Essay on Deteriorating Patient

Running head: DETERIORATING PATIENT 1
Deteriorating Patient
Name
Institution

DETERIORATING PATIENT 2
Deteriorating Patient
Introduction
Due to their altered psychological conditions, critically ill patients are at a huge risk of
experiencing deteriorating health conditions if the appropriate nursing interventions are not
applied. An appearance of abnormal vital signs could be the initial indications the patient’s
health is deteriorating and the vital signs may start showing after several hours in a gradual
manner (Considine & Currey, 2015). The nurse should be able to identify, observe, and assess
these psychological abnormalities to enable them in developing the best care plan and ensuring
the patient safety. According to Creed & Spiers (2010), failure to address these abnormalities and
health deteriorations could escalate the patient’s condition into a critical state that may,
unfortunately, lead to death.
The nurses normally apply the between the flags system to intervene in the in situations
of clinical deterioration of a patient’s health condition. This system may be described as a safety
net for patients in most of the healthcare facilities (Pain et al., 2017). The aim of its design is to
prevent an unnoticed deterioration of patients and to ensure that the patients get the best care in
case of deterioration. This helps in improving the quality of care and ensuring patient safety. In
the intervention to prevent patient deterioration, there exists a slippery slope diagram that has
four phases of intervention (Hughes, Pain, Braithwaite & Hillman, 2014). The phases include
prevention, clinical review, rapid response and advanced life support. In this essay, we will
discuss the four phases of the slippery slope, and identify what happens in each of the phases.
Additionally, the essay addresses the safety of the patient from the perspective of a registered
nurse.

DETERIORATING PATIENT 3
Phase 1: Prevention
From the observation presented in the scenario, it is clear that John’s condition is
deteriorating. According to between the flags a normal respiratory rate of adults should be
between 12 to 20 breaths per minute. John’s respiratory rate, however, is 28, which could be an
indication of respiratory distress. A 90% SpO2 may be an indication of a decrease in perfusion
and a blood pressure of 122/64 is a sign of an elevated blood pressure. Also, the abrasion on the
left side of his chest extending around to the middle of his back and chest discomfort may be an
indication of chest injury or damage to the heart valve. Further, an extensive bruise on the left
hip and around to buttock, unable to weight bear, constant sharp pain in the upper thigh and hip
region may be an indication of fracture NOF. These abnormal vital signs may be associated with
John’s pain that may establish from chest injury or fracture NOF.
The management of pain in elderly is very important, as John is 81 year old, because
usually elderly patients amplified with anxiety and stress, therefore due to this challenge their
conditions may further deteriorate. Initial pain assessment, an appropriate and timely pain
management for trauma patients is vital because it can induce severe complications that may lead
John to further deteriorate (Brown, Edwards, Seaton & Buckley, 2017). Therefore, pain
management in trauma patients is an important part of the systemic approach to trauma. Brown
et al. (2017), further ascertain that the complication of pain includes problems with ventilation,
perfusion abnormalities due to muscle splinting, increased myocardial workload, decrease in the
risk of pulmonary embolism and decreased gastrointestinal motility as John has a medical history
of GORD.

DETERIORATING PATIENT 4
Several complications of the respiratory system such as pneumothorax, atelectasis and
respiratory failure may be caused by inadequate ventilation as a result of an injury to the chest
(Unsworth, Curtis & Edward, 2015). Injury to chest and pain causes hypoventilation in the
patient characterized by shallow and fast respirations like in John’s case. This will lead to
impaired gas exchange in the lungs, where the level of alveoli is perfused (Unsworth et al.,
2015). Management of pain also aids in decreasing incidence of chronic pain, Post-traumatic
stress disorder, shortens the length of hospital stay, lowers costs, and ultimately reduces the rate
of morbidity and mortality.
Additional assessment such as an ECG to detect any abnormalities in the heart due to the
injury as John is experiencing chest discomfort. Also closely monitoring the vital signs
especially respiratory rate and the spo2 level is important for John to prevent the development of
further complications. Monitoring these vital signs will help to determine which treatment
protocols to follow, confirm feedback on treatments provided, and provide critical information
needed to make life- saving decisions and when to make a met call (Mok, Wang & Liaw, 2015).
Monitoring respiratory rate and the spo2 level will help to decrease the respiratory distress and
risks of developing hypoxia.
Phase 2: Clinical Review
During this phase, John's condition is further deteriorating. He is going down in clinical
review phase according to slippery slope diagram. He is speaking in short sentences, has shallow
breaths and he is tender to touch. Additionally, he has dusky pink peripheries that are cool to
touch with a capillary refill of greater than four seconds. He also experiences pain during the
palpitations of the abdomen. Pain 10 out of 10 on the left hip when moving may indicate

DETERIORATING PATIENT 5
fracture NOF as mentioned in phase one. Pain in the abdomen may indicate injury to his
abdomen. In addition to between the flag, he is tachycardic, hypotensive and the SPO2 level is
still not normal even with 6L Hudson mask. Furthermore there is a decrease in blood pressure
and a drop in the Glasgow coma scale.
According to (Arora, Flower, Murray & Lee, 2012) injury in the abdomen can cause
severe pain and may lead to shallow breathing as in the case of John. Failure to treat abdominal
palpitations could lead to some serious complications that may affect the normal operation of the
lungs and the heart. The elevated abdominal pressure can interfere with respiration, decreases
venous return from the lower extremities, causing hypotension and hypoxemia. All of this may
increase the risk of developing pneumonia. Indigestion caused by stomach palpitations leads to
expansion of the stomach with gases. These gases cause stomach spasms and in serious
conditions, a shortness of breath may be experienced as mentioned in the john’s case.
There may be a possibility for John to develop hypovolemic shock as he may have an
abdominal injury and fractured hip. According to Egol, Koval & Zuckerman (2010), this kind of
injury can result in two to three liters of blood loss. Blood is delivered to the femoral head by 3
terminal arterial branches (Reynolds, 2013). However, this may not be happening in John’s case,
which leads to the development of some abnormal findings such as dusky pink peripheries, cool
extremities, and capillary refill greater than four seconds. Also an increased heart and respiratory
rates and decreased oxygen level.
Phase 3: Rapid Response
John’s condition is further deteriorating at this stage. His Glasgow coma scale has
dropped to 11 and he has become confused. This could be an indication of moderate brain injury.

DETERIORATING PATIENT 6
His blood pressure has dropped to 92/54 mmHg and the heart rate has increased to 134 beats per
minute. John’s respiratory rate has also increased to 30 breaths per minute and despite being on
the 6L Hudson mask, his SpO2 has dropped to 88%. It is also reported that he has cool
extremities with a capillary refill of 4 seconds. He is supplied with a maintenance fluid at 200
ml/hr which could be an indication that he has lost too much body fluids.
From the scenario presented, it could be possible that John might have suffered a fall that
led to a mild traumatic brain injury. An injury to the brain requires an immediate intervention or
the patient risks suffering complications such as coma, hydrocephalus which can be described as
the buildup of fluids in the brain, damage to the blood vessels that supply the brain which could
lead to blood clots and stroke (Iverson & Lange, 2011). John could also experience a condition
known as vertigo if his brain injury is not treated promptly. This is a condition where a patient
who has suffered a traumatic brain injury experiences dizziness almost every time. The nurse
must ensure that John has an adequate supply of blood and sufficient oxygen. Additionally, his
blood pressure needs to be maintained to prevent the escalation of the above-mentioned
complications (Iverson & Lange, 2011). He could also be given medications such as diuretics
and anti-seizure drugs.
Additionally, John could develop a hypovolemic shock if he is not attended to as soon as
possible. This is a condition that is developed when an individual loses more than 20% of their
body fluid or blood (Kobayashi, Costantini & Coimbra, 2012). The fact that John is on a
maintenance fluid is an indication that he has lost a lot of body fluid due to the injuries that he
had suffered. This excessive loss of blood means that the blood floor is not sufficient thus
leading to a capillary refill time of more than 4 seconds. The abdominal injuries suffered by John
in addition to the bruises and abrasions could lead to severe blood loss. This condition could be

DETERIORATING PATIENT 7
characterized by rapid heart rates and rapid respiratory rate that is characterized by shallow
breaths. Another symptom of hypovolemic shock is a cold skin.
A failure to treat this condition could lead to several other complications such as heart
attack, damage to body organs like the brain and kidneys, gangrene of the legs and arms, and
death at worst. It is worth noting that taking blood thinners like clopidogrel and aspirin increases
the risks of developing hypovolemic shock (Myburgh & Mythen, 2013). Some of the
interventions that can be used to manage this condition are to ensure that the patient gets
sufficient oxygen supply to all the body organs. This can be achieved by substituting the Hudson
mask with a rebreather mask. Additionally, the nurse should do everything possible to limit the
loss of blood before a replacement of the lost blood and other fluids is done intravenously.
Phase 4: Advanced Life Support
This is the last phase of the slippery slope in the between the flag system. John’s
condition is further deteriorating. His blood pressure has fallen to just 52/26 mmHg with an
increased heart rate of 144 beats per minute. We had been previously informed that John had
chest pains which could be as a result of a chest injury. Additionally, he could experience a
collapse of lungs due to the chest injuries. The chest injuries and a collapse of the lungs could
lead to hemothorax (Yalcin, Choong & Eizenberg, 2013). This is a condition that causes blood to
accumulate in the pleural space surrounding the lungs. A traumatic injury to the chest can cause
a rupture of the pleural membrane that lines the lungs and the chest thus spilling blood into the
pleural space. This condition is characterized by low blood pressure, a rapid heart rate,
difficulties in breathing, and rapid but shallow breathing among others (Yalcin et al., 2013).
Some of these symptoms are exhibited by John in the presented scenario.

DETERIORATING PATIENT 8
Failure to promptly treat hemothorax could lead to other complications such as lung
problems, infections, and scarring. Lung problems such as a collapse of the lungs could lead to a
respiratory failure. Failure to treat hemothorax could possibly lead to infections of the lungs and
the pleura in the chest. It is also important to note that if the blood stays in the pleural space for
far too long, a condition known as retained hemothorax could be developed. This condition leads
to a blood clot that may be challenging to remove using a catheter (Villegas, Hennessey, Morales
& Londoño, 2011). Hemothorax is treated by inserting a catheter into the chest through the ribs
and draining the blood that is within the pleural space (Yi et al., 2012). After the pleural space
has been drained, the same tube could be used to expand the lungs in the event of a collapse of
the lungs.
Conclusion
Patients with deteriorating health conditions need prompt interventions to prevent the
condition from escalating to something worse and jeopardize their safety. The deterioration of a
patient is assessed using four phases of the slippery slope in the between the flags system. These
phases include prevention, clinical review, rapid response, and advanced life support. Each of the
phases plays a role in preventing and managing deteriorations thus enhancing the safety of the
patient. Patient safety is a nurse’s main priority and if the right interventions are employed in
each of the phases then patient safety could be guaranteed. After the interventions in the fourth
phase have been applied, we can notice John’s clinical conditions beginning to get back to
normal an indication that the nurse has achieved success in ensuring the delivery of quality care
and patient safety.

DETERIORATING PATIENT 9

DETERIORATING PATIENT 10
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