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Identifying the Phases of the Slippery Slope

John Smith - 81-year-old retired farmer, married to Jean. They are both physically and socially active within the community.

At 0600hrs this morning John rolls his tractor down a 6 M embankment and is not found until 0930

Jess goes looking for him and finds him at semi-conscious and calls an ambulance.

On arrival at Emergency Department:

Obs: RR 28, SpO2 90% RA. GCS15, BP122/64, HR94 sinus rhythm, T36.4 tympanic. Abrasions across left side of chest extending around to middle of his back. Extensive bruising to left hip and around to left buttock. Unable to weight bear, no shortening of legs, constant sharp pain 8/10 in left upper thigh and into left hip region.  Also complaining of left sided chest discomfort 3/10 under his rib cage. HNPU.

Treatments given: FiO2 6L Hudson, 20G IVC in R cubital fossa with NS at 200ml/hr. 250ml bolus given on route. IVI Morphine 2mg stat at scene at 1020hrs and repeat 2mg Morphine on route at 1030hrs. Left hip and buttock pain now 6/10 and chest discomfort 1/10.

PH- non-smoker, ETOH 3-5/ week. Reading glasses and hearing aids. He is 180cm tall and weighs approximately 104kg. John has a medical history of GORD and TIA 2 years ago. John’s regular medications are Zantac and Clopidigril.

You commence your nursing assessment of John and note the following:

John’s is speaking in short sentences, breathing is shallow but with symmetrical rise and fall of the chest. Breath sounds on auscultation normal but he is tender to touch. There is grazing over left side of the chest.

Peripheries are a dusky pink colour and now cool to touch with a capillary refill <4 seconds. Pt states pain in L hip as 6/10 at rest and 10/10 on movement. Normal sensation in all limbs. Grimaces in pain on abdominal palpitation.

Vital signs : RR26, SpO2 92% 6L Hudson, BP 96/50, HR120 sinus tachycardia, T35.9. GCS=14. PEARTL size 4. BGL 6.0 mmols.

You initiate a clinical review.

A clinical review is attended and the medical team has provided the following plan:

  • For urgent abdo CT
  • Surgical consult and NBM.
  • Maintain systolic BP >100mmHg if <100 for rapid response
  • Insert IDC

A Left CVAD inserted. Maintenance fluid 200mls/hr

John becomes confused with a GCS 11, BP 92/54, HR134, RR 30 SpO2 88% 6L Hudson mask. PEARTL size 4. Cap refill is 4 seconds – cool extremities.

A rapid Response is activated

John continues to deteriorate as his BP falls to 52/25, HR 144.

Cardiac monitor then alarms demonstrating pt in VT.

CPR is commenced and the ALS team attach him to an AED.

Patient is delivered 200joules for a shockable rhythm with no effect.

Adrenaline IV is administered.

Second shock delivered and reverts to SB with multifocal VEB’s.

Obs: BP 72/48, HR 89 sinus arrhythmia. Two minutes later John’s vital signs are BP 99/64, HR 82 Sinus Rhythm, RR 14, SpO2 88% Non-Rebreather mask and a GCS 14.

You are to examine the case study and identify what was happening for the patient, clinically, in each of the "Between the Flag" phases.

Include in your discussion the importance of:

  • knowing and identifying the four phases highlighted in the 'Slippery Slope' for the patient in the case study; and
  • patient safety from the perspective of a Registered Nurse.
Identifying the Phases of the Slippery Slope

Due to their altered psychological conditions, critically ill patients are at a huge risk of experiencing deteriorating health conditions if the appropriate nursing interventions are not applied. An appearance of abnormal vital signs could be the initial indications the patient’s health is deteriorating and the vital signs may start showing after several hours in a gradual manner (Considine & Currey, 2015). The nurse should be able to identify, observe, and assess these psychological abnormalities to enable them in developing the best care plan and ensuring the patient safety. According to Creed & Spiers (2010), failure to address these abnormalities and health deteriorations could escalate the patient’s condition into a critical state that may, unfortunately, lead to death.

The nurses normally apply the between the flags system to intervene in the in situations of clinical deterioration of a patient’s health condition. This system may be described as a safety net for patients in most of the healthcare facilities (Pain et al., 2017). The aim of its design is to prevent an unnoticed deterioration of patients and to ensure that the patients get the best care in case of deterioration. This helps in improving the quality of care and ensuring patient safety. In the intervention to prevent patient deterioration, there exists a slippery slope diagram that has four phases of intervention (Hughes, Pain, Braithwaite & Hillman, 2014). The phases include prevention, clinical review, rapid response and advanced life support. In this essay, we will discuss the four phases of the slippery slope, and identify what happens in each of the phases. Additionally, the essay addresses the safety of the patient from the perspective of a registered nurse.

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.

Pain Management and Trauma Patients

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.

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.

Assessing Injuries and Vital Signs

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.

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.

Continued Deterioration and Importance of Monitoring

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.

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.

Complications and Risks Associated with Abdominal Injuries

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

Arora, S., Flower, O., Murray, N. P., & Lee, B. B. (2012). Respiratory care of patients with cervical spinal cord injury: a review. Critical Care and Resuscitation, 14(1), 64.

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2017). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Considine, J., & Currey, J. (2015). Ensuring a proactive, evidence?based, patient safety approach to patient assessment. Journal of clinical nursing, 24(1-2), 300-307.

Creed, F., & Spiers, C. (Eds.). (2010). Care of the acutely ill adult: an essential guide for nurses. OUP Oxford.

Egol, K. A., Koval, K. J., & Zuckerman, J. D. (2010). Handbook of fractures. Lippincott Williams & Wilkins.

Hughes, C., Pain, C., Braithwaite, J., & Hillman, K. (2014). ‘Between the flags’: implementing a rapid response system at scale. BMJ Qual Saf, bmjqs-2014.

Iverson, G. L., & Lange, R. T. (2011). Mild traumatic brain injury. In The little black book of neuropsychology (pp. 697-719). Springer, Boston, MA.

Kobayashi, L., Costantini, T. W., & Coimbra, R. (2012). Hypovolemic shock resuscitation. Surgical Clinics, 92(6), 1403-1423.

Mok, W. Q., Wang, W., & Liaw, S. Y. (2015). Vital signs monitoring to detect patient deterioration: An integrative literature review. International journal of nursing practice, 21(S2), 91-98.

Myburgh, J. A., & Mythen, M. G. (2013). Resuscitation fluids. New England Journal of Medicine, 369(13), 1243-1251.

Pain, C., Green, M., Duff, C., Hyland, D., Pantle, A., Fitzpatrick, K., & Hughes, C. (2017). Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System. International journal for quality in health care, 29(1), 130-136.

Reynolds, A. (2013). The fractured femur. Radiologic technology, 84(3), 273-291.

Unsworth, A., Curtis, K., & Asha, S. E. (2015). Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scandinavian journal of trauma, resuscitation and emergency medicine, 23(1), 17.

Villegas, M. I., Hennessey, R. A., Morales, C. H., & Londoño, E. (2011). Risk factors associated with the development of post-traumatic retained hemothorax. European Journal of Trauma and Emergency Surgery, 37(6), 583-589.

Yalcin, N. G., Choong, C. K., & Eizenberg, N. (2013). Anatomy and pathophysiology of the pleura and pleural space. Thoracic surgery clinics, 23(1), 1-10.

Yi, J. H., Liu, H. B., Zhang, M., Wu, J. S., Yang, J. X., Chen, J. M., ... & Wang, J. A. (2012). Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. Journal of Zhejiang University SCIENCE B, 13(1), 43-48.

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