(PDF) Managing Deteriorating Patients

Essential Nursing Care:
Managing the Deteriorating
Patient
Table of Contents
INTRODUCTION...........................................................................................................................1

MAIN BODY...................................................................................................................................1
Analyse the case study and develop a discussion of the application of each element of the
Clinical Reasoning Cycle.......................................................................................................1
Identify moments of deterioration and four appropriate evidence-based nursing interventions
................................................................................................................................................3
ISBAR communication tool...................................................................................................4
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................6

INTRODUCTION
Nursing care refers to effective policiess and practices which are required to be carried
out in order provide treatment to a sick person. It includes a registered nurse who is required to
be graduate in related field, passed state board examination and been registered & licensed to
practice nursing (Odell, 2015). The present reports is based on case study of patient named Mary
Smith and having age of 82 years old along with underwent a left total knee replacement under
general anaesthesia 6 hours ago. This assignment will focus on application of every element of
the clinical reasoning cycle in context of given case study. It will also include determining
moments of deterioration and number of interventions applicable for the same. The use of
ISBAR communication tool
MAIN BODY
Analyse the case study and develop a discussion of the application of each element of the
Clinical Reasoning Cycle
According to the given case study, Mary Smith is 82 years old with weight of 100 kgs patient
having undergone a left total knee replacement under general anesthesia 6 hours ago. She has
past medical history including osteoarthritis in both knees along with limited range of movement
and pain on weight bearing in left knee. However, she also has a problem of Type 2 diabetes
Mellitus which has been diagnosed 3 years ago. In addition to this, patient has essential
hypertension, fatty liver disease with moderate enlargement and diabetic neuropathy in both feet
with intermittent mild neuropathic pain and no neurological deficit (Della Ratta, 2016).
Moreover, clinical reasoning cycle was promoted by a nursing professor named as Tracy- Levett
Jones which is useful in nursing settings to deal with sick people. It consist eight steps which are
described here.
Consideration of facts from the patient or situation – Initial phase consist the situation
when a nurse come to know about clinical case about a patient having specific health issue
including their symptoms and receiving other related information. It includes making current
status of patient in order to make report to discuss with specialist for deciding regarding
appropriate medication for their wellness. In context of Mary Smith, nursing staff is required to
analyses her problem of pain in left knee and other problems determine about in order to provide
appropriate medication to her.
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Collection of information – This step includes gathering more detailed information
about patients including their past medical history along with their preferred medications for the
previous determined health problems. It is necessary to gain knowledge regarding historical and
present issues faced by an individual because results of investigation provide support to accurate
nursing care plan for their wellbeing (O'Leary, Nash and Lewis, 2016). Nurse is required to
analyze findings using established physiology, pharmacology, culture and ethics to provide
desired treatment in proper way. The nursing assistant appointed in case of Mary smith is should
gather information about her medical history of having Type 2 diabetes, osteoarthritis &
hypertension to give more favorable medication according to acceptance of her immune system.
Processing gathered information – The third step can be considered as a critical stage
and core of clinical reasoning including processing the data on present health status of a patient
in relation to pharmacological and pathophysiological patterns. It is helpful to evaluate detailed
relevant data and identify potential outputs for possible decisions made by a registered nurse for
welfare for an individual. In case of Mary Smith, nurse is helpful to determine actual health
problem of like pain in left knee, blood pressure, pulse rate and temperature.
Identify the problem – This includes the criteria of processing phase along with solid
information through which a registered become capable to determine reasons and causes behind
particular health issues including present state of sick person. In context of Mari Smith, she has
Type 2 Diabetes Mellitus and pain in left knee which is due to not providing proper care to her
and improper nutrition intake.
Establish goals – The goals of nursing plan include treatment objectives which are
expected for situation of a patient. However the nursing plan of treatments is not open ended or
without a time oriented goal (O'neill and et. al., 2015). It include every step with it effectiveness
and overall plan with goals of wellness of an individuals. In addition to this, Mary Smith to
provide proper care for overcome her pain and remains healthy.
Take action – This step can be described as to apply nursing plan of care in order to meet
actual requirements of patient according to their specific health issue which facilitate to make
them healthy. Meanwhile, nurse of Mary Smith should apply established plan in more effective
as well as efficient manner with help of healthcare team in respect of completing set goals of
wellness of sick person.
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Evaluation – This phase involve the criteria of evaluating effectiveness of actions taken
by care team including nurse in order to make an individual healthy. It is helpful to a registered
nurse for identifying about need to readjust or continue specific line of action as per acceptance
of Mary Smith’s immune system.
Reflection – The final phase of clinical reasoning action is required provide views about
new aspects learned through dealing with specific sick person.
Identify moments of deterioration and four appropriate evidence-based nursing interventions
The moment’s deterioration can be explained about those aspects which provide
indications about worse situation of an individual. As per given case study of Mary smith, she
has several vital signs examined 60 minutes ago including BP 123/70, radial pulse 55, RR 18,
SpO2 96%, FiO2 0.21, T 36.2, peripheral capillary refill 2 seconds and warm digits. In
comparison to this, she indicates certain vital symptoms in present time such as BP 105/56,
radial pulse 66 regular, RR 20, SpO2 93%, FiO2 0.21, T 36.4 tympanic, BGL 11.5 mmol/L,
Peripheral capillary refill is 3 seconds plus pate cool digits. However, the changes in such factors
within 60minutes can be considered as moments of deterioration determined in case of Mary
Smith which is required to be focused immediately and identify actual cause behind the same. It
has been analyzed that diastolic blood pressure is abnormal, radial pulse has enhanced from the
base line of the same, increasing respiratory rate, decreased saturation of oxygen, reduced
capillary refill and peripheries are pale & cool (Adam, Osborne and Welch, 2017). In context of
given patients several evidence based interventions are required to be followed in order to make
her wellbeing with the help of solving specific medical problems.
Initially, the first interventions consists the criteria to carrying out assessment of airway,
breathing and circulation in an appropriate manner. It is necessary take action of administering
oxygen concentration; provide fluids in order to maintain ventilation and circulatory volume for
adequate perfusion of an organ system. However, the second intervention includes administering
insulin to Mary Smith since she is hyperglymic. Moreover, her blood sugar is high at
11.5mmol/L which demands for insulin and oral hyperglymic agents like metformin to lower it
to normal values including 3.5 to 7.4 mmol/L (Lucas, 2014). In addition to this, the third
intervention involves to maintain nasogastric tube in order to feed Mary Smith once the bowel
sounds are present. Meanwhile, the metabolic response to injury needs adequate calories as well
as proteins and the adequate feeding provides help to speed up recovery period respectively.
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Furthermore, the fourth intervention consist the action of make sure about that bowel and bladder
care are adequately completed which facilitate to boost up comfort level of sick person along
with reducing the incidences of sepsis. Additionally, another intervention consist two hourly
turning in respect of reducing the rate of pressure sores on the bony prominences accordingly.
Considering above described effective interventions step by step as they are much
efficient for evaluating actual problems faced by Mary Smith in order to take accurate actions
suitable to her. It consists to analyze overall condition and make sure about actions that they are
favorable for patient otherwise it is required to conduct readjustments to make them healthy.
Moreover, the mentioned interventions are much effective to make Mary Smith feel comfortable
and relieved.
ISBAR communication tool
The ISBAR communication tool can be considered as mnemonic generated in respect of
boosting up safety in context to transfer of critical information. However, it stands for identity,
situation, background, assessment and recommendation which provide support to transfer and
maintain clinical information secure as well as accurate respectively (Endacott and et. al., 2015).
ISBAR is frequently used framework in clinical settings which facilitate to develop a handover
script to Medical officer.
Identity – I am a first year graduate Registered nurse (RN) in a general surgical department and
going to present a report to Medical report. The name of patient is Mary Smith whose age is 82
years old who is female and admitted in general surgical department.
Situation – The purpose of calling you is providing a report about patient that she has present
symptoms that result into deterioration condition. We have taken several effective steps to
maintain her worse condition to stable her respectively.
Background – The patient is underwent a left total knee replacement under general anesthesia 6
hours ago. She has history of osteoarthritis of both knees with limited movement and pain on
weight bearing in left knee. She has medical history of having Type 2 diabetes Mellitus,
hypertenstion and fatty liver disease. In addition to this, medications incudes Metformin,
Empagliflozin, Metoprolol, Atorvastatin, Karvezide, fish oil and Hypericum in suitable amount.
The vital signs changed within 60 minutes and BP, radial pulse, RR, capillary refill, BGL and
temperature become abnormal hence results into deteriorative condition.
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Assessment – The deterioration moments has been examined with the help of assessing airway,
breathing and circulation to analyse problem. The intervention is administering oxygen & fluids
to maintain ventilation along with circulatory volume for adequate perfusion of organ system.
Requirement – I am requesting you to please provide advanced technologies in this institution
because it is difficult monitor patients 24 hours and diagnose health issues immediately by
saving time which is very precious in healthcare.
CONCLUSION
From the above report, it has been analysed that nursing is an important health professional
having roles and responsibilities to provide care services by following legislation, care standards
and clinical practices. It includes the clinical reasoning cycle which is effective in clinical
settings including its several phases such as consideration of facts from the patient or situation,
collection of information, processing gathered information, identify the problem establish goals,
take action, evaluation and reflection. It consists moments of deterioration and ISBAR
communication tool including identity, situation, background, assessment and requirement to
submit report to Medical officer.
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REFERENCES
Books and journals
Odell, M., 2015. Detection and management of the deteriorating ward patient: an evaluation of
nursing practice. Journal of clinical nursing. 24(1-2). pp.173-182.
Della Ratta, C., 2016. Challenging graduate nurses' transition: Care of the deteriorating patient.
Journal of clinical nursing. 25(19-20). pp.3036-3048.
O'Leary, J., Nash, R. and Lewis, P., 2016. Standard instruction versus simulation: Educating
registered nurses in the early recognition of patient deterioration in paediatric critical
care. Nurse education today. 36. pp.287-292.
O'neill, B. and et. al., 2015. Nursing home nurses' perceptions of emergency transfers from
nursing homes to hospital: A review of qualitative studies using systematic methods.
Geriatric Nursing. 36(6). pp.423-430.
Adam, S., Osborne, S. and Welch, J. eds., 2017. Critical care nursing: science and practice.
Oxford University Press.
Lucas, A. N., 2014. Promoting continuing competence and confidence in nurses through high-
fidelity simulation-based learning. The Journal of Continuing Education in Nursing.
45(8). pp.360-365.
Endacott, R. and et. al., 2015. Leadership and teamwork in medical emergencies: performance of
nursing students and registered nurses in simulated patient scenarios. Journal of clinical
nursing. 24(1-2). pp.90-100.
Online
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despite-inadequate-feeding-showing-that/>
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