of consciousness), neurological status
If Mary continues to lose oxygenation to her brain she will become more difficult
to arouse or confused, this could be a sign of advancing shock. She may also begin
to have difficulty protecting her own airway ( Cone et al., 2016). Assessing Mary’s
neurological status is necessary because with poor perfusion, her mental status will
deteriorate, risking airway compromise due to loss of the usual reflexes that allow
secretion management and protection from aspiration ( Cutrer et al., 2017)
ISBAR
Clinical handovers are part of the everyday routine in clinics. A clinical handover
ensures accurate and timely transfer of information, responsibility and
accountability. First, the patient should be informed and assessed, communication

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CLINICAL REASONING AND DETERIORATING PATIENT
has been made to the receiving clinician and documentation completed (Mannix,
Parry & Roderick, 2017).
Introduction
Hello doctor Rudd my name is Tendayi I am a nurse calling from surgical ward F.
I am calling in regards to Mrs Mary Smith from Australia and is 82 years old.
Status
Mrs Smith situation is deteriorating as Evidenced by hypotension, capillary refill,
pain and tachycardia. She has reduced cardiac output related to vasodilation and
decreased intravascular volume. I am suspecting that she is in hypovolemic shock
given her low cardiac output. Mrs Smith has had unstable vital signs. Low blood
pressure, increased heart rate and respiration, paleness, nausea, pain, and
restlessness. This assessment was done 30 min ago
Background
Mrs Smith had been diagnosed with Osteoarthritis of both knees, with limited
range of movement and pain on weight bearing in the left knee. She has Type 2
Diabetes Mellitus, essential hypertension, and diabetic neuropathy in both feet with
intermittent mild neuropathic pain and no neurological deficit. She weighs 100kgs.
Following total knee replacement, I suspect she lost a lot of blood volume during
surgery and has internal bleeding from her wound site evidenced by the surgical

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CLINICAL REASONING AND DETERIORATING PATIENT
wound dressing that is dry and has no ooze resulting in hypovolemic shock which
decreased her blood pressure and increased her heart rate. She has fluids running at
80mls per hour through an intravenous placement. She has pain of 7/10 in her Left
knee and she feels lightheaded. She has not wanted to eat and has tried sips of
water and she feels nauseated.
Assessment and Actions
She is hypotensive and the filling of her capillary in three seconds plus pale cool
digits. This indicates a possibility of peripheral vascular disease and hypovolemia.
I have positioned Mrs Smith in a semi fowler position/Trendelenburg’s position to
increase her venous return from the legs. I administered analgesic dose via her
PCA to manage her 7/10 pain score, increased the frequency of her vital
observations to 15 minutely and I also conducted a bladder scan to check for
obstruction and retention. She seems to be unstable and she might get worse if she
does not get immediate intervention.
Recommendations
To avoid further deterioration I suggest that you review her immediately,
commence rapid fluid resuscitation to restore homeostasis, increase her oxygen
flow to prevent further hypoxia, and conduct blood gases to assess her pulmonary
gas exchange and her acid base homeostasis. I also suggest blood samples for a

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CLINICAL REASONING AND DETERIORATING PATIENT
complete blood count for haemoglobin and to help rule out or suggest infection and
other conditions. Also a CT scan to find out if she is bleeding internally.
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