Critical Care Nursing Assignment

This assignment provides a detailed review of critical care nursing topics, including prehospital needle decompression for tension pneumothorax, early recognition of deteriorating patients on general wards, surgical stabilization of severe rib fractures, simulation in nursing practice, structured patient assessment frameworks, physiology and cardiovascular effect of severe tension pneumothorax, pneumothorax and asthma, caring for critically ill patients outside ICUs due to a full unit, prognostics and health management, and assessment and management of the septic patient. The assignment also includes references to relevant studies and articles in the field of critical care nursing.

Running head: NURSING CASE STUDY 1
Care for a Critically Ill Patient
Name
Institution

NURSING CASE STUDY 2
Care for a Critically Ill Patient
Introduction
Patients who are admitted as critically ill into hospitals are at huge risk of experiencing
deteriorating health conditions as a result of their altered psychological state. The development
of these deteriorating conditions happens gradually over several hours and can be suspected if
the patient starts showing abnormal vital signs (Considine & Currey, 2015). The abnormalities
are a sign of failing cardiovascular system, in addition to the neurological and the respiratory
system (Tinker & Rapin, 2013). These psychological abnormalities need to be identified,
corrected quickly and supported efficiently or the patient risks seeing his/her condition progress
to a critical illness that may even lead to death. According to Silva et al. (2015), the nurse is the
best-placed individual to observe and assess the patient in the period that precedes the critical
illness and intervenes early enough to prevent deterioration of the patient’s condition.
The safety of a critically ill patient is the primary concern of the nurse and other health
practitioners. The nurse should be able to recognize the signs of health deterioration to prevent
the possibility of unintentional harm to the patient (Morton, Fontaine, Hudak, & Gallo, 2017).
Changes in the physical condition of the patient which leads to hemodynamic instability can be
detected by observing and recording the vital signs such as the blood pressure, respiratory rate,
temperature, and heart rate that usually become more abnormal as the clinical condition of the
patient keeps deteriorating. It is therefore important to note that the effective nursing observation
is crucial in identifying any signs of clinical concern and recommending the most appropriate
nursing interventions to prevent the progression to a critical illness (Michelle Aebersold & Dana
Tschannen 2013). In this essay, therefore, we will talk about the role of the nurse in providing

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effective patient care. Additionally, we will talk about the potential complication that Mrs. Smith
might encounter and the appropriate interventions for these complications.
Best Practice in Caring for Deteriorating Patients
The focus on the recognition and response to the deteriorating health conditions of nurses
has increased in recent years. In most cases, patient deterioration may not be recognized early
enough and responded to in a timely manner (Tinker & Rapin, 2013). The failure to recognize
these deteriorations and promptly responding to them can escalate to critical illness. Below, we
will discuss the several themes that underpin the recognition of patient deterioration and how to
respond to these deteriorations.
Assessment of the Patient
Patient assessment is very significant in identifying the deteriorating clinical conditions
of the patient. It enables the nurse to identify the worsening health conditions in a timely manner
and respond to them appropriately (Douw et al., 2015). Observation and recording of the vital
signs such as the rate of heartbeat, temperature, respiratory rate, and blood pressure are important
in assessing the patient and recognizing deterioration (Bogossian et al., 2014). Studies reveal that
alterations in the vital signs of the patients are enough indicators of declining health conditions.
Identification of these vital signs can be used as cues to determine timely deterioration and aid in
effective decision-making to help in delivering quality care to the patient. There are two types of
assessment that include the primary assessment and the secondary assessment.
Primary Assessment of a Critically Ill Patient

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Primary assessment is the initial approach to assessing and treating a critically ill patient
who may require an emergency attention. It is also known as the ABCDE approach that means
the Airway, Breathing, Circulation, Disability, Exposure approach (Munroe, Curtis, Considine &
Buckley, 2013). The aim of a primary assessment is to save a life, to break down the complicated
clinical situations into ones that can be easily managed, and to give the health practitioners
enough time to establish an ultimate diagnosis and treatment. Additionally, this approach acts as
an algorithm for assessment and treatment. Furthermore, it helps in establishing an all-inclusive
situational awareness for all the healthcare providers (Munroe et al., 2013)
The acronym A stand for Airways that requires a health practitioner to assess and treat
the obstruction of air. Failure to air obstruction may lead to low levels of oxygen saturation and
the partial pressure of oxygen (Zirpe & Gurav, 2015). From the provided scenario, Mrs. Smith’s
oxygen saturation is 89% which is below the normal level that ranges between 95-100%. The
practitioner should, therefore, add Mr. Smith more oxygen to address the issue of airways
obstruction.
B stands for breathing which is used to assess if the breathing is sufficient. Mrs. Smith
had initially suffered a fall that led to her breaking her four ribs. Her breathing rate of
32breaths/minute is higher than the normal rate of 25. Fracture of the ribs may incapacitate the
lungs and cause cyanosis which leads to insufficient supply of oxygen in the body (Adam, 2017).
It is thus important to perform assisted ventilation if breathing is insufficient.
The next step of the assessment is circulation that is represented by the letter C.
performing a skin inspection can give the clues to problems in circulation. Mrs. Smith’s blood

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pressure is 95/50 mmHg which may be a sign of hypotension. Hypotension could be an
indication of poor circulation (Vaughan & Parry, 2016).
The next step in the primary assessment is D which means disability. It is used to assess
the patient’s level of consciousness (Brown, Edwards, Seaton & Buckley, 2017). Mrs. Smith
should be assessed whether she is alert, voice responsive, pain responsive or unresponsive.
Another step known as Exposure that is represented by letter E. Mrs. Smith should be assessed
for any signs of trauma or bleeding through a thorough physical examination (Adam, 2017).
After exposure, it is necessary to assess her fluid balance represented by F. From the scenario we
are informed that she has a decreased output of urine. The final step is looking at blood glucose
level, assigned letter G.
Secondary Assessment of a Critically Ill Patient
Secondary assessment is divided into an assessment of the head, thoracic cavity,
abdominal cavity and long bones. During the assessment of the head, it is required that the
physician observes the face of the patient for any forms of abnormalities (Brown et al., 2017). It
may also be important to observe Mrs. Smith’s lips for any signs of cyanosis especially given the
fact that she had suffered broken ribs that could incapacitate her lung's ability to exchange
oxygen with blood.
The next step is the assessment of the thoracic region. This is done to check whether the
expansion of the chest is symmetrical or asymmetrical. Asymmetrical movements of the chest
may be a sign of broken ribs like is the case with Mrs. Smith (Vaughan & Parry, 2016). After
this assessment, the practitioner initiates a suitable intervention. The next step is the assessment
of the abdominal cavity. This is done to check for any signs of injury, wounds, and bruises.

NURSING CASE STUDY 6
During this assessment, the nurse may be able to notice the skin tear present on her right arm.
The final step is the assessment of the long bones or the legs. The legs are checked for any signs
of swelling or discoloration (Vaughan & Parry, 2016). Discoloration may be as a result of
cyanosis.
Potential Complications Mrs. Smith could encounter
From our case study, we are informed that Mrs. Smith fell and broke her ribs. Upon
admission to the hospital, the nurses realize her deteriorating clinical condition. Some of the
observations made include a pulse rate of 110 beats per minute, a blood pressure of 95/50
mmHg, a tympanic temperature of 37.8º C, and a respiratory rate of 32 breaths per minute.
Additionally, she has an indwelling catheter in-situ. From these assessments, it is evident that her
condition is critical and may lead to several other complications. Some of the possible
complications that Mrs. Smith could encounter are discussed below.
Tension Pneumothorax
Tension pneumothorax can be defined as the progressive accumulation of air in the
pleural space. This accumulation of air is in most cases caused by the laceration of the lungs, that
allows the entry of air into the pleural space and the air is not allowed to come out (Nelson et al.,
2013). The accumulated air is normally under pressure and this may lead to a collapse of the
lungs. Tension pneumothorax is a life-threatening condition that needs a prompt intervention to
prevent the condition of a patient from getting worse. What makes this complication to be life-
threatening is that air escapes into the pleural cavity and is not released during expiration
(Porpodis et al., 2014). As a result, the air pressure within the thorax builds up above the

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atmospheric pressure thus compressing the lungs. What happens is that the mediastinum is
displaced to the opposite side leading to cardiopulmonary impairment.
From the presented scenario, we are told that Mrs. Smith suffered a fall and broke four of
her ribs. The fractured ribs may lead to lung laceration and thus cause insufficient ventilation.
This insufficient ventilation is further characterized by the fact that she has a decreased bilateral
entry of air. This condition may also block the venous return to the heart. It can be characterized
by hypotension like in Mrs. Smith’s case whose blood pressure is 95/50 mmHg. Other additional
signs may be increased airways pressure and tachycardia.
Hemothorax
This complication is characterized by the presence of blood in the pleural space. It is
commonly caused by a traumatic injury to the chest (Broderick, 2013). From the case study, we
realize that Mrs. Smith has four broken ribs. The broken ribs may cause a puncture wound to the
pleural membrane that surrounds the lungs thus spilling blood into the pleural space. The build-
up of blood in this space may lead to a collapse of the lungs as the blood keeps pushing on the
outside of the lungs. Some of the readings from Mrs. Smith’s assessment are as follows; a pulse
rate of 110 beats per minute, a respiratory rate of 32 breaths per minute and a blood pressure of
95/50 mmHg. These readings could all be possible signs of hemothorax, which is characterized
by abnormally fast heartbeat, quick breaths, and low blood pressure or hypotension (Broderick,
2013). Tension pneumothorax can also cause hemothorax among the critically ill patients.
Sepsis
This condition may result from the body’s autoimmune response to an infection. It
develops as a result of the chemicals that inflammation caused throughout the body by the

NURSING CASE STUDY 8
chemicals released by the immune system into the bloodstream to fight an infection. According
to Adam (2017), this complication may lead to septic shock and cause a massive decline in blood
pressure which may even cause death. It is, therefore, a very life threatening condition that needs
prompt intervention (Angus & Van der Poll, 2013). From the case study, we notice that Mrs.
Smith’s pulse rate is 110 beats per minute. Additionally, she has a respiratory rate of 32 breaths
per minute. We are further informed that her urine output has been extremely reduced.
Furthermore, her blood pressure is extremely low at 95/50 mmHg which could be a sign of
hypotension. Some of the characteristics of sepsis include a respiratory rate above 20 breaths per
minute, a reduced urine output, a heartbeat rate higher than 90 beats per minute and an
abnormally low blood pressure (Adam, 2017). This abnormal reduction of blood pressure may
lead to septic shock.
Nursing Interventions to Address the Complications
The above complications can be prevented from happening or aggravating by using the
appropriate nursing interventions. The nurse must be skilled and knowledgeable enough to know
the most appropriate intervention for the sake of patient safety. These interventions ensure the
delivery of quality patient care and prevent the deterioration of the patient’s clinical conditions.
Some of the most appropriate interventions are discussed below.
Tension pneumothorax can be managed by the use of needle thoracostomy. This is a form
of chest decompression whereby an intravenous cannula is inserted into the space of the second
rib along the mid-clavicular line (Dominguez et al., 2013). The needle is used to aspirate air from
the pleural space into a syringe connected to the needle. After withdrawing the needle, the
cannula is left open to air and this intervention helps in changing the tension pneumothorax into

NURSING CASE STUDY 9
a simple pneumothorax. Another more efficient intervention is known as the chest drain
placement. In this case, a chest tube is rapidly placed into the patient’s thoracic cavity. After a
blunt dissection, the tension is decompressed after which the chest tube is placed (Dominguez et
al., 2013). Chest tube placement is considered to be the sure treatment for tension pneumothorax.
The intervention for hemothorax is almost similar to that of tension pneumothorax. The
attending doctor firstly inserts a needle into the chest and uses a syringe attached to the needle to
remove blood and air trapped within the pleural cavity. A sedation is then used to insert a
catheter into the chest and the catheter may be used to expand the affected lung after the chest
has been drained (Broderick, 2013). This chest tube may be left attached to a closed system that
permits the escape of air and fluid from the pleural cavity but blocks entry of more air.
According to Majercik et al. (2015), a surgery may also be recommended to correctly treat this
complication by stopping the bleeding at its cause.
The Center for Disease Control and Prevention has recommended three approaches that
may help to prevent infections that may lead to sepsis. The attending doctor may recommend a
vaccine against pneumonia and flue that are possible causes of infections. From the scenario, we
are told that Mrs. Smith has an infection in her right arm. As a nurse assigned to care for her, I
have to ensure that this wound is clean to avoid infections (Adam, 2017). It is further important
to stay alert to any symptoms such as rapid breathing, fever, chills, rapid pulse rate, and
confusion that are all associated with sepsis. Administration of oxygen could also be important
by use of a tube placed near the nose or by use of a gas mask. An intravenous saline
administration may also be recommended to help in boosting the blood pressure (Angus & Van
der Poll, 2013). A surgery may also be necessary in some cases.

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Conclusion
Critically ill patients require extensive care because they are at a huge risk of
experiencing major clinical deteriorations. Their safety should be the number one priority of the
nurses and associated health practitioners. Clinical deteriorations are characterized by abnormal
vital signs that may include failing cardiovascular, respiratory and neurological systems. Nurses
must, therefore, observe these vital signs and assess them to be able to recognize deteriorations
in the health of the patient. Observation and assessment are crucial in recommending the most
appropriate intervention thus ensuring quality care and patient safety. Recognition and response
to the deterioration of clinical conditions of the critically ill patients are important in the nursing
practice. Several themes surround the recognition of these declining conditions and they include
a patient assessment that involves primary and secondary assessments. Failure to recognize the
worsening health conditions and responding to them in a timely manner can lead to other
complications such as sepsis, tension pneumothorax, and hemothorax complications. Appropriate
nursing interventions can, however, prevent or reduce these complications.

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