Nursing Assignment on Deterioration and Wound Management

Running Head: DETERIORATION 0
Nursing Assignment
Student Details

DETERIORATION 1
Table of Contents
Introduction................................................................................................................................2
Assessment.............................................................................................................................3
Observation of patient with deterioration..............................................................................4
Action was taken....................................................................................................................6
Role of an assistant practitioner.............................................................................................7
Importance of observing the efficacy of medicine.................................................................7
Wound management...............................................................................................................8
End of life care: knowledge and skills.................................................................................12
Conclusion................................................................................................................................13
References................................................................................................................................14

DETERIORATION 2
Introduction
Deterioration may refer to worsening of health. It is common in hospitalized patients. Clinical
deterioration is a main contributor to the inpatient mortality. Analysis of clinical deterioration
contributes to the identification of risk factors and the intervention that can be assisted to
prevent clinical deterioration inpatient (Jones et al. 2013).
Nursing care can be provided to the patient with deterioration:
1. Respiratory rate should be recorded for each observation because RR is the early sign
of clinical deterioration.
2. SpO2 (oxygen saturation) required to be measured by pulse oximetry.
3. Body temperature should be measured at regular time intervals. The temperature of
the internal body is preferable to measure over axilla.
4. Measuring systolic blood pressure is very important in the patient with acute
deterioration. This can be done either by automatic machines or by using
sphygmomanometer.
5. Heart rate should be checked to palpate pulse and to assess rhythm, rate, and volume.
6. Level of consciousness should be checked. To easily asses the consciousness of a
patient AVPU can be examined, where A is Alert, V in response to the voice, P and U
in response to pain or unresponsive (Royal College of physicians, 2012).
7. Nurses should take help from seniors when it is necessary
8. It should be ensured that the patient is assessed promptly and effectively managed to
achieve the health goals already set for them to get positive outcome (Nursing and
Midwifery Council NMC, 2015).

DETERIORATION 3
Assessment
ABCDE approach can be used to assess the condition of a patient with deterioration. ABCDE
stands for Airway, breathing, circulation, disability, and exposure.
Airway
The signs of airways obstruction such as ‘see-saw’ respiration, central cyanosis, diminished
air entry and noisy breathing need to be observed.
Breathing
 During an immediate assessment of breathing, life-threatening conditions such as
acute asthma, tension pneumothorax, pulmonary oedema and massive haemothorax
should be diagnosed.
 Signs related to respiratory distress like sweating, use of an accessory muscle to
breath, central cyanosis and abdominal breathing should be observed.
 Respiratory rate should be count. The increasing RR (>25 min -1 ) is determined as
abnormal
 The depth and pattern of respiration should be checked
Circulation
 Hypovolaemia is considered as a primary cause of shock in almost all emergency
cases. Provide intravenous fluids to the patient fast heart rate and cool peripheries.
 Limb temperature should be checked by feeling the hand of the patient
 CRT (capillary refill time) should be assessed. This can be measured by applying
pressure for 4-5 seconds on the fingertip. Note the time of returning the skin to its
natural color after releasing the pressure. The normal value of CRT is < 2 seconds.
A prolonged CRT determined as poor peripheral perfusion.