Recognising And Rescuing The Deteriorating Patient

Recognising
and rescuing the deteriorating patient

Objectives

The
objectives for this assessment item are for students to:

1. demonstrate the use of evidence
   for nursing practice from the nursing literature.
2. increase skills in synthesising
   and analysing information.
3. understand and demonstrate the
   nurse’s role in monitoring and intervening in response to patient’s needs.
4. discuss the complexities of specific
   patient care issues (e.g. altered level of consciousness, neurological
   impairment)
5. communicate synthesised
   information comprehensively and cohesively.
6. demonstrate skills in academic writing.
7. demonstrate skills in citing
   published material appropriately.

Background to the Essay

Nurses
have a pivotalrole in promoting optimal patient outcomes. The appropriate
monitoring and assessment of patients in acute care settings is crucialto
effective healthcare.Dresser
(2012),state that ‘a turn of
events unacknowledged by a nurse can markedly alter the course of a patient’s
condition and outcome’.There is concern demonstrated in the literature around
issues of patient safety and risk of harm when a patient’s physical condition
deteriorates expectantly(Henneman,
Gawlinski, & Giuliano, 2012; Odell, Victor, & Oliver, 2009).Australian
Commission on Safety and Quality in Health Care (2010)have
issued a national consensus statement that prioritises the goal of improving
the recognition and response to clinical deterioration in hospitals and
healthcare facilities.

Early response to changes in a patient’s level of consciousness is a
nursing interventionwhich can positively affect patient outcomes and includes(Australian Commission
on Safety and Quality in Health Care, 2010). Variations in a patient’s neurological
functioningcan be common in acute care settings, manifestingswiftly and leading
to potentially fatal consequences.This is particularly true in elderly patientswho
can present with multiple comorbidities. Accurately assessing andrecording the
neurological function of patients is aprimary part of nursing care(Ashcraft & Owen,
2014). Mismanagement of neurological decline can
contribute to significant morbidity and mortality. However, effective clinical
reasoning skills can help a nurse to recognise and manage patient deterioration
early, thus preventing adverse patient outcomes(Levett-Jones et al.,
2010). Time is a critical factor in the nurse’s clinical
reasoning because patient problems need to be identified in a timely manner so
that nursing actions can be instituted to act on abnormal findings(Levett-Jones et al.,
2010).Dresser (2012) advises that the collection of assessment information
and continual analysis and interpretation of that datais necessary to
successfully monitor patient conditions. This is the responsibility of
registered nurses.

Studies
have shown that nurses are sometimes reluctant to act on adverse findings(Hogan,
2006; Preston & Flynn, 2010). This may be related to
limited understanding of the degree of urgency if the nurse does not understand
the physiology involved in what they observe as changes in the patient’s
condition(Australian
Commission on Safety and Quality in Health Care, 2010; Preston & Flynn,
2010). To improve your
understanding of the role of the nurse in monitoring a patient’s consciousstate
and your knowledge of the meaning of cues in a patients clinical status, you
are asked to write your NUR2100 assignment based on the task/criteria
below.

Assignment Task

Title:Recognising and rescuing the
deteriorating patient

Task:
Write a2000 (+/- 10% including in-text references) word assignment utilizing
scholarly resourcesand include the following:

a)
Justify
your intended discussion by identifying (from the literature) the importance of
nursing assessment and interventions which reduce adverse patient events for a
person with impaired neurological functioning.

b)
Develop
a case scenario where the patient in an acute care setting demonstrates changes
to their homeostasis related to an impaired neurological functioning and
leading to clinical deterioration.

c)
Develop
appropriate nursing actions for assessing, monitoring and intervening in the case
you havecreated. This will be based on nursing evidence for practice.

d)
Include
an introduction explaining a theme for the essay and a conclusion that
reinforces the appropriateness of the clinical decisions in the body of the
essay.

Task
in more detail:

1.
Justify
your intended discussion by identifying (from the literature) the importance of
nursing assessments and interventions which reduce adverse patient events.

There are a number of
articles provided which will help you establish this. It is expected that this section would be
one or two paragraphs. The emphasis
should be on how nurses can facilitate optimal patient outcomes, when they use
appropriate monitoring skills and how they respond to changes in a patient’s
condition.

2.
Develop
a case scenario where the patient in an acute care setting demonstrates changes
to their homeostasis related to an impaired neurological functioning and
leading to clinical deterioration.

This is a case study that
you create. It helps you work through
the ‘normal’ parameters for someone with the situation and condition you
describe and what might be indications that they are showing signs of a
worsening condition. This should be set in
an acute care setting where a nurse would be involved in monitoring the patient
and it should be reflective of episodes covered in NUR2100. The description should include at least two
parameters which show early cues towards the potential for deterioration in the
patient’s present condition.

This is a case study you are creating – and
referencesare not requiredin section 2.

Some examples:

I.
A
person with septic shock.

II.
Someone
who has had a stroke.

III.
A
person with complications of renal disease

IV.
A
person who is prescribed narcotic analgesia for palliative pain management.

V.
A
person who has sustained a head injury

3.
Discuss
the appropriate nursing actions for assessing, monitoring and intervening with
the situation you’ve described. This will be based on appropriate and
documented evidence for practice.

Section
3 should include both ‘I’ and ‘II’ below.
It is expected that all material which you have sourced from texts or
journal articles is acknowledged and referenced appropriately.

I.
This section includes a
physiological explanation of physiologicalchanges resulting in signs or
symptoms expressed in the case.

II.
This section also includes evidence
that the nurseshould assess clients beyond undertaking routine observations and
recording vital signs.Concepts addressed in the justification for the essay may
be applied here with specifics related to the proposed case study.

4.
Include
an introduction (with a theme for the essay) and a conclusion.

You
may set the theme related to what best fits the focus of the essay.

Some
suggestions include:

‘Appropriate monitoring of patients
requires actions beyond routine vital sign protocols’

‘Acting on early cues in an episode of
altered consciousness may prevent patient deterioration’

‘Nurses who are observant in the early
detection of complications are in a position to minimize negative outcomes for
the patient.’

5.
Utilize
appropriate academic resources

A minimum of six references is
expected for this essay.More are allowed and encouraged if they support the
writing. Threeof the references used must be from the list cited for this
assignment brief.Assignments which do not include at least three articles from
the list will have marks deducted.

You may supplement the articles
provided with other material you source, including current nursing textbooks.

Extra resources have been included in
the reference list below. They will help to guide your understanding of the
concepts of this assignment.

Format:

Acceptable
font for this assignment is times new roman or arial and line spacing is 1.5 or
2. Headings and subheadings are permitted.
You must use the provided template for
marking purposes, i.e. with the marking matrix already incorporated.

Assignments
are only accepted through the on-line assignment portal located on the study
desk

References cited above:

Ashcraft, A. S., &
Owen, D. C. (2014). From nursing home to acute care: signs, symptoms, and
strategies used to prevent transfer. Geriatric
nurse, 35(4), 316-320. doi: 10.1016/j.gerinurse.2014.06.007

Australian
Commission on Safety and Quality in Health Care. (2010). National consensus statement.
Sydney: Retrieved from .safetyandquality.gov.au/wp-content/uploads/2012/01/national_consensus_statement.pdf”>http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/national_consensus_statement.pdf.

DeBourgh, G. A.,
& Prion, S. K. (2012). Patient Safety Manifesto: A Professional Imperative
for Prelicensure Nursing Education. Journal
of Professional Nursing, 28(2), 110-118. doi: .doi.org/10.1016/j.profnurs.2011.05.001″>http://dx.doi.org/10.1016/j.profnurs.2011.05.001

Dresser, S.
(2012). The role of nursing surveillance in keeping patients safe. Journal of nursing administration, 42(7-8),
361-368. doi: 10.1097/NNA.0b013e3182619377

Duff, B.,
Gardiner, G., & Barnes, M. (2007). The impact of surgical ward nurses
practising respiratory assessment on positive patient outcomes. Australian journal of advanced nursing, 24(4),
52-56.

Elliott, M.,
& Coventry, A. (2012). Critical care: the eight vital signs of patient
monitoring. Br J Nurs, 21(10),
621-625. doi: 10.12968/bjon.2012.21.10.621

Gazarian, P.,
Henneman, E., & Chandler, G. (2010). Nurse Decision Making in the Prearrest
Period. Clinical Nursing Research, 19(1),
21-37.

Henneman, E. A.,
Gawlinski, A., & Giuliano, K. K. (2012). Surveillance: A strategy for
improving patient safety in acute and critical care units. Crit Care Nurse, 32(2), e9-18. doi: 10.4037/ccn2012166

Hogan, J. (2006).
Respiratory assessment. Why don’t nurses monitor the respiratory rates of
patients? Br J Nurs, 15(9), 489-492.

Jonsson, T.,
Jonsdottir, H., Moller, A. D., & Baldursdottir, L. (2011). Nursing
documentation prior to emergency admissions to the intensive care unit. Nurse critical care, 16(4), 164-169.
doi: 10.1111/j.1478-5153.2011.00427.x

Levett-Jones, T.,
Hoffman, K., Dempsey, J., Jeong, S. Y., Noble, D., Norton, C. A., . . . Hickey,
N. (2010). The ‘five rights’ of clinical reasoning: an educational model to
enhance nursing students’ ability to identify and manage clinically ‘at risk’
patients. Nurse Educ Today, 30(6),
515-520. doi: 10.1016/j.nedt.2009.10.020

Maxwell, L. G.,
Buckley, G. M., Kudchadkar, S. R., Ely, E., Stebbins, E. L., Dube, C., . . .
Yaster, M. (2014). Pain management following major intracranial surgery in
pediatric patients: a prospective cohort study in three academic children’s
hospitals. Pediatric Anesthesia, 24(11),
1132-1140. doi: 10.1111/pan.12489

Nisbet, A. T.,
& Mooney-Cotter, F. (2009). Comparison of selected sedation scales for
reporting opioid-induced sedation assessment. Pain management nursing, 10(3), 154-164. doi:
10.1016/j.pmn.2009.03.001

Odell, M.,
Victor, C., & Oliver, D. (2009). Nurses’ role in detecting deterioration in
ward patients: systematic literature review. J Adv Nurs, 65(10), 1992-2006.

Preston, R.,
& Flynn, D. (2010). Observations in acute care: evidence-based approach to
patient safety. Br J Nurs, 19(7),
442-447. doi: 10.12968/bjon.2010.19.7.47446

Suddaby, B.,
& Mowery, B. (2002). Altered Level of Consciousness in a 2-Year-Old. Pediatric Nursing, 22(3), 260-261.

Zare,
M. A., Ahmadi, K., Zadegan, S. A., Farsi, D., & Rahimi-Movaghar, V. (2013).
Effects of Brain Contusion on Mild Traumatic Brain-Injured Patients. International Journal of Neuroscience, 123(1),
65-69. doi: 10.3109/00207454.2012.728653

NUR2100 Episodes of Nursing Practice Assignment Marking Guide 2015
Introduction
· No / inadequate introduction, o E.g. scope / direction not evident o focus of case study is not apparent · No evidence of theme to be discussed	· Unclear / limited introduction o E.g. scope / direction needs clarity, too broad not focused to case study · Theme minimally outlined, needs clarity	· Introduction good/ satisfactory o E.g. scope / focus of case study outlined, mostly clear direction · Theme outlined however requires some further explanation	· V. good excellent introduction o E.g. describes scope / direction clearly /succinctly o focus of case study clear · Theme clear succinctly articulated and detailed
0	0.5	1	1.5
Content: Case study development
· Case study inappropriate / inadequate /not developed / researched / does not give necessary detail, has very limited information. · No / minimal signs / symptoms / cues for detection of deterioration included	· Case study not accurate/ demonstrates little research of case, little evidence of detail, some elements are not fully developed · Marginal use of signs / symptoms / cues for detection of deterioration	· Case study mostly accurate / demonstrates some research & sufficient detail to read as a logical whole · Mostly appropriate signs & symptoms / cues for detection of deterioration included	· Case study accurate, demonstrates research through use of appropriate signs & symptoms / cues for early detection of deterioration
0	0.5	1	1.5
Critical skills: Clinical reasoning
· Minimal / no clinical reasoning / judgements demonstrated / lack of synthesis of concepts / lack of understanding (e.g. related to pt cues, goals / expected outcomes / evidence) · No / lack of logical progression of concepts underpinning case study · No analysis evident e.g. lack of priority development in actions/ interventions / approach to dealing with deterioration	· Some clinical reasoning demonstrated / some synthesis of concepts within the case study evident. Attempts at judgements made however further explanation / justification (e.g. related to pt cues, goals / expected outcomes / evidence), required for clarity of approach · Some logical progression of concepts / ideas however further development / clarity needed · Minimal analysis e.g. attempts to prioritise however further development required	· Satisfactory understanding demonstrated with synthesis of concepts. Sound judgements made however needs further justification(e.g. related to pt cues, goals / expected outcomes / evidence) for actions taken · Logical / clear progression of concepts / ideas, could be more succinctly articulated · Satisfactory analysis, good attempts at prioritising issues/ care within the case study	· V. good / excellent clinical reasoning and synthesis of concepts arising from the case study, justifies judgments and reasons for decisions / courses of action (e.g. related to pt cues, goals / expected outcomes / evidence) · Logical / clear / succinct progression of concepts / ideas demonstrated / presents as a unified whole · V. good / excellent analysis, well prioritised care detailed and succinctly communicated.
0-1.5	2-2.5	3-3.5	4-5

Content: Nursing roles / actions / interventions
· Nursing actions / interventions minimal / not evident / inadequately prioritised · No / limited rationale included &/orinadequately explained · Nurses role in detecting deterioration absent/ minimal (e.g. equates assessment monitoring with routine observations only) · No / inadequate literature sources used to support actions e.g. over 8 years old and lack of evidenced based research e.g. uses mainly texts	· Some nursing actions / interventions detailed however priorities are not well defined · Rational included however explanation not clear or not focused / specific enough to the action/ intervention · Nurses role in detecting deterioration marginally detailed – some association made with cues / signs / symptoms presented (e.g. further explanation required to clarify relationships between cues and deterioration) · Fair breadth of sources utilised / lacks depth (e.g. mainly text / with 3 or less journal articles)	· Breadth of nursing actions / interventions included, some evidence of prioritisation of actions appropriate to the case study · Satisfactory rationale included / relates to the intervention / action chosen · Nurses role in detecting deterioration satisfactorily detailed however not fully developed / at times lacks detail (e.g. assessment / monitoring not fully explained, role in reporting not fully explained) · Sources demonstrate depth e.g. some use of evidenced based research (4-7 research papers used, mostly contextual to the case scenario)	· V. good / excellent breadth and depth of actions / clear / succinct in approach, priorities well defined · Rationale clearly / succinctly relate to interventions / actions detailed · V. good / excellent development of nurses role in detecting deterioration, includes at least 2 of the following o Early detection & timely intervention o Prioritising & clinical reasoning o Surveillance o Timely reporting / documenting · Sources to support actions / interventions quality (evidenced based) & demonstrate depth and breadth of reading (over 8 quality research sources – contextual to the case study)
0-3	4-5	6-8	9-10
Scholarly conventions
· Numerous (greater than 5) o Typographical o Punctuation o Grammatical o Referencing Errors · Does not conform to expected academic standards and scholarly conventions · Does not conform to Harvard or APA referencing style · Under word limit, greater than 20 % Over word limit, greater than 20 %	· Minimal (5 or less) o Typographical o Punctuation o Grammatical o Referencing (material cited correctly) Errors · Mostly presented in accordance with expected academic standards and scholarly conventions · Mostly conforms to the referencing style stated 3 or less errors Sources are mostly cited accurately · Within word limits	· Correct grammar, spelling, punctuation, citation of references · Presented in accordance with expected academic standards and scholarly conventions · Conforms to academic referencing style stated (1 typo allowed) · Within word limits.
0	1	2

Total mark:

Comments & Signature of marker: