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Mr Walker is a 72 year old male who presents to the Emergency Department of his local hospital in the early hours of Monday morning. He presents with lethargy, confusion, abdominal pain and distention. Pt’s wife states Pt has been taking bowel prep since yesterday, in preparation for routine colonoscopy today. Pt has not eaten in 20 hours and last drink was 2000hrs last night. 
Pmhx- History of bowel polyps.  MI- 5 years ago with 2 vessels stent. 
Usually manages own medications. Wife states he takes something for cholesterol, something for blood pressure and something to thin his blood.  
Social- independent of ADL’s, non-smoker, lives with wife at home. 

• Present your initial( A to G) assessment of Mr Walker in relation to his presenting condition. 
• Discuss other considerations in relation to recognising the deteriorating older person.  

3 hours after initial arrival to ED, Mr Walker starts to complain of chest pain. He is diaphoretic and tachycardic and becoming increasingly agitated. He is calling out and trying to get out of bed. 

• Discuss your priority and escalation of care 
• Discuss other considerations in relation to recognising the deteriorating older person.

• Document the events as you would in the nursing progress notes( Head to Toe ). 

A

Airway

·  The patient struggles to breath and feels some abdominal pain when breathing.

· There evident mouth swellings

· The airway partially blocked.

· The patient is snoring, coughing, and gargling.

· Air movement is evident but with pain.

· Patient is weak,

· lethargy,

· confusion,

· Abdominal

· Pain

· distension

B

Breathing

· The chest wall movement not normal and symmetric

· The patient uses neck and shoulder muscles but the impulses are very weak.

· The patient doesn’t speak properly and can hardly complete a sentence.

· Some stridor, wheezing, and gargling can be heard from the chest.

· The trachea is centrally positioned

· The patient is sweating profusely

· The patient lost a lot of water from most parts of the body.

C

Circulation

· Yellowish skin colour

· Patient’s central venous pressure is abnormal

· Jugular venous pressure is normal

· The patient complains of headache and is dizzy.

· The patient’s blood pressure is high

· Heart sound is abnormal and heart rate is slower.

· The patient’s hands are cold

· Large veins evident on the skin periphery.

· Patient’s peripheral pulses are weak, abnormal, and of slower rate

· Inconsistent pulse rate.

D

Disability

· The patient is conscious but the level of consciousness reduces rapidly with time.

· The face is asymmetrical, he makes some abnormal body movements and the limbs are weakening as time goes by.

· The patient has slow response to the external stimuli and at times could not detect and feel a source of heat.

· His speech was slurred.

· At times the patient could feel and external stimuli but could not react due to weakness in the muscles (van der Mars, Timken, & McNamee 2018, p. 358). He struggled to even raise hands after feeling the source of heat that was used for study.

E

Exposure

The patient has some wounds in the mouth that bleed.

There were some air leaks in the drains.

Some bowel sounds could be noticed

The lower abdomen produced some rumbling sounds.

F

Fluids

The patient had lost a lot of fluids through vomiting and bleeding through the wounds. The fluid lose rate was high and the patient was becoming drained. Urine colour was concentrated and little in amount.

The patient complained for thirst every time. Takes water but loses it almost instantly through the drains.

The skin turgor was not very timely. The skin takes much longer time than usual to come back to normal after an external irritation like pinching.

The skin could remain wrinkled for some time before returning to normalcy.

G

Glucose

The patient suffered low concentration level and seemed confused almost throughout. This suggested a low level of glucose in the blood. 

The patients thirst was almost impossible to quench. The patient’s orientation to new places like the hospital environment was poor.

The patient was sweating throughout from all parts of the body.

Observations and Considerations for Recognising Clinical Deterioration

There has been a rise in the number of sudden cases of adverse medical conditions among old members of the society that result into cardiac arrest and or deaths. It should be noted that such events follow a series of other events that at some points fail to be recognised and dealt with appropriately. These preceding events can always be noticed and treated within the required time to prevent deaths (Cionea, Hoelscher, & Ile? 2017, p. 300). Studies show that most of the unexpected deaths occur due to the fact that the preceding events go unnoticed and not acted upon appropriately. Response includes appropriate and timely treatment to the detected conditions. The National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration (ACSQHC) sates that recognition should follow the A-G assessment but other considerations may include

Recording the respiratory rate on every observation made in an old patient whose condition is considered worsening. Respiratory rate is deemed a sign of early clinical deterioration. Another consideration to make is the Oxygen Saturations (SpO2) in a patient’s blood (Coleman, Kearns, & Wiles 2016, p. 970). This consideration can be achieved by measuring the pulse oximetry.

Recognizing an abnormality in the health condition of an old patient can achieved by frequently observing the blood pressure of the patient and recording the findings. (Tyson, Duma, & Rowson  2018, p. 325). This process is normally done using some automated machines that may be vulnerable to taking inaccurate measurements; and in such a case manual sphygmomanometer needs to be applied. Another method of detecting an alteration in the patient’s conditions is taking note of his or her level of concentration on the surrounding or just a conversation. A sudden decrease in the patient’s concentration and being less alert should sound an alarm to the handlers.

Some adverse health events affect a patient’s consciousness; this refers to how fast an individual reacts when irritated by an external condition. The medical team handling an old patient needs to be keen on the consciousness of the patient; in that any abrupt decrease should trigger a response (Fisher, Harrison, Bruner, Lawson, Reeder, Ashworth, Sheppard, & Chad 2018, p. 115). To sum up, the whole process of recognition and response done by medical staff on the patient’s clinical deterioration should involve a chain of operations. These include taking and recording observations, proper clinical communication in, and efficient rapid response in case of detected challenges. If the first aid procedure does not yield effective results then the patient’s care need to be escalated by transferring the patient to a more advanced health centre with better technological facilities. Another effective way to avoid such sudden health malfunctions is to educating the public about the symptoms of the preceding events to the actual cardiac arrests or sudden deaths.

The Importance of Early Detection and Timely Treatment

There are always various observable changes that can be noted in an individual some time prior to an occurrence of major health deterioration. These alterations in the normal day to day activities of a victim’s body may include changes in oxygen level in a person, some vital changes on the skin and conscious rate (Henry, Wilsey, Melnikow, & Iosif  2015, p. 740). It should be noted there are always long period of time that such symbols occur in an individual’s body but they are not detected and acted upon. This delay may lead to late treatment hence the worse result like cardiac arrest or death.

Some physiological observations need to be compiled about a patient and any slight alterations from the normal should be considered and treated with the urgency it deserves. Such observations include respiratory rate, heart rate, temperature, oxygen concentration, conscious level, and blood pressure. According to HARREL and REGLIN (2018, p. 40), a comprehensive assessment needs to be carried out on daily basis to detect any variation from the normal status. 

The manner in which the observations are done need to be very simple and straight to the point. So that the specific diagnoses on the patient’s and changes in the procedure are documented (Lee, Weathers, Davis, Domino, & Sloan 2017, p. 60). Any modifications to the monitoring plan need to be documented.  These observations need to be taken right from the point of admission of the patient into the health facility. The number of times observations and documentations are done to a patient is influenced by the condition of the patient. It can be done at least ones per shift.

The observations, measurement and responsive actions taken at early stages of the patient’s stay at the facility may help prevent any further complications that can lead to cardiac arrest or death. The procures and systems followed during escalation of a patient’s health care are done with the intention of assisting patients within the required timeframe after some changes are detected on the patient. (Patel et al. 2018, p. 900). This process follows as predefined steps as guided in various health facilities. The protocols should address the following as in the above case.

  • Increasing the frequency of observations of conditions being monitored. This means that the observations need to be taken more regularly to detect the slightest change possible.
  • The intervention of other senior practitioners to help monitor the patient.
  • If the condition continues to worsen then there is the need to review the medical team that handle him.
  • The patient is served with some special facilities so help in assisting and managing the condition.
  • At some points the patient may be transferred to another higher level facility with better equipments for enhanced care.

Studies show that most of the unexpected deaths occur due to the fact that the preceding events go unnoticed and not acted upon appropriately (Tighe et al. 2015, p. 570).  The process of recognising and responding assist medical staff to identify the events that precede these deadly health conditions. The medical staff then take the appropriate actionsimmediatly to avoid any further damage.  Response includes appropriate and timely treatment to the detected conditions.

A Comprehensive Assessment for Patients

An escalation may lead the practitioner to understand some process of growth in order to know the exact action to take. From the etiological narrative, the client's case may be as a result of a previous event that led to some undesirable effects. She fears that if the rumors spread by her peers are not controlled, there is the likelihood of a repetition of a past event (Pentland, Twyman, Burgoon, Nunamaker, & Diller 2017, p. 980). The case needs to be solved to avoid future repetition.  In such instances in which the psychological development is put under test, an explanation by Charlotte Buhler explains that the main intentionality in adults in their effort to live a fulfilling life. At this stage, an individual makes decisions based on the following strategies (Pitt & Brumberg 2018, p. 960). If the set standards are to prevail, then informed decisions are made with the help of other superior members of the society, like the one the client seeks advice from. These standards include but not limited to choosing life goals, working towards the selected targets, evaluating goal attainment, and the carrying out revision on the life goals based on the prevailing environment. The last stage involves adapting to the new experiences and the environment. Butler argues that the life goals need o to be realistic, proper planning and the hard work to achieve the goals.

Date of Examination: 24/10/ 2018

Time of Examination: 2:20

Patient Name: Michael Jones

Patient Number: 0024102018

History

Status of the patient

Joseph was a little bit worse today

Joseph reports that the dizziness and unconsciousness continues even after administering the medications during the last treatment session. Abnormal body movements and the limbs are weakening as time goes by (Pitt & Brumberg 2018, p. 963). The condition has lead to Joseph have some guilty feelings. He keeps mentioning his failure to protect a sister who apparently died through road accident some few years ago. This confirms that the condition has affected his mental stability.

Joseph records some good sleep at night. His participation in physical activities is minimal may be due to lack of energy. But this factor can be attributed to negative attititude he has developed of late. The patient’s sigma also contributes in his lack of appetite and always trying distance himself from other patients. 

Sedative effects of the drugs are evident.

Patient reports frequent dry mouth most probably due to lose of much fluid from the body.

Escalation of Patient Care

The development of some mental instability leading to hallucinations, stigma and sense of guilt.

Joseph so far has developed some characteristics that make it more difficult to handle his situation. He has become more inattentive, glum, and downcast with minimal communication.  He appears restless and less energetic with time. The feeling of guilt complicates his condition as he keeps making noise uttering words that suggest he feels some level of stigma (Wilkinson, McCray, Beckmann, & McIntyre 2016, p. 332). His facial expression and his general demeanour show how depressed he is. The hallucinations he undergoes complicate the already worse situation in that he becomes very aggitative and not willing to take the prescribed medicine. This continues till the feeling of guilt comes after which he becomes inactive and no communicative. He some time exhibit signs of anxiety.

Joseph continues to experience gait that is not steady. This condition is more evident at night after midnight. He has been provided with call lights that are placed within reach. He has been given instructions to ring the nurse whenever he feels any strange feeling (Yoon, Shaffer, & Bakken 2015, p. 570). There are standby guards to control him whenever he becomes restless and can cause harm to other patients.

Healthcare Centre being a rural institution faces several challenges just like any other institution based in the rural area. According to the Chief executive in the facility, some of these challenges include shortage in the medical work force. This problem is brought by the fact that many health workers do not like working in the countryside; a fact that complicate the process of recruitment of the much needed workforce. The challenging working and living conditions make retention of workers low.  Additionally, acquiring funds to facilitate the rural based health facilities has been difficult as only a few investors agree to invest their capital in such areas. These factors lead to ineffective and inefficient utilization of the available resources such are electricity

List of Reference

Cionea, IA, Hoelscher, CS & Ile?, IA 2017, ‘Arguing Goals: An Initial Assessment of a New Measurement Instrument’, Communication Reports, vol. 30, no. 1, pp. 51–65, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=ufh&AN=120264701&site=ehost-live>.

Coleman, T, Kearns, RA & Wiles, J 2016, ‘Older adults’ experiences of home maintenance issues and opportunities to maintain ageing in place’, Housing Studies, vol. 31, no. 8, pp. 964–983, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=118482841&site=ehost-live>.

Fisher, KL, Harrison, EL, Bruner, BG, Lawson, JA, Reeder, BA, Ashworth, NL, Sheppard, MS & Chad, KE 2018, ‘Predictors of Physical Activity Levels in Community-Dwelling Older Adults: A Multivariate Approach Based on a Socio-Ecological Framework’, Journal of Aging & Physical Activity, vol. 26, no. 1, pp. 114–120, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=128142586&site=ehost-live>.

Preventing Adverse Medical Conditions

HARRELL, JC & REGLIN, G 2018, ‘Evaluation of a Community College’s Nursing Faculty Advising Program Relative to Students’ Satisfaction and Retention’, College Student Journal, vol. 52, no. 1, pp. 33–48, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=128618283&site=ehost-live>.

Henry, SG, Wilsey, BL, Melnikow, J & Iosif, A-M 2015, ‘Dose Escalation During the First Year of Long-Term Opioid Therapy for Chronic Pain’, Pain Medicine, vol. 16, no. 4, pp. 733–744, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=101868410&site=ehost-live>.

Lee, DJ, Weathers, FW, Davis, MT, Domino, JL & Sloan, DM 2017, ‘Development and Initial Psychometric Evaluation of the Semi-Structured Emotion Regulation Interview’, Journal of Personality Assessment, vol. 99, no. 1, pp. 56–66, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=120392289&site=ehost-live>.

 Patel, RR, Awan, SN, Barkmeier-Kraemer, J, Courey, M, Deliyski, D, Eadie, T, Paul, D, Švec, JG & Hillman, R 2018, ‘Recommended Protocols for Instrumental Assessment of Voice: American Speech-Language-Hearing Association Expert Panel to Develop a Protocol for Instrumental Assessment of Vocal Function’, American Journal of Speech-Language Pathology, vol. 27, no. 3, pp. 887–905, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=131116968&site=ehost-live>.

Pentland, SJ, Twyman, NW, Burgoon, JK, Nunamaker, JF & Diller, CBR 2017, ‘A Video-Based Screening System for Automated Risk Assessment Using Nuanced Facial Features’, Journal of Management Information Systems, vol. 34, no. 4, pp. 970–993, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=127056613&site=ehost-live>.

Pitt, KM & Brumberg, JS 2018, ‘Guidelines for Feature Matching Assessment of Brain-Computer Interfaces for Augmentative and Alternative Communication’, American Journal of Speech-Language Pathology, vol. 27, no. 3, pp. 950–964, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=131116971&site=ehost-live>.

Tighe, P, Buckenmaier, CC, Boezaart, AP, Carr, DB, Clark, LL, Herring, AA, Kent, M, Mackey, S, Mariano, ER, Polomano, RC & Reisfield, GM 2015, ‘Acute Pain Medicine in the United States: A Status Report’, Pain Medicine, vol. 16, no. 9, pp. 1806–1826, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=109463474&site=ehost-live>.

Tyson, AM, Duma, SM & Rowson, S 2018, ‘Laboratory Evaluation of Low-Cost Wearable Sensors for Measuring Head Impacts in Sports’, Journal of Applied Biomechanics, vol. 34, no. 4, pp. 320–326, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=131127608&site=ehost-live>.

van der Mars, H, Timken, G & McNamee, J 2018, ‘Systematic Observation of Formal Assessment of Students by Teachers (SOFAST)’, Physical Educator, vol. 75, no. 3, pp. 341–373, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=130439568&site=ehost-live>.

Wilkinson, SA, McCray, S, Beckmann, M & McIntyre, HD 2016, ‘Evaluation of a process of implementation of a gestational diabetes nutrition model of care into practice’, Nutrition & Dietetics, vol. 73, no. 4, pp. 329–335, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=118415486&site=ehost-live>.

Yoon, S, Shaffer, JA & Bakken, S 2015, ‘Refining a self-assessment of informatics competency scale using Mokken scaling analysis’, Journal of Interprofessional Care, vol. 29, no. 6, pp. 579–586, viewed 24 October 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=111554904&site=ehost-live>.

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