Between the Flags Method: A Case Study of Essential Nursing Care

This essay discusses the implementation of the Between the Flags method in a case study of essential nursing care for a patient named John. It covers the four phases of the slippery slope response and the role of nurses in patient safety. The essay also includes information on John's health status, past history, and observed parameters in each phase.

Essential Nursing Care
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Introduction:
In this essay, case of John is being discussed. He was being hospitalised after being
unconscious. After admission to the hospital between the flags method being implemented to
him to assess his deterioration and to provide adequate response. In each of these phases,
accurate assessment of the John was done and decision for further step was being taken on
the outcome of the previous phase. Decision making in between the flags method in accurate
because each of the phases of this method are associated with vital signs threshold for the
escalation. This method also comprises of clinical response team with advanced life support
skills. The slippery slope diagram can be useful in implementing between the flags method.
Using this slippery slope diagram, deterioration of the patient can be effectively assessed
using two interventions like Clinical Review and Rapid Response. In each of these phases,
John was being assessed for physical, physiological and psychological aspects. Each of these
phases were linked to the pathophysiology and role of nurse in patient is being discussed.
Introduction about patient:
Phase 1: First phase in the slippery slope is prevention. It is a continued treatment plan. John
was presented in the unconscious state at the emergency department. On the arrival, his vital
parameters were determined. Information related to health status and past history was
collected. It was evident that he was non-smoker and consume alcohol 3-5 times per week.
His height is 180 cm and weight 104 kg, indicating BMI 32. It indicates he is obese. He was
having Gastro-oesophageal reflux disease (GORD) and transient ischemic attack (TIA), two
years ago. He was consuming Zantac which contains ranitidine useful in reducing stomach
acid production in GORD. He was also consuming clopidigril which is useful in reducing the
risk of heart disease and stroke.
Phase 2 :
In the second phase different vital and specific parameters of John were determined and
appropriate clinical care plan was implemented. Based on the observation, few of the
parameters estimated in this phase would be estimated in the next phase. In this phase, few of
the parameters as compared to the prevention phase were deteoriated in John.
Phase 3 : Clinical review was activated based on the observed clinical parameters of phase
two. Clinical review is one of the components of the Clinical Emergency Response System
(Sulistio et al., 2015; Salvatierra et al., 2016). Nurse in charge should make decision whether
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to escalate or not the patient. Activation of clinical review should solely be based on the
clinical judgement. Consideration of clinical judgement is required to ensure safety of patient.
Nurse should decide on clinical review activation on different aspects like usual condition
and requirements of the patient, whether documented alterations are available for activation
of clinical review, whether more than one yellow zone observations were observed in John
and whether nurse was concerned about the John condition. Frequency of repeat observations
should be above 8 hours. Nurse should record all the information related to patient to ensure
appropriate treatment and safety of the patient.
Phase 4 : Based on the observed parameters in the phase three, rapid response was activated
for providing care to John. It was considered as red zone response and medical officer was
called for the immediate action (Hillman et al., 2005). In this phase all the observed
parameters in John were in the red zone. In the last phase patient was completely deteriorated
and efforts were made to revive patient by giving him shock (Chan et al., 2010).
Discussion:
Unexpected cardiac arrest exhibit, rapid signs of deterioration. In such case, trained medical
and nursing staff should take rapid decisions to implement between the flag methodology
using slippery slope (Al-Qahtani et al., 2013). Rapid response system can be implemented by
following four phases of slippery slope. These four responses include prevention, clinical
review, rapid response and resuscitation (Gao et a., 2007). In these four phases, medical and
nursing staff used to respond quickly to abnormal vital signs of the patient, certain conditions
and nurse’s concerns. It is difficult to identify deterioration of patient with exact levels of
single sign or vital sign. Hence, incorporation of these four phases can be helpful in
integrating different vital signs can be helpful in identifying deteriorating condition of the
patient. Along with identifying deteriorating condition of patient, early response can also be
given to the patient by using these four phases. Early response can be given by activating
clinical review and rapid response phases (White et al., 2015; Maharaj et al., 2015).
Phase 1 : His respiratory rate was 28, which can be considered as normal considering his age.
His observed SpO2 was 90%. GCS score observed in John was 15. His observed blood
pressure was 122/64. His resting heart rate was 94 (Fagan et al., 2012). In patients with cardia
arrest, there is decrease in the circulating blood flow. It results in the less supply of oxygen to
the different tissues. It results in the hypoxia and peripheral capillary oxygen saturation. Due
to hypoxia, lung increases its activity to compensate for the hypoxia. Hence, lung breaths at
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the faster rate. It results in the increase in the respiratory rate. Due to reduced circulatory
blood flow, heart also increase its activity and it pumps at the faster rate. Hence, it can results
in the increase heart rate. Increased heart rate can put pressure on the blood capillaries which
can result in the increase in the blood pressure (Fagan et al., 2012).
Tympanic temperature observed in John was 36.4, which can be considered as the normal
temperature. Abrasions and bruising were observed in different parts of John. Abrasions were
observed on left side of chest and around middle of back. Bruising was observed on left hip
and around the left buttock. In left upper thigh and into left hip region, he was having pain
with the scale of 8/10. Moreover, he was not able to talk, listen and move due to this severe
pain (Hosking et al., 2014). He was having pain with scale 3/10 in the left side of the chest in
the rib region. He was administered with supplemented oxygen with floe rare of 6 L per
minute using Hudson mask. He was administered with morphine, an analgesic drug two times
through IV route (Simmes et al., 2013; Melia et al., 2015).
Phase 2 : He was talking short sentences to express his pain and feelings. He was having
shallow breathing which is mostly due to chest breathing. Hence, there was symmetrical rise
and fall of the chest. People with breathing problem exhibit shallow breathing which is due to
drawing air into the chest area using the intercostal muscles instead of lungs via the
diaphragm. On auscultation, it was observed that his breath sound was normal which
indicates there was no deposition of secretion in the respiratory tract. Shallow breathing can
lead to pathological conditions line alteration in the Pao2, Paco2, or pH. It can lead alteration
in the input from the both carotid body and the medullary chemoreceptors. As a result of
alteration in the chemoreceptor input, there is alteration in the tidal volume and consequently
alteration in the respiratory rate. Hypoxaemia lead to augmented ventilation. Augmented
Paco2 can lead to CO2 narcosis and consequently depression of the respiratory centres (Kheir
et al., 2015).
Grazing was observed on the chest due abrasion and scratching after his fall. His peripheries
were dusky pink in color and cool to touch. His capillary refill was <4 seconds. It indicates
possibility of shock, dehydration and reduced peripheral perfusion (Lovett et al., 2015). His
pain in the region was 6/10 at rest and 10/10 at movement. He was having distressing pain at
rest and unable to move at movement. Chest pain in patients with cardiac arrest can occur due
to reduced supply of heart muscles. It is also called as cardiac ischemia and it results in the
damage to heart muscles. It results in the reduced capability of the heart to pump the blood.
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Chest pain in the cardia arrest patients radiates to the shoulder region and to one or both the
arms. Moreover, this pain gets exaggerated on movement in comparison to the rest (Melia et
al., 2015).
On abdominal palpitation, he was expressing grimaces. Observed respiratory rate, oxygen
saturation, blood pressure, heart rate and GCS were 26, 92 %, 96/50, 120 and 13 respectively.
There was slight improvement in the respiratory rate and oxygen saturation (Simmes et al.,
2013). However, there was deterioration in the cardiovascular parameters like heart rate and
blood pressure (Jones et al., 2009).
Global ischemia can produce adverse effect at the cellular level which results in the organ
dysfunction after resuscitation. It can lead to cellular damage and edema formation. Edema
formation is more significant in the brain which produced augmented intracranial pressure
and corresponding reduced cerebral perfusion postresuscitation. It can lead cerebral
dysfunction which produces altered alertness and mild coma and confusion.
Phase 3 : After initiating, appropriate clinical care assessment of John was reassessed for all
the parameters. Observed respiratory rate, oxygen saturation, blood pressure, heart rate and
GCS were 30, 88 %, 92/54, 134 and 11 respectively. His all the parameters were deteriorated
in this phase. In this phase, deterioration of John might be due to stroke (Downar, 2014).
Phase 4 : After activating rapid response phase cardiovascular parameters in John were
reassessed. Observed blood pressure and heart rate 52/25 and 144 respectively. Ventricular
tachycardia (VT) was observed in John. VT is nothing but pulse rate more than 100 with
three or more irregular hertbeats. Increased heart rate can lead to augmented pumping of the
blood through the heart. Due to this blood vessels through which blood is being flowing get
dilated. Hence, there can be reduced blood pressure in such patients. In ventricular
tachycardia, pathological changes occur are related to the scarring of the heart muscle mainly
due to earlier myocardial infraction. Due to scar, there is absence of electrical activity mainly
due to circuit around the formed scar. It results in the tachycardia (Ulus et al., 2013).
John was attached to Automated external defibrillator (AED) which is a automatic heart
rhythm analyser and it can also be used to assess response to shock provided to restore
normal heart rhythm. John was applied with pads and shock with 200 joules. However, it
didn’t exhibit effect on John. Second shock was given to John and it was observed that
ventricular ectopic beat (VEB) was observed. It is an additional heart-beat originating in the
lower chamber of the heart (Mitchell et al., 2014; Barwise et al., 2016). After giving second
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shock, all the parameters were assessed in John. Observed respiratory rate, oxygen saturation,
blood pressure, heart rate and GCS were 14, 88 %, 72/48, 89 and 14 respectively.
Improvement in the parameters like respiratory rate, heart rate and GCS were observed.
Nurse and patient safety:
Nurses can play significant role in implementing this methodology to ensure patient safety.
Nurses are committed with code of ethics for providing safe, competent and ethical care to
the patients. Patient safety is fundamental aspect of nursing and it is mandatory fir the nurses.
While providing safe care to the patients nurses should consider workload, physical
environment, complexity of patient condition and technology. Nurses voices should be
listened for providing safe care to the patient. In this case medical officers should respond
within the time to activate clinical review and rapid response (DiCuccio, 2015; Kirk et al.,
2015).
Conclusion:
Between the flags system was effectively implemented in case John. It helped in assessing
deterioration of john at each step of slippery slope response. Assessment of deterioration at
each step helped in providing accurate intervention at each step. Intervention for next step
was planned based on the assessment of the previous phase. Implementation of the between
the flags method helped in reducing harm to John. It helped in reducing failure to recognise
and respond to John’s deterioration. Strong support from the staff is very important in
implementing between the flags system. Between the flags system proved helpful in the
building foundation for improving safety of John.
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