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NRS312 Essential Nursing Care: Managing The Deteriorating Patient

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Clinical Case Study

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

Phase 1 – On Presentation

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.

Phase 2 – On Assessment – Clinical Review Activated

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

Phase 3 – Rapid Response

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

Phase 4 – Resuscitation

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.
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