NSG3TCN: Case Studies on Patient Deterioration - Nursing Actions

This assignment presents four case studies focusing on patient deterioration, addressing key issues, pathophysiology, nursing actions, and professional challenges. Case Study One involves a patient with heart failure experiencing potential cardiac arrest, pulmonary edema, and myocardial infarction, emphasizing the need for immediate intervention and addressing professional concerns regarding communication and escalation. Case Study Two explores a post-operative patient experiencing hypovolemia, pain, and potential respiratory distress, highlighting the importance of fluid resuscitation, pain management, and addressing communication gaps. Case Study Three centers on a patient with recurrent pneumothorax, discussing tension pneumothorax, hypoxemia, and pain management, while considering cultural sensitivity in patient care. The assignment requires students to analyze each case, provide nursing actions, and identify professional issues, referencing relevant literature and professional standards.

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Table of Contents
Case Study One................................................................................................................................2
Case Study Two...............................................................................................................................3
Case study Three..............................................................................................................................5
Case study Four...............................................................................................................................6
References........................................................................................................................................8

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Case Study One
1a) Pathophysiology and rationales
William is a 64-year-old patient with a history of heart failure. He has called for immediate
assistance as he is unable to breathe without discomfort. Upon examination, it was seen that his
heart rate was above the normal while other vitals were well within the normal range. The key
issues that William is suffering from are potential cardiac arrest, pulmonary oedema and
myocardial infarction.
William has not undertaken any exercise and yet his breathing is troubled. It is a common
symptom in level IV heart failure (Coccia et al. 2016). The heart muscles have weakened and is
unable to pump enough oxygenated blood to the body organs. The tachycardia along with
troubled breathing is often a symptom of atrial tachycardia. It may be a response to the electrical
signal generated in the atrial tissues as opposed to the sinoatrial node. It is a common reaction to
drugs or other medication (Arrigo et al. 2016). All the symptoms hint towards a possible cardiac
arrest which is an abrupt loss of the heart’s function and the prevents normal circulation of
blood. The vital organs are deprived of oxygen and if left untreated can cause organ death.
Together with Pulmonary oedema, a condition where the lung is filled with excess fluid, it may
prove to be fatal. Due to pulmonary oedema the air sacs are filled with fluid, which hampers the
exchange of gasses, as a result, the heart cannot receive enough oxygenated blood to the organs
(Walsh et al 2018). As the blood flow to the heart decreases, myocardial infarction or a heart
attack can follow as the heart muscles cannot fuel themselves without oxygen.
The issue that is of top priority is troubled breathing as it prevents the cells to fuel their activity.
In order to compensate for the increased need in the cells and tissues. It is a common
complication arising in level IV heart failure and hints to the weakening of the heart muscles
(Mentz & O'connor, 2016).
1b) Nursing actions and rationales
The issue that needs to be relieved immediately is laboured breathing. After performing a
respiratory test to check for any blockage in the respiratory passage, presence of cough or any
pulmonary infection such as pneumonia (Louge et al. 2016). William’s position can be changed
to improve his breathing. His bed can be inclined less and he may be asked to sit straighter or
even bend a little for clearly any obstruction to breathing. In case of further complications like a

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cardiac arrest, CPR can be provided. Other than that supplemental oxygen can be provided to
make the breathing easier (Harjola et al. 2017). The next issue, tachycardia can be resolved once
the underlying cause is identified. For this purpose, it is safe to call on the doctors as is clearly
mentioned in the instructions.
1c) Professional Issue
A professional issue noticed is that of no unanimous understanding can be attained about
William’s present condition. The buddy nurse that is deployed is unwilling to call the doctors
and considers the issues like laboured breathing and tachycardia as normal symptoms associated
with a terminally unwell patient suffering from level IV heart failure. Moreover, a third-year
student is required to take action beyond his learning and power (Mentz & O'connor, 2016). A
nursing student is unable to administer any medication or treatment approach to the patient
without the supervision and permission of the Residential nurse (Arrigo et al. 2016). However, in
the present case, the nurse deems that no such action is required. However, the vitals chart
indicates that a medical review is necessary in case of an elevated but the RN is unwilling to
call the doctors. The issue can be escalated to the ANUM or the educator. In order to negate any
chances of complication and to safeguard the health of the patient, it is required to call the
doctors to get a better understanding of William’s present condition (Coccia et al. 2016).
Case Study Two
2a) Pathophysiology and rationales
Carol is a 59-year-old woman who has recently undergone total knee replacement surgery. She
has been transferred to the ward and is accompanied by her partner Dianne. Carol has normal
vitals but low blood pressure and her surgical site also appear to be dry and normal. The issues
that Carol may face are Hypovolemia, pain and respiratory distress due to morphine side effect.
Hypovolemia or hypovolemic shock is caused due to a decrease in the quantity of flowing blood
in the body. The drowsy feeling and low blood pressure are some of the symptoms associated
with it. It is a common complication after a major surgery where a high volume of blood has
been lost. Anaemia is another posing threat due to her blood loss (Harjola et al. 2017). Patients
who have undergone recent surgery are often seen to develop respiratory distress which severely
decreases their chances of wellbeing and recovery (Kislitsina et al. 2019). In Carol’s case, a
threat of respiratory distress can be associated with the use of Morphine. Anaesthetics are related

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to common side effects like a decrease in the breathing rate and low blood pressure and even
respiratory pauses in sleep (Walsh et al. 2018).
Carol is suffering a 6/10 pain which is severe even after being given morphine. It is natural to
feel pain after surgery. It may erupt from the healing wound and inflamed tissues. The tissues
near or around the incision area send nociceptors during and after the surgery that cause pain and
sesnitisation around the area. This means that the dosage of morphine needs to be adjusted but it
may increase the chances of respiratory distress. A combination of other opioids can be given
that are associated with fewer side effects (Harjola et al. 2017). Carol can also be provided
patient controlled analgesic as it would be able to relived her pain better. However, the dosage
still would need to be reviewed by a nurse to ensure that she is not overdosing and abusing the
liberty.
2b) Nursing actions and rationales
It is essential to treat Hypovolemia conditions and the shock caused can be dangerous for the
organs. It may cause severe dehydration and can cause hypoxic tissue damage, organ failure
resulting in death (Gaieski & Mikkelsen, 2016). Under the care of a resident nurse, Carol can be
provided supplementary oxygen so that the cell can receive oxygen in spite of the loss of blood
volume. Resuscitation fluids can be administered intravenously to make up for the loss of plasma
volume and prevent any chances of dehydration. The next concern is Carol’s respiratory distress
can be resolved for a while using supplementary oxygen source and using anaesthetics that have
limited side effects. For the pain, adjuvant analgesics and a combination of strong opioids can be
used instead of morphine (Siddall, Khatri & Radhakrishnan, 2017). The use of morphine may be
the underlying cause towards the respiratory distress, as a result, some other opioids or a
combination of them need to be used in combination in order to ensure that they are strong
enough to relieve Carol’s pain.
2c) Professional Issue
The professional issue noticed here is that no follow up was received from the registered nurse
overlooking Carol. It has been past one hour after she was transferred. Follow-ups are required to
be discussed among nurses who precede or succeed one another as this ensures that no key
information about the patient is missed (Gulati, 2016). Also, some information may not be
recorded in the vital chart which may include the patient’s personal preference or discomfort.

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The second issue is that Carol is under the effect of morphine and feels drowsy. She is unable to
answer the question and inform much about her condition. However, he has relayed about feeling
severe pain. Her partner Dianne, accompanying Carol in the room wishes to not disturb Carol
from her sleep and answer questions regarding Carol’s condition herself. She even reasoned
about Carol’s low blood pressure being because of her fit body. However, it is necessary to
collect information directly from the patient themselves as long as they are able to make an
informed decision and are in stable mental condition (Carlson & Fitzsimmons, 2019).
Considering the information provided by someone else, be it someone close to the patient, will
be considered as a breach of privacy and patient centred practice.
Case study Three
3a) Pathophysiology and rationales
Glenn has a history of right pneumothorax which is recurrent. He has an underwater sealed drain
in situ and is being considered for talc pleurodesis. He appears to be anxious, taking shallow and
elevated breathing rate of above 24 while resting. He is also feeling bearable pain where the tube
is inserted within his chest. His issues are tension pneumothorax, hypoxaemia and pain.
Tension pneumothorax is a gradual build-up of air within the pleural space through a laceration
in the lung membrane (Carlson & Fitzsimmons, 2019). The air is able to enter from the
laceration but cannot leave as the laceration acts as a one-way valve. The air within the pleural
membrane pressurises the lung and prevent blood from flowing back to the heart. As a result, the
oxygen concentration level in the blood is decreasing giving rise to hypoxaemia (Mentzer, Tsuda
& Loring 2018). The symptoms of elevated breathing rate and shortness of breath are also
associated with this condition. The mild chest pain can be because of the pressurised and
collapsed lung caused due to air accumulation, the inflamed cells around the chest tube opening.
This type of pain can be nociceptive that is caused due to the incision made and the friction
caused as the tube moves against tissues and cells. It may also be visceral pain that originates
among the visceral organs such as lungs.
3b) Nursing actions and rationales
The tension pneumothorax needs to be relieved soon as it may be fatal if not treated promptly. A
small pneumothorax without any underlying issue is able to treat itself. However, Glenn has a
medical history of recurrent pneumothorax and it needs to be acted upon quickly. The free air

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accumulated needs to be released through a chest tube (Kesieme et al. 2016). If even after
inserting a chest tube the condition recovers then a operative approach needs to be considered.
From the visual cues, the right lung also appears to be slightly deflated. However, imaging tests
are required to be sure.
Nursing action for hypoxaemia will aim to raise the oxygen concentration in blood and the best
way is to treat the underlying condition. In Glenn’s case hypoxaemia is caused due to tension
pneumothorax. Medication can also be used along with oxygen therapy through a breathing mask
or cannula tube. Glenn can be given a mild dosage of analgesics to relieve pain that does not
have any respiratory side effects.
3c) Professional Issue
Glenn is an indigenous man who may not feel comfortable being within a closed room. It is
essential to note that the health beliefs and behaviour of an indigenous man hailing from a
different cultural background is likely to be different than what is commonly observed. As a
result, the hospital is required to be aware of his specific needs, ensure that he is comfortable and
does not feel alienated.
He wants to move outside in fresh air. This is probably because he feels his shortness of breath
and elevated breathing rate is due to the closed environment of the room. He believes he will be
able to breathe more comfortably once he is outside. In the case of person-centred practice, the
patient and the nursing professionals are seen as equal partners who are on a journey for
recovery. In this case, it is necessary to consider the opinions and wishes of the patients (Walsh
et al. 2018). It is not possible to override their wishes and not acknowledging them (Lichtenstein,
2016). Glenn wants to be outside for five minutes, however, the medical orders state that “he is
to remain on the bed”. There is a difference in the opinions of the patient and the medical
professionals. In this case, the patient can be explained about his condition and made to
understand that his present discomfort will not be soothed if he goes out (Casha et al. 2016).
Accepting help from an aboriginal liaison officer can make the situation better. It is highly likely
that in their presence, Glenn will be more comfortable and more eager to accept help and
treatment.

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Case study Four
4a) Pathophysiology and rationales Can we see another issues here as I feel it is not
appropriate and linking together with the case study. We need two issues and need the
pathophysiology related to it. We have to link the issues with the symptoms of the patient.
There is no signs of blood in the case study, however I need to link coughing and nausea
with bleeding.
Wendy is an 8-year-old girl who is kept under surveillance for four hours after undergoing a
bilateral tonsillectomy. She says that she is sick but cannot give any more information. She is
crying and coughing intermittently. The IV cannula has been removed as it was thought to be
causing her distress. The two possible issues can be haemorrhage and throat, ear pain.
Wendy relays that she is feeling sick. However, she cannot explain more about it. This is
probably due to postoperative nausea and can cause vomiting. She is sleeping on the side. This is
not advised immediately after the surgery as the uvula is likely to swell. This will block the
throat passage and make it difficult for her to breathe. Difficulty in breathing is common after the
surgery and the complications include hypopnea, airway obstruction and sleep apnea.
Her frequent vomiting and coughing may also hint towards tonsillar bleeding. Coughing will also
irritate and may rupture the scabs around the area to allow free flowing of blood. Tonsillar
bleeding occurs within the first 24 hours after the operation and is common in the first 6 hours.
Secondary can also occur after 5-10 days. It can also arise due to infectious causes due to
bacteria or virus. A small amount of bleeding is common as the scabs from the surgery fall off in
a few days (Kelly et al. 2015). However, bright red bleeding from the mouth or nose and blood
in vomiting are signs of haemorrhage. If the tissues around tonsil do not form a scab to prevent
the blood flow of arteries, blood may continue to seep. Continuous bleeding for about 1 hour can
cause loss of blood up to 250ml (Mitchell et al. 2019). Loss of blood is not acted upon quickly
can lead to anaemic conditions.
4b) Nursing actions and rationales (Please fix my nursing actions according to issues)
Haemorrhage needs to be acted upon quickly to prevent further loss of blood. Tonsils are located
close to four of the major vessels in the mouth, as a result, the amount of blood loss is serious. In
case of serious bleeding immediate cauterisation if the wound is required. In this process, the
flesh of the tonsils and the area of the bleeding is burst using a heated or caustic instrument. This

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also prevents the chances of further infection. The low dosage of antibiotics can be given to
prevent any infections and as an adjuvant analgesic to relieve pain (Finestone et al. 2019).
For managing pain and discomfort in the throat, ear and neck after the surgery mild analgesics
can be given. Other non-medicinal interventions can include the application of ice pack on the
area of pain. However, anaesthesia is likely to cause nausea and vomiting.
4c) Professional Issue
It is necessary to keep a patient who has undergone surgery for surveillance to safeguard them
from any postoperative complications. In the ambulatory ward, the minimum post-surgical
discharge time is four hours. Within this time the postoperative complications like vomiting and
bleeding are likely to occur. It is, therefore, recommended to keep the patient under medical care
in case they need to be rushed to the operation theatre again (Francis et al. 017). However,
Wendy’s mother wants to take Wendy back home as she has to pick her another children from
school. She is rushing the nurse to finish the paperwork soon. It is important to keep the patient
under monitoring for the recommended time period as this ensures their safety and help can be
provided quickly in case of complication.
Another issue is that Wendy is 8 years old and is unable to give a clear description of her
condition. Under such a scenario, other methods such as action and number or visual pain scale
need to be used to understand their condition (Sathe et al. 2017). It is required that some
professional be present who is more verse with the body language and emotions displayed by
children under distress.

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References
Arrigo, M., Parissis, J. T., Akiyama, E., & Mebazaa, A. (2016). Understanding acute heart
failure: pathophysiology and diagnosis. European Heart Journal Supplements,
18(suppl_G), G11-G18. Retrieved from
https://academic.oup.com/eurheartjsupp/article/18/suppl_G/G11/2633740
Carlson, B., & Fitzsimmons, L. (2019). Shock, Sepsis, and Multiple Organ Dysfunction
Syndrome. Priorities in Critical Care Nursing, 474. Retrieved from
https://books.google.co.in/books?
hl=en&lr=&id=jySDDwAAQBAJ&oi=fnd&pg=PA474&dq=Carlson,+B.,+
%26+Fitzsimmons,+L.+(2019).+Shock,+Sepsis,
+and+Multiple+Organ+Dysfunction+Syndrome.+Priorities+in+Critical+Care+Nursing,
+474.+&ots=-XLB0iJ3MC&sig=aDDuYIslIr9G3aYTg_dtoQ5ETS8
Casha, A. R., Manché, A., Camilleri, L., Gatt, R., Dudek, K., Pace-Bardon, M., ... & Grima, J. N.
(2016). A biomechanical hypothesis for the pathophysiology of apical lung disease.
Medical hypotheses, 92, 88-93. Retrieved from
https://www.sciencedirect.com/science/article/pii/S0306987716300809
Coccia, C. B., Palkowski, G. H., Schweitzer, B., Motsohi, T., & Ntusi, N. A. B. (2016).
Dyspnoea: Pathophysiology and a clinical approach. SAMJ: South African Medical
Journal, 106(1), 32-36. Retrieved from http://www.scielo.org.za/scielo.php?
script=sci_arttext&pid=S0256-95742016000100013
Finestone, S. A., Giordano, T., Mitchell, R. B., Walsh, S. A., O’Connor, S. S., & Satterfield, L.
M. (2019). Plain Language Summary for Patients: Tonsillectomy in Children.
Otolaryngology–Head and Neck Surgery, 160(2), 206-212. Retrieved from
https://journals.sagepub.com/doi/pdf/10.1177/0194599818817758

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Francis, D. O., Fonnesbeck, C., Sathe, N., McPheeters, M., Krishnaswami, S., & Chinnadurai, S.
(2017). Postoperative bleeding and associated utilization following tonsillectomy in
children: a systematic review and meta-analysis. Otolaryngology–Head and Neck
Surgery, 156(3), 442-455. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639328/
Gaieski, D. F., & Mikkelsen, M. E. (2016). Definition, classification, etiology, and
pathophysiology of shock in adults. UpToDate, Waltham, MA. Accesed, 8, 17. Retrieved
from
http://odyssey.calm.unimas.my/file.php/6998/dndupload/Definition_classification_etiolo
gy_and_pathophysiology_of_shock_in_adults.pdf
Gulati, A. (2016). Vascular endothelium and hypovolemic shock. Current vascular
pharmacology, 14(2), 187-195. Retrieved from
https://www.researchgate.net/profile/Anil_Gulati3/publication/286220614_Vascular_End
othelium_and_Hypovolemic_Shock/links/59396748a6fdcc58ae80a550/Vascular-
Endothelium-and-Hypovolemic-Shock.pdf
Harjola, V. P., Mullens, W., Banaszewski, M., Bauersachs, J., Brunner‐La Rocca, H. P.,
Chioncel, O., ... & Fuhrmann, V. (2017). Organ dysfunction, injury and failure in acute
heart failure: from pathophysiology to diagnosis and management. A review on behalf of
the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the
European Society of Cardiology (ESC). European journal of heart failure, 19(7), 821-
836. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejhf.872
Kelly, L. E., Sommer, D. D., Ramakrishna, J., Hoffbauer, S., Arbab-Tafti, S., Reid, D., ... &
Koren, G. (2015). Morphine or ibuprofen for post-tonsillectomy analgesia: a randomized
trial. Pediatrics, 135(2), 307-313. Retrieved from
https://pediatrics.aappublications.org/content/pediatrics/135/2/307.full.pdf

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Kesieme, E. B., Prisadov, G., Welcker, K., & Abubakar, U. (2016). Thoracic endometriosis
syndrome: Current concept in pathophysiology and management. Orient Journal of
Medicine, 28(1-2), 1-10. Retrieved from
https://www.ajol.info/index.php/ojm/article/view/138733
Kislitsina, O. N., Rich, J. D., Wilcox, J. E., Pham, D. T., Churyla, A., Vorovich, E. B., ... &
Yancy, C. W. (2019). Shock–Classification and Pathophysiological Principles of
Therapeutics. Current cardiology reviews, 15(2), 102-113. Retrieved from
https://www.ingentaconnect.com/contentone/ben/ccr/2019/00000015/00000002/art00007
Lichtenstein, D. A. (2016). BLUE-Protocol and Pneumothorax. In Lung Ultrasound in the
Critically Ill (pp. 195-199). Springer, Cham. Retrieved from
https://link.springer.com/chapter/10.1007/978-3-319-15371-1_27
Louge, P., Coulange, M., Beneton, F., Gempp, E., Le Pennetier, O., Algoud, M., ... & Vairo, D.
(2016). Pathophysiological and diagnostic implications of cardiac biomarkers and
antidiuretic hormone release in distinguishing immersion pulmonary edema from
decompression sickness. Medicine, 95(26). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4937958/
Mentz, R. J., & O'connor, C. M. (2016). Pathophysiology and clinical evaluation of acute heart
failure. Nature Reviews Cardiology, 13(1), 28. Retrieved from
https://www.nature.com/nrcardio/journal/v13/n1/abs/nrcardio.2015.134.html
Mentzer, S. J., Tsuda, A., & Loring, S. H. (2018). Pleural mechanics and the pathophysiology of
air leaks. The Journal of thoracic and cardiovascular surgery, 155(5), 2182-2189.
Retrieved from https://www.semtcvspeds.com/article/S0022-5223(17)33037-4/fulltext
Mitchell, R. B., Archer, S. M., Ishman, S. L., Rosenfeld, R. M., Coles, S., Finestone, S. A., ... &
Lloyd, R. M. (2019). Clinical practice guideline: tonsillectomy in children (update).

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Otolaryngology–Head and Neck Surgery, 160(1_suppl), S1-S42. Retrieved from
https://journals.sagepub.com/doi/pdf/10.1177/0194599818801757
Sathe, N., Chinnadurai, S., McPheeters, M., & Francis, D. O. (2017). Comparative effectiveness
of partial versus total tonsillectomy in children: a systematic review. Otolaryngology–
Head and Neck Surgery, 156(3), 456-463. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639321/
Siddall, E., Khatri, M., & Radhakrishnan, J. (2017). Capillary leak syndrome: etiologies,
pathophysiology, and management. Kidney international, 92(1), 37-46. Retrieved from
https://www.kidney-international.org/article/S0085-2538(17)30073-X/fulltext
Walsh, S., Clare, H., Minnock, C., Gaine, S. G., & McCullagh, B. N. (2018). Hypoxaemia Cause
or Consequence of Pulmonary Hypertension. In AMERICAN JOURNAL OF
RESPIRATORY AND CRITICAL CARE MEDICINE (Vol. 197). 25 BROADWAY, 18
FL, NEW YORK, NY 10004 USA: AMER THORACIC SOC. Retrieved from
https://www.atsjournals.org/doi/pdf/10.1164/ajrccmconference.2018.197.1_MeetingAbstr
acts.A2126