Nursing: Anticipating Clinical Deterioration Signs in Patients

Running head: NURSING
Nursing
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Author’s note

1NURSING
Clinical deterioration is a challenging issue for nurse in health care setting. Nurses need
to be highly engaged in the care of patient and understandthe process needed to recognize and
respond to signs of clinical deterioration (Mohammmed Iddrisu et al., 2018). This essay aims to
develop understanding regarding the manner in which a nurse anticipates clinical deterioration
signs in patient and uses their critical thinking to manage deterioration. It aims to review the
presenting condition of Kenneth Bradman, a 67 year old man who has been admitted to the
surgical high dependency unit post a large per rectum bleeding and identify two signs and
symptoms of clinical deterioration for the patient. The essay will further discuss the priority
problem and two nursing intervention to address the priority problem. To promote full recovery
of Kenneth, the essay gives discussion regarding potential psychosocial issue for the client.
The first priority during care of patient is to identify sign and symptoms of clinical
deterioration. This is essential to prioritize appropriate care for patient. The case study is about
Kenneth, who has been hospital for bleeding rectum and he had to be given emergency
gastroscopy for upper gastrointestinal bleeding. The review of his most current assessment data
at 8: 25 am shows that the patient is pale and disorientated. His hand is cool to touch and his
pulse rate is 116 beats/minutes. His breathing pattern has become more labored and his SpO2 is
91%. The review of overall vital sign assessment done at 05: 00 hrs, 06:000 and 07:00 hrs shows
deterioration in almost all vital signs indicating that the patient condition is deteriorating further.
Hence, based on the review of his symptoms, his presenting problem is hypovolemic shock. This
is said because hypovolemic shock is a condition associated with decreased BP, poor pulse, cold
and pale skin, confusion and rapid heart rate (Carlson & Fitzsimmons, 2019). All these
symptoms were found for Kenneth too.

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Two signs or symptoms indicative of hypovolemic shock in patient includes labored
breathing indicated by high breathing rate and decrease SpO2 level; and increase in heart rate.
Hyopovolemic shock is a serious clinical condition occurring due to excess extracellular fluid
loss because of gastrointestinal fluid losses, renal loss of salt and fluid and dehydration due to
fluid loss (Kislitsina et al., 2019). In case of Kenneth, he sufferedfrom hypovolemic shock
because of upper gastrointestinal bleeding. The main pathophysiology behind the clinical
symptom of cool and clammy skin is understood from the changes in the body that takes place
due to excess fluid or blood loss. Due to depletion of intravascular fluid volume because of
fluid/blood loss, the body compensates for the same with increase in sympathetic tone. This
results in peripheral vasoconstriction, increased heart rate and peripheral vasoconstriction. The
first change observed in patient is narrowed pulse pressure along with increase in diastolic blood
pressure. After this oxygen, delivery to vital organs is affected resulting in further deterioration
of symptoms (Gaieski & Mikkelsen, 2016). Similar events were found in the case of Kenneth
too.
From the review of current clinical symptoms of Kenneth, one priority problem identified
for the patient includes deficient fluid volume evidenced by cool clammy skin, narrowed pulse,
tachycardia, bleeding, change in level of consciousness, decrease urinary output and cool and
clammy skin (Gaieski & Mikkelsen, 2016). In case of Kenneth, last assessment revealed
bleeding in the gastrointestinal tract and on systematic assessment, he is found to be pale and
disorientated indicating changes in level of consciousness. The severity of deficient fluid volume
is understood from pathological test which shows decrease in haemoglobin level. Normal range
of haemoglobin is 130-180g/L and his haemoglobin level results at 07: 45 hrs revealed values of
69 g/L. The main rationale for prioritizing deficient fluid volume or bleeding loss in Kenneth is

3NURSING
that it is the primary condition that leads to initiation of changes in the body of patient
(Ratnasekera, Reilly & Ferrada, 2018).
Decreased fluid volume leads to reduced blood return to the heart contributing to low
cardiac output. This in turn increases the heart rate and increases systematic vascular resistance
and tissue perfusion pressure. In later shock stage, blood volume rises and urine output decreases
(Gulati, 2016). Hence, uncorrected hypovolemia can be fatal and addressing decreased fluid
volume is most crucial to reduce further deteriorations in vital signs of patient. As Kenneth
experience hypovolemic shock because of decrease in blood volume due to excessive bleeding,
leaving the patient untreated may lead to hypoxic tissue damage, organ failure and ultimately
death (Mandal, 2016). Therefore restoring fluid volume is most crucial to save life of patient and
stabilise the condition of patient.
In response to the problem of deficient fluid volume due to bleeding and its impact on
deterioration of vital signs of Kenneth, two nursing intervention that is vital to stabilize the
patient condition includes administering crystalloid fluid in conjunction with vasoactive
medications and blood transfusion. Use of crystalloid is the first fluid of choice for resuscitation
of patient who experience hypovolemic shock due to blood loss (Walley, 2018). In addition,
vasoactive agents like dopamine can help to increase blood pressure of patient. The two
interventions have been prioritized considering the past medical history of patient too. Kenneth is
a patient with chronic kidney disease and hypertension. Hence, low fluid volume due to fluid
volume can have many negative complications on his kidney functions and blood pressure
(Feehally & Khosravi, 2015). Therefore, to prevent problem in blood circulation and kidney
function, crystalloid infusion is important to restore fluid and vasoactive medication is necessary
to control blood pressure respectively.