Recognising the Deteriorating Patient

Research Proposal
August 27, 2020
Network Design and Troubleshooting
August 27, 2020

CASE STUDY DEMONSTRATING THE APPLICATION OF THE  PROCESS OF DECISION MAKING IN CARING FOR AN ACUTELY ILL/DETERIORATING PATIENT

A deteriorating patient is one who from the perspective of an ACU or an ICU nurse is rapidly progressing towards critical illness and is displaying symptoms of “predictable and symptomatic worsening of the physiological condition”. The NHS offers guidelines for the care of acutely ill patients to enable nurses to detect and better recognise the early symptoms of deterioration. It involves measuring the patient’s physiological observations at a minimum such as heart rate, respiratory rate, blood pressure, consciousness, temperature, and oxygen saturation during the initial assessments taking into account possible comorbidities and patient diagnosis. The guidelines also promote the use of a suitable academic framework such as the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) for conducting the immediate assessment procedure. The ABCDE framework is a systematic approach to treating critical patients and has been proven to be an effective measure efficient in preventing sudden deterioration in condition.

Further, the monitoring should continue to be done in every 12 hours of hospitalisation unless specifically advised to be done more frequently on detection of abnormality or in other similar particular events. Under certain circumstances, the track and trigger response should be initiated, and a graded aggregated score should be used to evaluate the patient condition status. My case study will outline a similar case of a deteriorating patient. It will reflect upon my decision-making process that guided my actions during the care delivery process and prevented further exacerbation of the patient’s condition.

The National Health Service death records state that around 750 people admitted in the NHS died due to poor decision making. According to the “London School of Hygiene and Tropical Medicine,” most of these deaths are preventable, and every one in twenty deaths is caused by communication breakdown and poor care delivery (theguardian.com, 2020). In response, Jeremy Hunt, Health Secretary, stated that health is still very much a priority for the government and a probe has been issued to identify shortcomings in the system and develop means to address it. The study was conducted in 2015, and since then, several measures have been taken to prevent avoidable deaths in hospitals. One among them is an emphasis on the “process of decision making”. It is a theoretical nursing concept that enhances the decision-making skills of training nurses in acute care (Nibbelink, C and Brewer, B, 2018).

Decision making is an essential process in which communication plays a contributory role and which influences patient outcomes. In nursing, making an informed decision requires the precise measurement of several complex contributing factors to accurately determine and satisfy the patient’s need. Error in judgement can have fatalistic consequences but has been unavoidable due to the lack of a systematic approach in clinical medicine (Chinn and Kramer, 2017). However, in recent years, the medical fraternity has stressed upon the use of objective measurement tools such as the ABCDE framework and have used subjective analysis such as SBAR and NEWS score to categorise, evaluate, and analyse the status of the patient. Reflective studying has also gained popularity in nursing studies. The aim is to develop self-reflection and enable learners like me to conduct an unbiased intuitive internal assessment of self-performance with a sole motive to reconsider our actions and gain lessons from experience. It will help nurses refine their collective skills and empower them to make more unprejudiced judgments (Johansen and O’Brien, 2016).

The subject of the composition under consideration, Mr Ryan Artington, is a 50-year-old male, smoker, who came in through the emergency ward after having developed a dry cough and fever five days before admission. The name, Mr Ryan Artington, is a pseudonym. It will be used throughout the composition to protect the identity. Patient confidentiality safeguarded under the data protection legislature (“Data Protection Act, 2018”) which prohibits the use of personal data collected from the patients without their consent or permission for any activity that does not concern the well being of the patient and is a necessary step that is taken to protect the vital interest of the patient (privacy-regulation.eu, 2018). The patient had come in with chills accompanied by high fever, coughing, shortness of breath, rapid shallow breathing, fatigue, loss of appetite, and general weakness. He was mildly obese and has had been a smoker for the past twenty-five years and have only quit recently due to him developing chronic smokers cough which according to him is mild and only occurs a few times in a day.

Additionally, the patient has high blood pressure and hypertension, takes medication independently daily, but no history of cardiac irregularities. He was non-diabetic, and at some point, in the early times, the patient underwent appendicitis and has also been treated for a hairline fracture that was the result of an accidental fall. Otherwise, the patient was healthy, conscious, and interactive with the care providers. It was suspected to be a case of acute respiratory infection possibly pneumonia by the primary care provider who attended Mr.Artington, and he was admitted in for further analysis and treatment. Acute respiratory infection is a condition that affects the upper or lower respiratory tract (Schuetzet al. 2018). Common cold or flu is the most common acute respiratory disease that happens in the United Kingdom however complex diseases like Bronchitis, Bronchiolitis, Pneumonia, and Chest infection are also prevalent and accounts for more than 700,000 admissions in the United Kingdom annually. Causes of acute respiratory disease are varied and are often caused due to viral, bacterial, or fungal infections.

I was on my regular night shift and went on to meet Mr.Artington as his observations were due for that day. Also, my VitalPAC, a patient monitoring software, analytics, was stating that the patient was in considerable distress. VitalPAC is a weighted track and trigger system that monitors a patient’s vital signs and assigns them a score in between 1 and 21. The higher the score, the greater the risk of deterioration (nice.org.uk, 2016). In this way, it helps nurses and physicians to categorise cases according to their urgency and even proceed with prompt response in case of a sudden collapse. Mr.Artington had a score of 10, so I thought it would be prudent if I approached him first and made a candid assessment of his health status. I approached Mr.Artington, who was lightly resting, introduced myself and of my intentions and sought permission for physical examination. The patient was alert, and even though his eyes were red and glazed, he responded vocally and granted me permission to examine him and ask him a few questions. As part of my initial assessment, I asked the patient about his present state of health (Giddens, 2019).

Mr.Artington replied that he was feeling well during the day after he was administered medicines. Still, from a moment ago, he is not feeling well. I urged him to elaborate further, and he said that about half an hour ago, he started having difficulty breathing and felt a sharp sensation on his right chest every time he breathed in along with nausea. I assured him and went on to check his medicine charts to look for any issues in the medicines that might have had any detrimental impact on his health and found none. From my assessment, I can state that I found Mr.Artington conscious but panicky. It was evident from his facial contortions that he was having difficulty while speaking and spoke in short sentences breaking up often gasping for air.

Obstruction of air passage or pathway among ARS patients is common. It is a sign of deterioration in patients suffering from AR infections. Air passage obstruction is easily detected from difficulty in breathing, adventitious sounds, confusion, panic, and fatigue. His breathing rate was 24, and it was laboured. I could distinctly hear a crackling or wheezing sound during expiration, and there was mild bluish tinge on his lips and fingers. Immediately I counted the number of breaths he was taking in a minute by counting the number of times his chest was rising at rest. The NHS states that the normal respiration rate for an adult male is about 16 to 18 breaths per minute. According to my calculations, he was breathing 24 times per minute which was way beyond the normal limit. An abnormal breathing rate is an indication of a progressively worsening condition, especially in patients undergoing treatment for pneumonia (rcni.com, 2020). Pneumonia causes the lungs, air sacs or alveoli to become

inflamed and filled with pus which does not allow oxygen to adequately reach the bloodstream. The medical fraternity considers respiratory rate a good indicative parameter for pneumonic patient’s and recommends continual monitoring of the vital sign to determine any change in patient condition (sciencedaily.com, 2020). Next, I checked the pulse oximeter attached to his finger to assess the oxygen saturation level in the blood. An oximeter instrument measures the ratio of oxygenated haemoglobin to deoxygenated haemoglobin to determine the percentage of oxygen in the blood (Pimentel et al. 2016). It was reading 92% on air which was slightly lower than normal but not low enough to cause concern. However, smokers, in general display an oxygen saturation level that is normally higher than their actual oxygen saturation level in blood. It is so because of the high level of carbon monoxide in their blood that the machine cannot distinguish from oxygen (Goelet al. 2020).

I remained unconvinced of his condition, his CBAR score was 2 and NEWS score was 6. So I decided it would be better if the medical team came in and took a look at his condition (Iget al. 2019). Accordingly, I went in and informed my senior nurse about the patient’s condition and on her advice, I communicated the same to the medical doctor. Communication is essential in the medical profession. Poor communication and unstructured news delivery can make people make uninformed decisions that would later be seen as detrimental to the cause of the patient (Grove and Gray, 2018). Mr.Artington thought was alert when I came for observation. Still, as I was leaving to inform my nurse, I noticed that he was becoming mildly unresponsive. It is evident from the physiological parameters that he needed immediate medical attention. After completing the protocol, I came in again to Mr.Artington to help the registered nurse position him in a comfortable position. “Ineffective Airway Clearance” is a recommended nursing intervention for pneumonia and practitioners advise placing the patient in an elevated bed and changing positions frequently to support breathing. While the registered nurse was going about taking steps to clear passage as a trainee nurse, I was supporting her actions but continually monitoring the vitals observing for any signs of change. I continued to do so for the entire night until the end of my shift, after which I had to hand over the duty to my colleague.

SBAR 

Situation – I am making a request for Mr.Artington, a 59-year-old patient suffering from acute respiratory infection pneumonia and is currently occupying bed number 30. His vital signs are consistently deteriorating (BR- 24, 112 Heart Beats per minute) and while on admission, his CRB65 score was 1. He is feeling intense pain in his right chest that is aggravating during inspiration. He is running a fever, and his body temperature is at 39 Degrees accompanied by coughing and purulent tracheobronchial secretions.

Background
Mr.Artington was admitted that following morning and came in through the emergency complaining of persistent coughing, chill, weakness, fatigue, and shallow breathing. Primary care providers suspected acute respiratory syndrome and CRP test confirmed pneumonia. According to a conventional protocol, the patient was administered antibiotics, expectorants, and hydrating fluids.

Assessment
Patient condition stabilised for a brief period following antibiotic administration; however, he has recently developed a right chest pain that worsens with inspiration. The patient is also running a fever and is having difficulty breathing. He is breathing fast, and his blood pressure has also dropped considerably. I am unsure as to what could have caused such a response. Still, I am extremely worried that the patient’s condition is rapidly worsening.

Recommendation
Mr.Artington needs urgent medical intervention and possibly ventilator support. Recognising symptoms of deterioration and acting upon it is a challenge for trainee nurses like me. However, the theoretical concepts that I developed during my time as a nursing student at the University and my recent experiences of delivering care to ill-patients have adequately prepared me to work in collaboration with a multidisciplinary team and contribute veritably to the care of the patient by interacting, bridging the gap between patients, registered nurses, and doctors. Using the tools provided to me by the institution, I can make informed, evidence-based decisions and can act upon it by correctly identifying the needs of the patient and communicating the same to the practitioner. From the study, I can also confidently differentiate between the states of the patient and recognise the signs of deterioration. Understandably, my contributory role being a trainee nurse is limited in its scope. Still, the knowledge that I gained will help me develop my career as a clinical nurse in acute settings. Even after being restricted by my limited knowledge, I have tried to support the actions of my team by closely monitoring the vital signs of the patient.

References
Books
Chinn, P.L. and Kramer, M.K., 2017. Knowledge Development in Nursing-E-Book: Theory and Process. Elsevier Health Sciences.
Giddens, J.F., 2019. Concepts for Nursing Practice E-Book.Elsevier Health Sciences.
Grove, S.K. and Gray, J.R., 2018. Understanding Nursing Research E-Book: Building an Evidence-Based Practice. Elsevier Health Sciences.
Journals
Goel, A., Gupta, P., Deepak, D., Pandey, H.S. and Moinuddin, A., 2020. Total and differential leukocyte count and oxygen saturation of hemoglobin changes in healthy smokers and non-smokers. National Journal of Physiology, Pharmacy and Pharmacology, 10(9), pp.0-0. DOI: 10.5455/njppp.2020.10.05116202023052020
Ilg, A., Moskowitz, A., Konanki, V., Patel, P.V., Chase, M., Grossestreuer, A.V. and Donnino, M.W., 2019. Performance of the CURB-65 score in predicting critical care interventions in patients admitted with community-acquired pneumonia. Annals of emergency medicine, 74(1), pp.60-68. DOI:
https://doi.org/10.1016/j.annemergmed.2018.06.017
Johansen, M.L. and O’Brien, J.L., 2016, January. Decision making in nursing practice: a concept analysis. In Nursing forum (Vol. 51, No. 1, pp. 40-48). DOI: https://doi.org/10.1111/nuf.12119

Pimentel, M.A., Johnson, A.E., Charlton, P.H., Birrenkott, D., Watkinson, P.J., Tarassenko, L. and Clifton, D.A., 2016. Toward a robust estimation of respiratory rate from pulse oximeters. IEEE Transactions on Biomedical Engineering, 64(8), pp.1914-1923. DOI: https://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=7748483

Schuetz, P., Wirz, Y., Sager, R., Christ-Crain, M., Stolz, D., Tamm, M., Bouadma, L., Luyt, C.E., Wolff, M., Chastre, J. and Tubach, F., 2018. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. The Lancet infectious diseases, 18(1), pp.95-107. DOI: 10.1016/S1473-3099(17)30592-3

Online Articles
Nibbelink, C and Brewer, B, (2018), Decision-Making in Nursing Practice: An Integrative Literature Review, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5867219/#:~:text=Clinical%20judgment%20or%20decision%2Dmaking,been%20described%20in%20nursing%20literature. [Accessed on 13-08-2020]

Websites
nice.org.uk, (2016), VitalPAC for assessing vital signs of patients in hospital, available at https://www.nice.org.uk/advice/mib79 [Accessed on 13-08-2020]
privacy-regulation.eu, (2018), Data Protection Act, 2018, Article 6, Protection of Personal Data, available at: https://www.privacy-regulation.eu/en/article-6-lawfulness-of-processing-GDPR.html [Accessed on: 13-08-2020]
rcni.com, (2020), Breathing, available at: https://rcni.com/hosted-content/rcn/first-steps/breathing [Accessed on 13-08-2020]
sciencedaily.com , (2020), Prognosis of pneumonia: the value of respiratory rate often overlooked, available at https://www.sciencedaily.com/releases/2014/08/140812121845.html [Accessed on 13-08-2020]
theguardian.com, (2020), Avoidable Death NHS hospitals Study, available at https://www.theguardian.com/society/2015/jul/14/avoidable-deaths-nhs-hospitals-study [Accessed on 13-08-2020]