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Question:

Discuss about the Identification of Patient Physiologic Deterioration.

This is a case study analyzing the condition of our client John who is an 81 year old retired farmer. John is married to Jean and together they live a happy life. They are involved in the community and they are fit both physically and socially. John has a history of transient ischemic attack and gastro esophageal reflux. He takes clopidigrel for the transient ischemic attack and zantac for the gastro esophageal reflux (Kletzl, 2015). John wears reading glasses and he is a non-smoker. He goes for regular medical check-ups and he weighs 104 kilograms with a height of 180 centimeters. On calculating his basal mass index our client John has a basal mass index of 57.7 which indicates that he is obese.

At the scene of the accident John was given morphine 2miligrams stat for the sharp pain he was experiencing on the left upper thigh into and into the hip region, and on route he was given a repeat dose of 2milligrams morphine, he was also given 250 milliliters of normal saline stat before arrival to the emergency department (Hadzic, 2017). On arrival to the emergency department John was started on oxygen(fraction of inspired oxygen at 6litres per minute) and he was hydrated with normal saline at 200mililitres per hour in the right cubital fossa.

This case study focuses on the day John was found unconscious in his farm. He had abrasions on his chest, extensive bruising to the left hip, he was unable to bear weight and his legs were not shortening (Stenhagen, 2014). John reported sharp pain on the upper thigh and left hip region, he also reported chest discomfort. He was taken to the hospital in a fairly stable condition with a Glasgow coma scale of 15 an elevated heart rate of 94 and a slightly elevated respiratory rate of 28 breaths per min. His condition later deteriorated to an extent he was resuscitated. John responded to the resuscitation which involved the use of adrenaline and defibrillation.

In this case study I will analyze the care provided to John and the events which might have led to the deterioration of his condition. I will analyze the factors that may have predisposed john to the complications he acquired while in the hospital and the drug interaction between zantac and clopidigrel (Naidoo, 2016).

On arrival to the emergency department the patient was fairly stable and he was started on oxygen therapy and hydration with normal saline. On the first nursing assessment that was conducted John had a shallow breathing with a symmetrical rise and fall of the chest. He could speak in small sentences. On auscultation the breath sounds were heard and they normal but his chest was tender to touch, which could have resulted from the abrasions on the chest. There was grazing over the left side of the chest and his capillary refill was less than 4 seconds. John had pink extremities and they were cool to touch.

Clinical Review and Assessment

On pain assessment, John stated that he was in pain and ranked it at 3/10 during rest and 10/10 during movement, john had normal sensation on all his limbs. He was still on oxygen and his oxygen saturation was at 92%, his Glasgow coma scale was at 14 and his heart rate was at 120 beats per minute which indicated sinus tachycardia with a reduced blood pressure of 96/50. His respiration rate was slightly elevated at 26 breaths per minute (Wijdicks, 2015). John had a temperature of 35.9 Celsius which was markedly reduced in comparison to his temperature during admission which was 36.4 degrees Celsius.

Our client condition is deteriorating as indicated by the vital signs. His blood pressure is falling and his temperature is falling. He had an initial blood pressure of 122/54mmHg but on the nurses assessment in the clinical review his blood pressure had dropped to 96/50mmHg. His temperature had dropped from an initial temperature of 36.4 degree Celsius to 35.9 degree Celsius. His heart rate had also increased to 120 beats per minute. All of these changes in his vital signs indicate a worsening condition that requires urgent attention to halt the onset of complications.

According to John’s history he has been on zantac which is a histamine-2 blocker and clopidigrel which is used in the prevention of a heart attack for patients who are predisposed to heart attacks. John was predisposed to developing a heart attack because he had a history of transient ischemic attack. His gastro esophageal reflux is attributed to his alcohol intake which is 3-5 times a week, which is why he is on Zantac histamine 2 antagonist medications (Gyawali, 2017).

During the review a CT scan of the abdomen was requested and the surgical team was consulted. An indwelling catheter was inserted and John was put on nil per oral. This meant that he was not supposed to take any solid or liquid food through the mouth.

Ensure that John receives all the prescribed medication at the right time in order to prevent occurrence of complications and promote complete adherence to medication (Morton, 2017).

Provide warm blankets and a warm environment to prevent him from experiencing hypothermia, which may result from his falling temperatures (Morton, 2017).

Provide fluids as prescribed in order to raise John’s blood pressure. The falling blood pressure might result in a complication that is why John is on normal saline to help raise his blood pressure (Morton, 2017).

Use aseptic technique while inserting the catheter and ensure that John has been taken for the abdominal CT scan and all the preparations are made including contacting the surgical team. This is to ensure that the entire tests prescribed are conducted and urinary output is measured (Morton, 2017).

Ensure that John receives his oxygen and is on complete bed rest with minimal interference to reduce the chances of complications (Morton, 2017).

John condition was assessed by the clinical team and strategies were formulated to prevent any further decline in his health status. Preventive measures were taken to ensure that his blood pressure was maintained at more than 100mmHg (Manning, 2015). Despite the intervention John’s condition further deteriorated and the rapid response measures were initiated (Harshman, 2017).

Medications Prescribed for John

John’s vital signs continued to worsen, his blood pressure dropped to 92/54mmHg, his respiratory rate increased to 30 breaths per minute, and his heart rate increased to 134 beats per minute. His oxygen saturation reduced to 88% despite being on artificial oxygen at 6litres per minute (Chan, 2018). His Glasgow coma scale reduced to 11 and his capillary refill was at 4 seconds.

These changes lead to the initiation of the rapid response. A central venous access device was inserted which is used for measuring central venous pressure and is also used as a quick access to the blood circulatory system during resuscitation. John was receiving fluids at 200mililitres per hour with an aim of raising the blood pressure (Ozekcin, 2015).

Due to John’s worsening condition a rapid response was initiated because he was not in the intensive care unit. His condition was closely monitored for further complications. His condition was tracked for possible complications which were associated with his past medical history of experiencing a transient heart attack and gastro esophageal reflux. His past medical history predisposed him to complications such as heart attacks and gastrointestinal bleeding which would result from over-production of gastric acid (Ozekcin, 2015).

The insertion of the central venous access device is done at the right time, by the right person and strict aseptic technique is observed to prevent complication such as infections which may arise from the procedure (Morton, 2017).

That the access site is not bleeding and administer pain medication to help manage the discomfort associated with the insertion of the central venous access device (Morton, 2017).

That the clinical indicators which would detect any form of complications are carefully monitored, because our client is in the rapid response phase (Morton, 2017).

The nurse should ensure the client receives his medications to promote drug adherence (Morton, 2017).

John’s condition continued to worsen. His vital signs further deteriorated which called for resuscitation. His blood pressure significantly dropped to 52/25mmHg. This was the only indicator to raise an alarm for quick action. A drop of systolic pressure from 92 -52 signifies and worsening state of condition and the need for urgent attention to raise this blood pressure to prevent further complications like death and total unconsciousness. His diastolic pressure dropped from 50- 25mmHg and this was an additional indicator for resuscitation and his heart rate significantly increased to 144 beats per minute from 120 beats per minute. The drop in John’s blood pressure and the increase in his heart rate showed that John’s condition was worsening. The cardiac monitor raised and alarm because John was in ventricular tachycardia and he needed to be resuscitated quickly to normalize the heart rhythm (Osborne, 2015).

Cardiopulmonary compressions were started and the advanced life support team was called to assist in stabilizing John’s deteriorating condition. John was attached to an automated external defibrillator, a rhythm of 200joules was administered but it did not cause any effect on the ventricular tachycardia rhythm. John remained unresponsive and this state prompted the team to administer adrenaline which was augmented with a second rhythm to revert the abnormal rhythm to a normal heart rhythm (Osborne, 2015).

The second shock made John responsive and his vital signs improved. His blood pressure rose to 72/48mmHg and the heart rate rose to 89 beats per minute, the cardiac monitor indicated a sinus arrhythmia and two minutes later John vitals reverted back to almost normal (Watkins, 2016). His blood pressure rose to 99/64mmHg, his heart rate rose to 82 beats per minute, and his respiratory rate normalized at 14 breaths per minute and his oxygen saturation remained at 88 %. John was put on a non-Rebreather mask with an increase in the Glasgow coma scale to 14 from 11 (Teasdale, 2014).

After being put into the rapid response state, John’s condition worsened which lead him to being resuscitated by use of cardiopulmonary compressions and defibrillation. Resuscitation on the first attempt did not work, but on the second attempt with use of adrenaline and electrical shock wave from an automated external defibrillator reversed John’s worsening condition; therefore he was able to respond and his condition improved.

The nurse should ensure that no harm comes to John and that the person offering the resuscitation is highly skilled and qualified at resuscitation (Morton, 2017).

Preventive Measures and Interventions

The nurse should ensure that John is well oriented to what happened to prevent psychotic episodes that may be caused by fear and anxiety from being resuscitated (Morton, 2017).

The nurse should ensure that John’s vital signs are well documented and all the procedures performed on him are documented for future reference (Morton, 2017).

Conclusion

According to the bio data availed John is and elderly man who is at risk of developing cardiac arrest due to his experience with a transient ischemic attack. He is also on medication for gastro esophageal reflux which may predispose him to abdominal pain and bleeding due to ulcer formation as a result of increased secretion of gastric acid (Roman, 2017).

The complication experienced by John may be associated with his increasing age which results to reduce physiologic process such as reduced gastric motility and reduced patency of the blood vessels. John is also at risk of developing complications associated with obesity because of his increased basal mass index. These complications may have led to further complicating his current condition.

John uses clopidigrel a drug used to prevent the risk of developing cardiac arrest in individuals at risk, thus drug increases the rate of bruising and it may explain why extensive bruising to the left hip and chest had (Naidoo, 2016). The pain he was experiencing may have been caused by his fall at his far. Risk for falls is highly increased in the elderly because of osteoporosis which worsens with old age (Horgas, 2017)s. John’s gastro esophageal reflex may be worsened by clopidigrel; however this effect is counteracted by zantac.

Due to his increased risk of developing cardiac arrest and his age John should be closely monitored and his health condition should be closely followed up.

Chan, V. K. (2018). Oxygen Saturation and Heart Rate Variations as Predictors of Intradialytic Hypotension. Nephrology Nursing Journal,, 1(45), 53-61.

Gyawali, C. P. (2017). Classification of esophageal motor findings in gastro?esophageal reflux disease: Conclusions from an international consensus group. Neurogastroenterology & Motility,, 12(29), e13104.

Hadzic, A. (2017). Textbook of regional anesthesia and acute pain management. McGraw-Hill Medical Publishing Division.

Harshman, L. A. (2017). Intradialytic Hypotension: Potential Causes and Mediating Factors. n Pediatric Dialysis Case Studies (pp. (pp. 141-148). ). Cham: Springer.

Horgas, A. L. (2017). Pain Management in Older Adults. Nursing Clinics,, 4(52), e1-e7.

Kletzl, H. (2015). Effect of gastric pH on erlotinib pharmacokinetics in healthy individuals: omeprazole and ranitidine. Anti-cancer drugs,, 5(26), 565-572.

Manning, L. S. (2015). Short-term blood pressure variability in acute stroke: post hoc analysis of the controlling hypertension and hypotension immediately post stroke and continue or stop post-stroke antihypertensives collaborative study trials. Stroke, 6(46), 1518-1524.

Morton, P. G. (2017). Critical care nursing: a holistic approach. Lippincott Williams & Wilkins.

Naidoo, V. (2016). Proton pump inhibitors. SA Pharmaceutical Journal,, 1(83), 9-12.

Osborne, S. (2015). The primacy of vital signs–acute care nurses’ and midwives’ use of physical assessment skills: a cross sectional study. International Journal of Nursing Studies,, 5(52), 951-962.

Ozekcin, L. R. (2015). Simulation education: early identification of patient physiologic deterioration by acute care nurses. Clinical nurse specialist,, 3(29), 166-173.

Roman, S. (2017). Ambulatory reflux monitoring for diagnosis of gastro?esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterology & Motility,, 10(29), 1-15.

Stenhagen, M. (2014). Accidental falls, health-related quality of life and life satisfaction: a prospective study of the general elderly population. Archives of gerontology and geriatrics,, 1(58), 95-100.

Teasdale, G. (2014). The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology, 8(13), 844-854.

Watkins, T. (2016). Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit. Journal of clinical nursing,, 1-2(25), 278-281.

Wijdicks, E. F. (2015). Comparison of the full outline of unresponsiveness score and the Glasgow Coma Scale in predicting mortality in critically ill patients. Critical care medicine, 2(43), 439-444.

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