Nrs312 Essential Nursing Care: Managing Assessment Answer

Phase 1: Prevention

From the observation presented in the scenario, it is clear that John’s condition is deteriorating.  According to between the flags a normal respiratory rate of adults should be between 12 to 20 breaths per minute. John’s respiratory rate, however, is 28, which could be an indication of respiratory distress. A 90% SpO2 may be an indication of a decrease in perfusion and a blood pressure of 122/64 is a sign of an elevated blood pressure. Also, the abrasion on the left side of his chest extending around to the middle of his back and chest discomfort may be an indication of chest injury or damage to the heart valve. Further, an extensive bruise on the left hip and around to buttock, unable to weight bear, constant sharp pain in the upper thigh and hip region may be an indication of fracture NOF. These abnormal vital signs may be associated with John’s pain that may establish from chest injury or fracture NOF.

The management of pain in elderly is very important, as John is 81 year old, because usually elderly patients amplified with anxiety and stress, therefore due to this challenge their conditions may further deteriorate. Initial pain assessment, an appropriate and timely pain management for trauma patients is vital because it can induce severe complications that may lead John to further deteriorate (Brown, Edwards, Seaton & Buckley, 2017). Therefore, pain management in trauma patients is an important part of the systemic approach to trauma. Brown et al. (2017), further ascertain that the complication of pain includes problems with ventilation, perfusion abnormalities due to muscle splinting, increased myocardial workload, decrease in the risk of pulmonary embolism and decreased gastrointestinal motility as John has a medical history of GORD.

Several complications of the respiratory system such as pneumothorax, atelectasis and respiratory failure may be caused by inadequate ventilation as a result of an injury to the chest (Unsworth, Curtis & Edward, 2015). Injury to chest and pain causes hypoventilation in the patient characterized by shallow and fast respirations like in John’s case. This will lead to impaired gas exchange in the lungs, where the level of alveoli is perfused (Unsworth et al., 2015). Management of pain also aids in decreasing incidence of chronic pain, Post-traumatic stress disorder, shortens the length of hospital stay, lowers costs, and ultimately reduces the rate of morbidity and mortality.

Additional assessment such as an ECG to detect any abnormalities in the heart due to the injury as John is experiencing chest discomfort.  Also closely monitoring the vital signs especially respiratory rate and the spo2 level is important for John to prevent the development of further complications. Monitoring these vital signs will help to determine which treatment protocols to follow, confirm feedback on treatments provided, and provide critical information needed to make life- saving decisions and when to make a met call (Mok, Wang & Liaw, 2015). Monitoring respiratory rate and the spo2 level will help to decrease the respiratory distress and risks of developing hypoxia.

Phase 2: Clinical Review

During this phase, John's condition is further deteriorating. He is going down in clinical review phase according to slippery slope diagram. He is speaking in short sentences, has shallow breaths and he is tender to touch. Additionally, he has dusky pink peripheries that are cool to touch with a capillary refill of greater than four seconds. He also experiences pain during the palpitations of the abdomen.  Pain 10 out of 10 on the left hip when moving may indicate fracture NOF as mentioned in phase one. Pain in the abdomen may indicate injury to his abdomen. In addition to between the flag, he is tachycardic, hypotensive and the SPO2 level is still not normal even with 6L Hudson mask. Furthermore there is a decrease in blood pressure and a drop in the Glasgow coma scale.

According to (Arora, Flower, Murray & Lee, 2012) injury in the abdomen can cause severe pain and may lead to shallow breathing as in the case of John. Failure to treat abdominal palpitations could lead to some serious complications that may affect the normal operation of the lungs and the heart. The elevated abdominal pressure can interfere with respiration, decreases venous return from the lower extremities, causing hypotension and hypoxemia. All of this may increase the risk of developing pneumonia. Indigestion caused by stomach palpitations leads to expansion of the stomach with gases. These gases cause stomach spasms and in serious conditions, a shortness of breath may be experienced as mentioned in the john’s case.

There may be a possibility for John to develop hypovolemic shock as he may have an abdominal injury and fractured hip. According to Egol, Koval & Zuckerman (2010), this kind of injury can result in two to three liters of blood loss. Blood is delivered to the femoral head by 3 terminal arterial branches (Reynolds, 2013). However, this may not be happening in John’s case, which leads to the development of some abnormal findings such as dusky pink peripheries, cool extremities, and capillary refill greater than four seconds. Also an increased heart and respiratory rates and decreased oxygen level.

Phase 3: Rapid Response

John’s condition is further deteriorating at this stage. His Glasgow coma scale has dropped to 11 and he has become confused. This could be an indication of moderate brain injury. His blood pressure has dropped to 92/54 mmHg and the heart rate has increased to 134 beats per minute. John’s respiratory rate has also increased to 30 breaths per minute and despite being on the 6L Hudson mask, his SpO2 has dropped to 88%. It is also reported that he has cool extremities with a capillary refill of 4 seconds. He is supplied with a maintenance fluid at 200 ml/hr which could be an indication that he has lost too much body fluids.

From the scenario presented, it could be possible that John might have suffered a fall that led to a mild traumatic brain injury. An injury to the brain requires an immediate intervention or the patient risks suffering complications such as coma, hydrocephalus which can be described as the buildup of fluids in the brain, damage to the blood vessels that supply the brain which could lead to blood clots and stroke (Iverson & Lange, 2011). John could also experience a condition known as vertigo if his brain injury is not treated promptly. This is a condition where a patient who has suffered a traumatic brain injury experiences dizziness almost every time. The nurse must ensure that John has an adequate supply of blood and sufficient oxygen. Additionally, his blood pressure needs to be maintained to prevent the escalation of the above-mentioned complications (Iverson & Lange, 2011). He could also be given medications such as diuretics and anti-seizure drugs.

Additionally, John could develop a hypovolemic shock if he is not attended to as soon as possible. This is a condition that is developed when an individual loses more than 20% of their body fluid or blood (Kobayashi, Costantini & Coimbra, 2012). The fact that John is on a maintenance fluid is an indication that he has lost a lot of body fluid due to the injuries that he had suffered. This excessive loss of blood means that the blood floor is not sufficient thus leading to a capillary refill time of more than 4 seconds. The abdominal injuries suffered by John in addition to the bruises and abrasions could lead to severe blood loss. This condition could be characterized by rapid heart rates and rapid respiratory rate that is characterized by shallow breaths. Another symptom of hypovolemic shock is a cold skin.

A failure to treat this condition could lead to several other complications such as heart attack, damage to body organs like the brain and kidneys, gangrene of the legs and arms, and death at worst. It is worth noting that taking blood thinners like clopidogrel and aspirin increases the risks of developing hypovolemic shock (Myburgh & Mythen, 2013). Some of the interventions that can be used to manage this condition are to ensure that the patient gets sufficient oxygen supply to all the body organs. This can be achieved by substituting the Hudson mask with a rebreather mask. Additionally, the nurse should do everything possible to limit the loss of blood before a replacement of the lost blood and other fluids is done intravenously.

Phase 4: Advanced Life Support

This is the last phase of the slippery slope in the between the flag system. John’s condition is further deteriorating. His blood pressure has fallen to just 52/26 mmHg with an increased heart rate of 144 beats per minute. We had been previously informed that John had chest pains which could be as a result of a chest injury. Additionally, he could experience a collapse of lungs due to the chest injuries. The chest injuries and a collapse of the lungs could lead to hemothorax (Yalcin, Choong & Eizenberg, 2013). This is a condition that causes blood to accumulate in the pleural space surrounding the lungs. A traumatic injury to the chest can cause a rupture of the pleural membrane that lines the lungs and the chest thus spilling blood into the pleural space. This condition is characterized by low blood pressure, a rapid heart rate, difficulties in breathing, and rapid but shallow breathing among others (Yalcin et al., 2013). Some of these symptoms are exhibited by John in the presented scenario.

Failure to promptly treat hemothorax could lead to other complications such as lung problems, infections, and scarring. Lung problems such as a collapse of the lungs could lead to a respiratory failure. Failure to treat hemothorax could possibly lead to infections of the lungs and the pleura in the chest. It is also important to note that if the blood stays in the pleural space for far too long, a condition known as retained hemothorax could be developed. This condition leads to a blood clot that may be challenging to remove using a catheter (Villegas, Hennessey, Morales & Londoño, 2011). Hemothorax is treated by inserting a catheter into the chest through the ribs and draining the blood that is within the pleural space (Yi et al., 2012). After the pleural space has been drained, the same tube could be used to expand the lungs in the event of a collapse of the lungs.

Conclusion

Patients with deteriorating health conditions need prompt interventions to prevent the condition from escalating to something worse and jeopardize their safety.  The deterioration of a patient is assessed using four phases of the slippery slope in the between the flags system. These phases include prevention, clinical review, rapid response, and advanced life support. Each of the phases plays a role in preventing and managing deteriorations thus enhancing the safety of the patient. Patient safety is a nurse’s main priority and if the right interventions are employed in each of the phases then patient safety could be guaranteed. After the interventions in the fourth phase have been applied, we can notice John’s clinical conditions beginning to get back to normal an indication that the nurse has achieved success in ensuring the delivery of quality care and patient safety.

References

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