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RECOGNIZING AND ACTING ON CLINICAL DETERIORATION Assignment NUR2100 Due date: April 29, 2013 Computer word count: 1,913

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RECOGNIZING AND ACTING ON CLINICAL DETERIORATION
Introduction Nursing has always been a profession that embraces diversity towards rendering holistic patient care. However, with the constant changes in nursing practice; patient safety has been at risk due to nurse’s competence towards detecting impending patient deterioration that may lead to further complications or even death. It is said that the most important practical lesson that can be given to nurses, is to teach them what to observe (Nightingale 1969). Having the ability to observe and interpret critical situations are the essential key features applied in clinical practice. Effective observation of ward patients is the first step in identifying the deteriorating patient and effectively managing their care (Odell, Victor & Oliver 2009, p. 1993). Studies have shown that poor vital sign recording, lack of knowledge, failure to respond to abnormal signs, lack of knowledge, lack of supervision and failure to report deterioration or seek advice, have all contributed to the suboptimal care of ward patients (Odell, Victor & Oliver, cited in McGloin et al. 1999; McQuilla et al. 1998; Smith & Wood 1998; Hodgetts et al. 2002, p. 1993). With constant observation established, patient safety is implemented and surveillance is then incorporated to be able to identify and prevent possible medical errors and adverse events that may be encountered. The purpose of surveillance is the early identification of risk and the need for intervention and to alert nurses to both anticipated and unanticipated changes in patient’s condition (Henneman, Gawlinski & Giuliano 2012). With both effective observation and surveillance integrated to the nursing practice, clinical reasoning is then established which (Levett- Jones et al. 2010, p. 516) involves clinical judgements and clinical decision-making. EARLY DETECTION: THE INTIAL RESPONSE TO PREVENT PATIENT DETERIORATION Throughout nursing practice, assessment is the initial intervention in detecting the severity of the condition of a patient. Taking the baseline vital signs observation are the core elements in identifying if the patient is in distress or even slowly deteriorating. It is believed that nurses enter the care of a particular patient with a fundamental sense of what is good and right and a vision for what makes exquisite care (Tanner 2006). But as years gone by, an increasing number of complications of patient’s condition and even unexpected death have led to questioning the nurse’s ability to diagnose a phenomenon. One of the essential signs of patient deteriorating is the respiratory rate. Respiration describes the process by which energy is produced in eukaryotic cells to ensure that bodily functions are carried out (Parkes 2011). Recording respiratory rates allow baseline assessments of ventilator function to be made and can give early indications of respiratory deterioration (Parkes cited in Kenward et al. 2001, p.12). Assessing and managing the respiratory function are important skills that all nurses should not take for granted. This skill is incorporated in the clinical reasoning skills among nurses in identifying essential
Comment [S1]: Good introduction but could have included an introduction to the case study also

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cues when a patient is experiencing distress. It was claimed by Parkes (cited in Alexis 2010, p. 16) that the guidelines for recording respiratory rate, along with the rest of the vital signs have often been disregarded due to relying too much in highly innovated machinery in taking the observation for documentation. Nurses with poor clinical reasoning skills often fail to detect impending patient deterioration resulting in a ‘failure to rescue’ (Levett-Jones et al., cited in Aiken et al. 2003, p. 515). Prioritising patients who are slowly deteriorating is the best solution in avoiding medical errors in the clinical setting. Clinical reasoning is not a one-way pathway, but rather a chain of interconnected critical, creative and intuitive thinking in order to prevent complication and deterioration. Case Study Mrs Suzanne Manthey, a 44 year old Indigenous Australian widow, is admitted on 21 April 2013 at 10pm due to experiencing severe wheezing, dyspnoea and anxiety under Dr Mark Ting. She was in the emergency department only 6 hours ago with an acute asthma attack. She can speak only one to three word sentences and complained that she began to experience increased shortness of breath and tightness in her chest when she returned home. Upon physical examination, she was using her accessory muscle to breathe, has audible wheezing, respiratory rate of 34 breaths/minute, auscultation reveals no air movement in lower lobes and a heart rate of 126 beats/minute. Her arterial blood gas result shows PaO2=80mmHg, PaCO2=35mmHg and a pH of 7.46 which shows that she is experiencing respiratory alkalosis. She has been smoking on and off for almost 20 years and just recently stopped a year ago. Mrs Manthey currently lives a few kilometres away from an industrial vegetable factory. Identifying of Cues To begin with, recognising the right cues and clusters of cues are the fundamental basis of clinical reasoning (Levett-Jones et al., cited in Elstein & Bordage 1991, p. 517). It is vital to continuously update nursing assessment data in order to provide the appropriate plan of care and implement the right interventions during an evolving situation. In the case of Mrs Suzanne Manthey, she is admitted to the hospital because she is experiencing severe wheezing, dyspnoea and anxiety. One of the risk factors for exacerbating her asthma attack that led to her admission is that she has been living near an industrial vegetable factory. In heavily industrialised or densely populated areas, climate conditions often lead to concentrated pollution in the atmosphere, especially with thermal inversions and stagnant air masses (Brown & Edwards 2012, p. 675). Exposure to pollutants such as wood and vegetable dust, pharmaceutical agents, laundry detergents, animal and insect dusts, secretions and serums, metal salts, chemicals, paints, solvents and plastics can lead to chronic pulmonary disease and respiratory cancer (Brown & Edward 2012, p. 675; Dempsey et al. 2009, p. 1204). The assessment of the person’s home and other relevant environments is important so that risk factors that may cause injuries and accidents can be
Comment [S6]: Good understanding of disease process Comment [CM4]: This is a significant cue on admission, yet below it has not been dealt with sufficiently Comment [S5]: The case study provides a good context for the assignment Comment [S3]: You have given a good explanation for the importance of nursing assessment and interventions with adequate supporting evidence Comment [S2]: You are using some older references, try to keep references to within the last 5 years

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identified (Dempsey et al. 2009, p. 683). She is experiencing severe wheezing and dyspnoea due to exposure to the triggering allergens or irritants which are clinically caused by intense inflammation associated with the classic immediate reaction of asthma, which consists of bronchial smooth muscle constriction, increased vasodilatation and permeability and epithelial damage (Brown & Edwards 2012, p. 676). Her anxiety is not an unexpected emotion during her asthma attack. Anxiety is a very normal response to not being able to breathe (Brown & Edwards 2012, p. 676). Upon assessment she was observed to be using her accessory muscle to breathe, has audible wheezing, respiratory rate of 34 breaths/minute, auscultation reveals no air movement in lower lobes and a heart rate of 126 beats/minute. All of these symptoms are warning signs of severe asthma exacerbation (Brown & Edwards 2012, p. 677). Her arterial blood gases result indicates that she is experiencing respiratory alkalosis as she is hyperventilating. Hyperventilation occurs during asthma attack as lung receptors respond to increased lung volume from trapped air and airflow limitation (Brown & Edwards 2012, p. 677). Another thing that needs to be closely considered in the case of Mrs Manthey is her smoking history. Cigarette smoking is a major contributor to lung disease and respiratory distress and is also a major factor in cardiovascular disease that may further impair oxygenation (Dempsey et al. 2009, p. 1203). Being aware of her health history gives the uniqueness and individualised care plan to be able to meet her needs, making it more person-centred approach. With all these early detection of cues, the right patient has been advocated. The nurse’s ability to recognise clinically ‘at risk’ patient is crucial (Levett- Jones et al., cited in Clark & Aiken, 2003, p. 518) to prevent failure to rescue. The nurse is then able to prioritise Mrs Manthey as a patient who needs immediate nursing care and intervention. Nursing Action To further prevent Mrs Manthey from deteriorating, the initial gathered cues during assessment should serve as a guide throughout her care and in monitoring any sudden abnormal changes in her condition. Ineffective airway clearance is the first cue that needs to be alleviated in order to eliminate her severe wheezing and recover her normal respiratory rate. The goal of care is to enhance effective breathing pattern indicated by absence of accessory muscle use and pain free deep breathing and coughing (Dempsey et al. 2009, p. 1215). The development of nurse’s skills and knowledge in relation to respiratory assessment needs to be proactively included in nursing practice to ensure that patient care is delivered in a safe and timely fashion (Duff, Gardiner & Barnes, cited in Trossman 2003; Coombs & Morse 2002, p. 53). First thing that needs to be done is to determine her baseline respiratory status which is use as a comparison point (Brown & Edwards 2012, p. 690). Ongoing observation of her chest movement, including symmetry, use of accessory muscles and at the same time auscultation of breath sounds, noting areas of decrease or absent ventilation are ways to evaluate respiratory status (Brown & Edwards 2012, p. 690). The nurse then administers her prescribed medication as appropriate and per
Comment [CM8]: See CM9 Comment [S7]: Good assessment

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policy and procedural guidelines to improve her respiratory function (Brown & Edwards 2012, p. 690). Documentation and charting the administration of the medication on the patient’s medication chart is necessary to prevent medication errors (Dempsey et al, 2009, p. 803). To improve her respiratory rhythm and rate, breathing and relaxation techniques should be taught. The nurse should also offer warm fluids to drink to liquefy secretions and promote bronchodilation (Brown & Edwards 2012, p. 690). Her arterial blood gas should be constantly monitored in order to prevent respiratory acidosis. The PaCO2 will normalise as Mrs Manthey gets tired which may lead to a warning sign signifying respiratory failure (Brown & Edwards 2012, p. 677). Another important cue that needs to be relieved is Mrs Manthey’s anxiety, to be able to achieve decreased anxiety with increased control of respirations (Brown & Edwards 2012, p. 690). The nurse should use calm, reassuring approach to provide reassurance (Brown & Edwards 2012, p. 690). Verbalising her feelings, perception and fears are to be encouraged to identify problem areas so appropriate planning can take place and be implemented on (Brown & Edwards 2012, p. 690). Conclusion In conclusion, having the ability to identify and prioritise clinical problems in a certain situation and integrate the stock knowledge and experience gives a nurse the skill of clinical reasoning. Higginson and Jones (cited in Bickley 2007, p. 456) stated that all nursing or medical intervention should be based upon a sound clinical assessment of the patient. Having a well planned patient centred intervention based on the gathered cues, provides an evidence of good quality care. The ability of the nurse to recognise a problem helps him or her distinguish the needs of Mrs Manthey and what is actually happening to her throughout the care. It is also essential not to only focus on her admitting clinical condition of severe wheezing, dyspnoea and anxiety, but also other factors that may contribute to further complication such as her history in smoking at the same time her environmental condition. Failure to monitor her other health problems may lead to an adverse event that may affect her wellbeing. A problem that is not recognised or is not responded appropriately by the nurse can cause deteriorating situation (Dempsey et al., cited in Aitken et al. 2003; Duffield et al. 2007; Thompson et al. 2008, p. 264). As a result, nurses should have the ability to gather the right cues and take the appropriate actions to the right patient for the right reason during the right time. As what Florence Nightingale (1969) quoted “The very first requirement in a hospital is that it should do the sick no harm.”

Comment [CM9]: Don’t forget gold standard bronchodilatiors

Comment [CM10]: The realities are that other indicators are monitored first to detect any signs of early changes, e.g. pulse o2, changes in resp status. Constant arterial stabs would be unkind.

Comment [S11]: You have demonstrated appropriate nursing actions for this case study. You also should have included nursing actions such as positioning and administration of oxygen

Comment [CM12]: Secondary citations should always have a page number

Comment [S13]: You have tied together your main points well, good conclusion.

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References Banning, M 2008, ‘Clinical reasoning and its application to nursing: concepts and research studies’, Nurse Education in Practice, pp. 177- 183, viewed 16 April 2013, EBSCOhost CINAHL with full text. Brown, D & Edwards, H (eds) 2012, Lewis’s medical-surgical nursing: assessment and management of clinical Problems, 3rd edn, Elsevier Australia, Chatswood, NSW. Dempsey, J, French, J, Hillege, S & Wilson, V 2009, Fundamentals of nursing & midwifery: a personcentred approach to care, Lippincott Williams and Wilkins, Broadway, NSW. Dempsey, J, Hickey, N, Hoffman, K, Levett- Jones, T, Noble, D, Norton, CA & Yeun- Sim Jeong, S 2010, ‘The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients’, Nurse Education Today, pp. 515- 520, viewed 19 April 2013, EBSCOhost CINAHL with full text. Duff, B, Gardiner, G & Barnes, M 2007, ‘The impact of surgical ward nurses practising respiratory assessment on positive patient outcomes’, Australian Journal of Advance Nursing, vol. 24, no. 4, pp. 5256, viewed 20 April 2013, EBSCOhost CINAHL with full text. Henneman, E, Gawlinski, A & Giuliano, K 2012, ‘Surveillance: a strategy for improving patient safety in acute and critical care units’, Critical Care Nurse, vol. 32, no. 2, pp. 9- 18, viewed 20 April 2013, EBSCOhost CINAHL with full text. Higginson, R & Jones, B 2009, ‘Respiratory assessment in critically ill patient: airway and breathing’, British Journal of Nursing, vol. 18, no. 8, pp. 456- 461, viewed 24 April 2013, EBSCOhost CINAHL with full text. Odell, M, Victor, C & Oliver, D 2009, ‘Nurses’ role in detecting deterioration in ward patients: systematic literature review’, Journal of Advanced Nursing, vol. 65, no. 10, pp. 1996- 2006, viewed 20 April 2013, EBSCOhost CINAHL with full text. Parkes, R 2011, ‘Rate of respiration: the forgotten vital sign’, Emergency Nurse, vol. 19, no. 2, pp. 12-18, viewed 24 April 2013, EBSCOhost CINAHL with full text. Tanner, C 2006, ‘Thinking like a nurse: a research-based model of clinical judgement in nursing’, Journal of Nursing Education, vol. 45, no. 6, pp. 204- 211, viewed 19 April 2013, EBSCOhost CINAHL with full text.

NUR2100 Episodes of Nursing Practice Assignment Marking Guide 2013
Areas Low Demonstration 0
Introduction has irrelevant material Poor or absent introduction – does not set up paper well; Introduction Does not state a theme

Partial Demonstration .5
Introduction present but confusing Intro uses simplistic language or lists"the paper will cover… then it will cover…" Theme stated but not relevant

High Demonstration 1

Totals

Rationale for topic is explored. Background from literature (if used) is referenced appropriately. Introductions gives an indication of the body of the paper Introduction articulates into the content of the assignment. Appropriate theme is stated 1/1

Nurse’s role in detecting deterioration in pt status Principles expressed in the literaturerelat ed to the nurse’s role in appropriately monitoring a client with indicators of deterioration in their condition

0-1.5
Importance of patient assessment/monitoring is not established Student equates process of patient assessment/monitoring with routine observations There is absent or minimal association of the nurse’s role in the strategies presented Sources are not utilized for this section Sources utilized are not academically credible

2-3.
Role of patient assessment/monitoring is established but not supported. Importance of patient assessment/monitoring is not explained well The nurse’s role is only partially established or not fully developed

3.5 – 5
Explains rationale for nursing role in safeguarding clients through effective monitoring/surveillance At least two of the following principles are addressed and synthesised well o Surveillance o Early detection and timely intervention/ o Failure to rescue o Clinical reasoning o Knowledge and judgment Student uses credible sources for this section The nurse’s role is integrated throughout the assignment

4/5

Importance of patient assessment/monitoring is not supported by literature

0
Case study presented does not demonstrate knowledge of respiratory difficulty Case study Case study is absent or inappropriate

.5
Case study is presented but is not realistic or plausible

1
Case study developed by student has appropriate symptoms/ is plausible Case study provides a context for the patient situation Physical cues presented are representative of ‘early cues’ which nurses should notice Case study demonstrates ongoing assessment of the patient

Inappropriate signs/symptoms/cues are presented

1/1

0 – 0.5
Actions do not relate to case study presented Actions are incomplete Nursing actions for Case study Actions are presented without rationale from sources Sources utilized are not considered academically credible sources Sources are used without acknowledgement

1 – 2.0
Demonstrates some nursing interventions – butthese are clearly explained or developed Knowledge of the relevant physiology for changes in the patient’s condition is not evident in the nursing interventions proposed Limited rationale is given for interventions

2.5-3
Nursing actions are appropriate for the nominated case study Interventions demonstrate appropriate content knowledge In this section, the rationalefor the nursing actions is provided from at least two academic sources (textbooks, journals) Rationale (when applicable) demonstrates knowledge of physiology related to symptoms/ signs or patient behaviours The effects of interventions are proposed 1.5/

3

0 – 0.5
Assignment is a 'patchwork' of quotes or paraphrased material without synthesis of material for the reader. Original Language Little evidence of the student analysing and developing the material and incorporating their own expression.

1

1.5 - 2
Student demonstratessynthesis of knowledge from several sources to substantiate a logical argument. There is evidence of the student analysing and developing the material and incorporating their own expression.

Partial synthesis which is not consistent throughout the assignment.

2/2

0 – 1.5
Written Expression


2-3
Written expression lacks consistency and does not demonstrate a high academic standard. Written language the student uses is conversational or colloquial and not the standard expected in an academic source Some paragraph structure but not consistent. Poor topic sentences Some inconsistencies in grammar and spelling

3.5-4
High standard of written expression. Language is appropriate and of a high academic standard. Well-written and well-structured paragraphs. No breaches of grammar or spelling. Punctuation/tenses and use of person are of a high standard.

            

Grammar

Poor written expression. Reader must re-read sections to understand content. Poorly written paragraphs without any structure. Uses dot points. Uses colloquial language. Changes tenses Inappropriate use of 1st person or switches to 2nd person Incomplete sentences Run on sentences Poor singular/plural use Inappropriate punctuation Misspelled words Inappropriate abbreviations (SMS) language

4

/4

0 – 0.5
Assignment uses material from sources without acknowledging source. Inappropriate use of cited material. Appropriate Referencing: In-text and Reference list Inappropriate paraphrasing from published literature Incorrect secondary citation; Incorrect use of 'et al.' Reference List isnot in alphabetical order. Inappropriate punctuation in list. Referencing is not done in one style. Assignment reads as a whole Consistent use of theme Appropriate Conclusion COUNT =

1-1.5
Some inconsistencies with style of in-text referencing (those in the body of the paper) Inconsistencies with reference list Does not use electronic format for electronic journal articles Moderate issues identified with referencing. Page numbers missing from intext quotes when these should be utilized

2-3
Consistently correct in-text referencing as per USQ guidelines. Correct use of Harvard AGPS or APA Referencing.

Correct expression of secondary citations. Assignment acknowledgessource of all referenced materials. Minimum of six references used with three from assigned list.

3/3

0
Material strays into tangents Points are covered but are not unified to theme Inappropriate or absent conclusion Referenced material in conclusion

.5
Theme was not consistently applied to the assignment. Assignment disjointed Conclusion includes new material or does not summarise adequately

1
Assignment reads as a unified 'whole’ Theme is clear and maintained throughout assignment. The material used supports theme. Conclusion ties together main points. Concl. reflects on importance of findings. Total obtained:

1/1

Computer WORD

Negative marks may be awarded here for Late Penalty, not attaching marking guide or significant discrepancy from word count (over or under by > 10%): = 1,845

17.5 /20

Markers name:

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Comments: Overall a very good assignment. Be cautious of your cues however, it is often the simple cues that we overlook that can lead to the greatest harm. For example the patients history of smoking. As a resp nurse I use to go as far as advocate for nicotine levels to be taken. These are a better indicator of the quantity of smoking undertaken by the patient. Indicators of the smell of cigarette smoke, absent or present. Often patients will say they have stopped and have not. Don’t forget gold standard bronchodilators as an intervention, I can guarantee that these would have been ordered.