NSG3RDP Recognising and Responding

The case study presents a scenario where Joanna Cleese, a woman in her mid-fifties who has suffered a fall from a ladder while cleaning her gutters. She was found by her neighbour, lying face down on the concrete road. She was initially unresponsive but responded to her neighbour's voice after a few minutes, in a confused manner. She was subsequently rushed to the hospital in an ambulance. She was found to sustain several injuries, including haemopneumothorax, fracture in the ribs, a broken neck of femur on the left side, fracture in the left radius and ulna, and a laceration in the head. The ISBAR chart provided indicates rapid deterioration of the patient. A fluctuating respiration rate, along with lowering of the blood pressure can have severe implications on the physiological state of the patient. Most of the signs that the patient is experiencing are consistent with the symptoms of haemopneumothorax (Inafuku et al., 2015).

The health condition is a rare phenomenon, marked by the accumulation of air, as well as blood, close to the lung tissue within the chest cavity. While the accumulation of either air in the chest cavity (pneumothorax) or blood (hemothorax) is prevalent, a condition where both the elements are present simultaneously in the chest cavity is not common and is brought about mainly due to a puncture in the chest wall and the pleural space, due to a traumatic accident or critical injury to the chest. The pleural space is what holds the visceral membrane and the parietal membrane in their positions, and the accumulation of blood and air in the space leads to the separation of the two membranes leading to the collapse of the lung. This leads to respiratory distress, with the patient no longer being able to breathe properly. This in turn leads to an elevation of the respiration rate of the patient, consistent with dyspnea. Impaired respiration would also mean the commencement of a hypoxaemia state. In such cases, the elevation of heart rate is observed, as a compensatory mechanism for relieving the hypoxic condition (Goulding et al., 2015).

The patient has suffered from a critical fall, and the injuries sustained by her are critical in nature. Her vital signs denote a steady deterioration of physiological state as time goes by. Her respiratory rate was seen dropping down to 10 to 14 breath per minute, before exhibiting a sharp spike to almost 30 breath per minute. Her oxygen saturation levels are seen to be steadily decreasing. He blood pressure levels too have been dropping down significantly since her hospital admission, and her heart rate has steadily increased, reaching a value well over 100 beats per minute.

Such critical accidents are often accompanied by both internal and external haemorrhage. Blood loss can lead to severe health outcomes in this scenario. Excess blood loss may lead to a fluid volume deficit, resulting in low blood pressure and impaired blood circulation (Curry & Davenport, 2019). Inadequate blood circulation might lead to a hypoxic condition in the tissue and organ system, while also resulting in tissue damage of the cardiac muscles. This can bring about myocardial infarction, or heart failure. Also, in case of severe hypoxia, brain tissues may sustain damage as well. Severe internal haemorrhage is equally damaging. It might lead to multiple organ system failures, seizures, coma, or even death. Additionally, the patient in this scenario, Joanna is at an increased risk of developing cardiovascular complications due to her obesity. Moreover, prolonged bed rest and internal injuries often lead to inadequate blood circulation, promoting the formation of blood clots.

These clots mostly form inside one of the deep-seated blood vessels, usually in those that are present in the lower limbs. Blockage in the blood vessels due to the formation of a blood clot is known as deep vein thrombosis (Di Nisio, van Es & Büller, 2016; Stubbs, Mouyis & Thomas, 2018). The blood clot may also reach a coronary or pulmonary blood vessel through the circulatory system, getting lodged in the same. Pulmonary embolism might lead to life-threatening implications if medical assistance is not availed immediately, and is one of the most common complications prevalent in patients such as Joanna.

Another complication Joanna might suffer from, due to her underlying conditions such as diabetes and obesity, is delayed wound healing and infection (Okonkwo & DiPietro, 2017). Patients suffering from diabetes often show a lack of wound healing due to impaired blood circulation. Inadequate oxygenation and supply of nutrients due to inappropriate circulation leads to worsening of the damage, leading to occurrences of infection. Moreover, diabetes has also been associated with improper functioning of the immune system and promoting inflammation in the system (Pouvreau et al., 2018).   

Nursing assessment is one of the most important aspects associated with the delivery of competent medical assistance. Assessing the patient is important since it provides the health care provider with important clues about the physiological, as well as the mental state of the patient, based on which the patient can be treated. A comprehensive assessment of the patient not only enables the health care personnel to make arrangements for appropriate interventions but also reduces the chances of faulty diagnosis and delivery of inaccurate treatment. There are mainly two distinct approaches one might adopt to properly assess the state of the patient, namely the head to toe assessment, and the ABCDE approach (Olgers et al., 2017).

The ABCDE assessment, also known as the primary assessment approach is a widely popular method of assessing patients in both emergency and non-emergency settings. The approach is extensively utilized by emergency health care teams, traumatologists, health care providers, et cetera to determine not only the current state of the patient but also to assess the extent of damage or injury the patient has sustained. The mnemonic ABCDE stands for airway, breathing, circulation, disability, and exposure. In this method, the health care expert checks the patient and assesses his or her condition based on the data retrieved by observing the aforementioned aspects in patients (Smith & Bowden, 2017).

The assessment is performed sequentially, based on the mnemonic, starting by observing the breathing patterns of the patient. In case of erratic or abnormal respiration, such as rapid and shallow breathing, presence of rattling noises, or wheezes, et cetera, which is indicative of the presence of an obstruction in the airway, can be considered. If indeed there is a blockage in one of the airways, immediate assistance should be availed to the patient since obstructed breathing is a critical situation. Health care providers percuss or auscultate the chest to get a clearer picture of the scenario. Next is to assess the state of blood circulation and cardiovascular health of the patient. This is especially important in cases where the patient is hypovolemic (Perner et al., 2018). Cases of fluid volume deficit are detrimental since they might lead to adverse events such as heart failure. Next, the state of consciousness of the patient is to be assessed.

If the patient is found to be unconscious or confused, immediate medical assistance should be availed. A physical assessment can be carried out too, to check for any other signs that might be present of the physical self of the patient. The ABCDE assessment tool does not require any special instrument as such and can be performed by any health care worker, at any place and scenario. This tool is especially beneficial in assessing victims of accidents or trauma, since it enables one to decipher abnormalities in a much shorter period of time, and allows the health care personnel to provide relief to the patient until more details can be acquired.

Head to toe assessment, as the terminology implies, is a much more detailed assessment tool (Purpora & Prion, 2018). This method is much more comprehensive compared to the ABCDE approach. In the head to toe assessment, the health care personnel examine and assess every physiological aspect of the patient, in order to obtain information about everything that the patient might require medical assistance for. The head to toe examination is commonly performed prior to hospitalization, to gather information about the patient in order to commence with the treatments immediately.

This approach is instrumental in enabling the health care facilities to deliver competent, evidence-based patient centred medical assistance while providing the basis for diagnosis and clinical decision making. The examination is carried out by inspection, palpation, percussion and auscultation, which provides the health care expert with important information about the physiological state of the patient. The assessment is mainly begun by taking the vitals of the patient, followed by examining the upper portions of the body, such as the integument, the head, along with the vision and hearing of the patient, then the mouth and sinus. The thorax, lungs and abdomen are checked next, and then the extremities such as joints, bones and muscles (Bryant, 2017).

In the given scenario, the patient, Joanna Cleese has been admitted to the hospital following a fall from a ladder. In her case, the head to toe examination will be much more suitable since initial relief has already been provided to her in the form of intercostals catheter, intravenous fluid administration, pain medication, et cetera. Moreover, the assessment is advisable in patients who are not in immediate danger but require competent evidence-based medical assistance to prevent further deterioration, whereas the ABCDE assessment tool is best for providing first aids to patients until stability is gained (Smith & Bowden, 2017).

Respiratory rate can be defined as the number of breath per minute, and it indicates the movement of air in and out of the lungs (Rolfe, 2019). Respiration rate is one of the most important vital signs, and a change or fluctuation of the respiration rate is consistent with the deterioration of the patient in most cases. Although an instrumental vital sign, respiration rate is frequently not observed in most of the patients unless specifically told otherwise; it is often recorded improperly, or not recorded at all. Many adverse health outcomes in the past have been attributed to the lack of properly documenting the vitals, especially the respiration rate.

Findings from recent research suggest that several signs of deterioration in patients appear as early as 24 hours prior to the adverse event, with respiration rate being one of the first signs. Therefore effectively monitoring the respiration rate in patients, especially those who are likely to develop complications, is advisable (Rolfe, 2019). Instances of both tachypnea, as well as bradypnea, can be indicative of several health implications, or an erroneous assessment, and timely monitoring of the vital signs can afford the health care personnel time to arrange for the rectifying interventions. Erratic breathing is one of the first and definite signs of the patient deteriorating and a steady decline of health. The patient in this scenario shows tachypnea, along with an increased heart rate and a severely low blood pressure level, all indicative of distress in the respiratory airways. Laboured breathing might also have other life-threatening implications such as blockages in the coronary pathway, septic shock, fluid volume deficit, et cetera (Liu et al., 2019).

The most accepted way of measuring the respiration rate in a clinical setting is by counting the number of time the chest expands in a minute, preferably with the help of a timer. But it is a time taking process, which may not feasible in a clinical setting, due to the shortage of staff and workload. Moreover, the respiration rate should always be taken with the patient resting, or at least in a relaxed position, so that the readings are accurate. Due to such issues, the usage of capnography monitors can be considered in critical patients such as Joanna Cleese (Carlisle, 2015). Capnography monitors are one of the most common instruments used for measuring respiration rate in health care settings. The technique detects the exhaled carbon dioxide with the help of infrared rays, plotting the same in a graph. The technique is preferred for being non-invasive, rapid, and for providing accurate readings without much involvement of the health care professionals (Kerslake & Kelly, 2017).

Reference List

Bryant, S. G. (2017). Keeping it in the program: second year nursing students as stand-in patients for first year head-to-toe assessment check-offs. Nurse educator, 42(2), 60-61.

Carlisle, H. (2015). Promoting the use of capnography in acute care settings: an evidence-based practice project. Journal of PeriAnesthesia Nursing, 30(3), 201-208.

Curry, N. S., & Davenport, R. (2019). Transfusion strategies for major haemorrhage in trauma. British journal of haematology, 184(4), 508-523.

Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary embolism. The Lancet, 388(10063), 3060-3073.

Goulding, R. M., Stevenson, N. J., Murray, D. M., Livingstone, V., Filan, P. M., & Boylan, G. B. (2015). Heart rate variability in hypoxic ischemic encephalopathy: correlation with EEG grade and 2-y neurodevelopmental outcome. Pediatric research, 77(5), 681-687.

Inafuku, K., Maehara, T., Yamamoto, T., & Masuda, M. (2015). Assessment of spontaneous hemopneumothorax: Indications for surgery. Asian Cardiovascular and Thoracic Annals, 23(4), 435-438.

Kerslake, I., & Kelly, F. (2017). Uses of capnography in the critical care unit. Bja Education, 17(5), 178-183.

Liu, H., Allen, J., Zheng, D., & Chen, F. (2019). Recent development of respiratory rate measurement technologies. Physiological measurement, 40(7), 07TR01.

Okonkwo, U. A., & DiPietro, L. A. (2017). Diabetes and wound angiogenesis. International journal of molecular sciences, 18(7), 1419.

Olgers, T. J., Dijkstra, R. S., Drost-de Klerck, A. M., & Ter Maaten, J. C. (2017). The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study. Neth J Med, 75(3), 106-11.

Perner, A., Cecconi, M., Cronhjort, M., Darmon, M., Jakob, S. M., Pettilä, V., & van der Horst, I. C. (2018). Expert statement for the management of hypovolemia in sepsis. Intensive care medicine, 44(6), 791-798.

Pouvreau, C., Dayre, A., Butkowski, E. G., De Jong, B., & Jelinek, H. F. (2018). Inflammation and oxidative stress markers in diabetes and hypertension. Journal of inflammation research, 11, 61.

Purpora, C., & Prion, S. (2018). Using student-produced video to validate head-to-toe assessment performance. Journal of Nursing Education, 57(3), 154-158.

Rolfe, S. (2019). The importance of respiratory rate monitoring. British Journal of Nursing, 28(8), 504-508.

Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard (2014+), 32(14), 51.

Stubbs, M. J., Mouyis, M., & Thomas, M. (2018). Deep vein thrombosis. bmj, 360.

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