Recognizing and Responding to the Deteriorating Patient

Injuries Sustained By Joanna Cleese After Falling From A Ladder

1. A 55-year-old female, Joanna Cleese had experienced a severe fall while cleaning the gutters (LATU, u.d). From the triage handover video, it was revealed that she fell from a ladder about two meters on the concrete and sustained serious injuries- she was found by her neighbour immediately after she fell lying face down on her left side. She lost consciousness for a few minutes and then responded to verbal stimuli in a confused way (LATU, u.d). Falls are the most frequent reason of unintentional death and injury in the elder population within sixty years of age; falls account for more than 40% of trauma-related deaths in this age group (CDC, 2018). Researchers have associated an increased possibility of severe injury, morbidity and mortality with increasing age which makes older people vulnerable to sustaining severe injuries that could prove to be fatal. Moreover, the injuries that were caused due to falling from a ladder were classified into injury locations such as spine, head, pelvic, abdominal, upper and lower extremities (Con et al., 2015). The changing condition of Joanna could be due to her ageing condition and recently diagnosed type II diabetes and pre-existing hypertension. From the handover video, it was known the patient had a Body Mass Index of 40 which puts her in the obese category and this could be a possible contributor to her changing condition (LATU, u.d). The prevalence of older individuals who are obese increases as the proportion of population above the age of 50 grows. The condition of obesity in the elderly population increases the risk of mortality in individuals belonging to this population (Petri et al., 2017; Jiang et al., 2016). In the elderly populace, energy intake does not increase significantly and tends to decrease with time. This leads to increase in fat mass with ageing which in turn, leads to an increase in the BMI. Pro-inflammatory cytokines such as IL-6 and TNF- a lead to sarcopenia and muscle loss due to the catabolic effects of these cytokines. The loss in muscle mass results in severe outcomes such as increased frailty and decrease in mobility. The endocrinologic changes that are a result of ageing have a role in decreasing the testosterone, growth hormone and DHEA in addition to resistance in insulin and leptin (McKee & Morley, 2020; Frasca et al., 2016). Moreover, the increased BMI could be a cause of hypertension and recently diagnosed type II diabetes as obesity puts individuals at an increased risk of developing these conditions (Petri et al., 2017; Jiang et al., 2016; Gaggero, 2020). In addition, researchers have shown an association between obesity and type II diabetes. Cardiovascular risk factors such as dyslipidaemia and hypertension and some forms of cancer have also been found to be common in older individuals with an elevated BMI that categorises them as obese (Kim, 2018). The elevated blood pressure observed in the patient during triage handover is commonly observed in patients with type II diabetes that is an impact of the patient’s obesity that led to insulin resistance. Therefore, the development of diabetes can be related to the existing hypertension as there has been evidence that suggest that diabetes is prevalent among hypertensive individuals (Tsimihodimos et al., 2018; Ohishi, 2018).  Assessment Of Injuries And Health Conditions Discussion Paper

Health Conditions That May Have Contributed To Joanna Cleese’s Injuries

After the fall from ladder, Joanna sustained injuries to her forehead, wrist, left thigh and left side of her chest. Her state of confusion indicates that she also sustained injuries to her head that has been reported by researchers to cause skull fractures, concussions and intracranial haemorrhage (Con et al., 2015). Moreover, the patient could develop diabetic complications upon reaching mid-stage diabetes because of the weakened glucose tolerance and early diabetes. In addition, worsening of diabetes in the patient can lead to diabetic nephropathy that can further impact the kidneys through increasing the glomerular pressure (Ohishi, 2018). The lacerations sustained by the patient on her forehead also indicates that her head injury can lead to further deterioration. The patient was reported to have a GCS score of 14 that puts her in the mild category of the distressing brain damages (LATU, u.d). Those with mild brain damages are usually in a good state, nevertheless as the patient fell majorly on her left side, it indicates that the injury could develop to a deteriorated state if a neurosurgical intervention is not applied. The pain in Joanna’s left chest wall that worsens on inspiration indicates that she could have pneumothorax fractures that could deteriorate to pneumothorax tension that is a condition when air trapped under positive pressure in the pleural cavity leads to a disease (Dogrul et al., 2020). In addition, pneumothorax complications can also arise due to the fracture such as hypoxemic respiratory failure, cardiac or respiratory arrest, pulmonary edema. The intensity of the fall that Joanna experienced was severe and it was a tragic physical trauma that caused multiple psychological and physical injuries. The injuries and pain areas that were detected in the patient could worsen to become life-threatening. Moreover, the patient could develop complications due to the blunt chest trauma upon falling from the ladder. The complications can also include pulmonary and chest wall injuries, pulmonary contusion. In addition, it is possible that the patient could present with respiratory arrest or dyspnea (Dogrul et al., 2020).

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2. The ABCDE assessment tool for primary assessment is the “gold standard” for assessing and treating deteriorating patients. It aids in the identification and response to patients presenting with serious conditions. This approach provides the nurse a systematic and dynamic way to collect and analyse primary data about the patient to deliver appropriate nursing care and diagnose the patient’s condition (Smith & Bowden, 2017). As part of the ABCDE assessment, the vital signs of the patient are measured and recorded using a tool that enhances the recognition of abnormalities that exist physiologically, indicating deterioration. The healthcare workers report the primary assessment results through an organized tool for communication that aids in optimisation of communication and escalating a deteriorating patient (Smith & Bowden, 2017). Head-to-toe assessment is a type of secondary assessment conducted by nursing professionals focuses on the complaint made by patients in relation to their health such as pain in certain areas that requires a particular testing after assessment. It is a systematic assessment that is conducted simultaneously with the primary ABCDE assessment. The assessment is carried out after the stabilization of a life-threatening condition. Head to toe assessment is important for assessing whether the patient has any co-morbidity that would place the patient at increased risk for complications that arise due to the injury (Smith & Bowden, 2017; Anita et al., 2015).

ABCDE Assessment Tool For Primary Assessment

The secondary treatment such as the head-to-toe assessment focuses on the diagnosis and treatment of the conditions that have been detected during the examination; on the other hand, primary assessment focuses on the stabilization of the individual’s potential life-threatening conditions. The ABCDE assessment is done before the head-to-toe assessment and that is why it is considered as the primary assessment that is conducted by nursing professionals (Anita et al., 2015). In this case of Joanna, the nursing professional would carry out the ABCDE assessment to determine if she is in any life-threatening condition that requires immediate stabilization. It also allows the professionals to determine the urgency of treatment that a patient requires in a triage setting (Anita et al., 2015). During the secondary assessment the professional would assess Joanna to inspect the lacerations that were reported during handover due to the fall and they would also check the vision status and a neurological exam as the patient was in a confused state (LATU, u.d). They would also palpate for any tenderness and broken bones that would help them develop a treatment plan for her.

Moreover, the nursing professional would develop an intervention to ease the pain that Joanna was feeling upon inspiration due to the chest trauma as it requires immediate attention as she could develop severe complications (Anita et al., 2015). Moreover, the suspected pneumothorax fracture would also be detected upon secondary assessment using the head-to-toe approach where the professionals would also be able to treat the 10 cm laceration on the left temple area of her head that was revealed in the handover video; also diagnosing the reason for abdominal tenderness upon palpation (LATU, u.d). Additionally, examination for deformities or fractures would also be performed for Joanna as she had pain in her left thigh and wrist that could be affected adversely due to the impact on falling primarily on the left side. In addition, during the secondary assessment, blood tests and other diagnostic tests could be ordered by the professional to further aid in the improvement of her condition (Anita et al., 2015.; HHS, 2021).

3. Changes in respiratory rate is a specific and sensitive indicator of clinical worsening that must be measured accurately and frequently. Changes in respiratory rate are a medical sign that aeration is being affected due to physiological deterioration as the patient’s body is attempting to maintain the delivery of oxygen to the various tissues in the body. The respiratory system immediately adapts to the demands and aids in the early identification of the observed changes that helps doctors in facilitating early treatment. The rate of respiration of a patient can predict critical events such as ITU admission and cardiac arrest. Moreover, it is an important component of several clinical assessment approaches such as the Early Warning Systems and the Systemic Inflammatory Response Syndrome and for assessing acute asthma in a patient (Philip et al., 2015). Respiratory rate is an accurate sign for prediction of clinical worsening in patients than the other vital signs. Researchers who conducted studies to assess the importance of changes in respiratory rate than other vital signs in predicting clinical deterioration reported that the study group of patients with clinical deterioration had a significantly higher respiratory rate than the other group which was treated as control (Mochizuki et al., 2017). It is reported that the rate of respiration is recorded in lower frequency in patients that walk-in to a clinical setting than those that are transported to the hospital in an ambulance (Mochizuki et al., 2017; Daw et al., 2020).

Head-To-Toe Assessment As A Secondary Assessment

The importance of respiratory rate in patient assessment has been demonstrated through its role in early identification of a worsening condition. Doctors utilise various methods for assessment of a patient’s respiratory rate that includes spot assessment and formal measurement (Philip et al., 2015). It has been reported that triage nurses assess respiratory rate in the emergency department, poorly and possess low sensitivity in detection of tachypnoea and bradypnea. Moreover, nurses were shown to have low confidence levels in the accurate measurement of respiratory rate in the observation charts. In addition, nurses were also reported to conduct spot assessment frequently through estimating the respiratory rate only by observing the patient (Philip et al., 2015). This was reported to be due to their belief that the rates were being estimated or invented without formally conducting the assessment using the recommended procedure. Therefore, nurses must measure the rate of respiration through measuring the number of breaths taken per minute by the patient instead of measuring it for thirty seconds and multiplying it by two. Additionally, to improve the accuracy of the measurement, the patient must be advised to relax and sit up in a chair or on a bed. The supervisors must observe the staff when they perform vital signs assessment so that the accurate and reliable measurement of the respiratory rate can be achieved (Philip et al., 2015). Moreover, the introduction and encouragement of using medical devices for accurately and reliably measuring respiratory rate must ben done by hospitals and clinics so that appropriate care can be provided to the patient; devices such as pulse oximeter that measures the oxygen saturation can also be used to accurately measure the rate of respiration in a patient (Addison et al., 2015).

References:

Addison, P. S., Watson, J. N., Mestek, M. L., Ochs, J. P., Uribe, A. A., & Bergese, S. D. (2015). Pulse oximetry-derived respiratory rate in general care floor patients. Journal of clinical monitoring and computing, 29(1), 113-120.  10.1007/s10877-014-9575-5

CDC. (2018). Morbidity and Mortality Weekly Report (MMWR). Retrieved from

https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a1.htm

Chojak, R., Ko?ba-Goszty?a, M., Paw?owski, M., & Czapiga, B. (2021). Deterioration After Mild Traumatic Brain Injury: A Single-Center Experience With Cost Analysis. Frontiers in Neurology, 1643.  10.3389/fneur.2021.588429

Con, J., Friese, R. S., Long, D. M., Zangbar, B., O’Keeffe, T., Joseph, B., … & Tang, A. L. (2014). Falls from ladders: age matters more than height. journal of surgical research, 191(2), 262-267. 10.1016/j.jss.2014.05.072

Daw, W., Kaur, R., Delaney, M., & Elphick, H. (2020). Respiratory rate is an early predictor of clinical deterioration in children. Pediatric Pulmonology, 55(8), 2041-2049. 10.1002/ppul.24853

Dogrul, B. N., Kiliccalan, I., Asci, E. S., & Peker, S. C. (2020). Blunt trauma related chest wall and pulmonary injuries: An overview. Chinese journal of traumatology, 23(03), 125-138. 10.1016/j.cjtee.2020.04.003

Frasca, D., Ferracci, F., Diaz, A., Romero, M., Lechner, S., & Blomberg, B. B. (2016). Obesity decreases B cell responses in young and elderly individuals. Obesity, 24(3), 615-625. https://doi.org/10.1002/oby.21383 Gaggero, A. (2020). The effect of type 2 diabetes diagnosis in the elderly. Economics & Human Biology, 37, 100830. 10.1016/j.ehb.2019.100830HHS. (2022). Primary, Secondary Survey – CHEMM. Retrieved from https://chemm.hhs.gov/appendix8.htm

Jiang, S. Z., Lu, W., Zong, X. F., Ruan, H. Y., & Liu, Y. (2016). Obesity and hypertension. Experimental and therapeutic medicine, 12(4), 2395-2399.  10.3892/etm.2016.3667 Kim, T. N. (2018). Elderly obesity: is it harmful or beneficial?. Journal of obesity & metabolic syndrome, 27(2), 84. 10.7570/jomes.2018.27.2.84

Mochizuki, K., Shintani, R., Mori, K., Sato, T., Sakaguchi, O., Takeshige, K., … & Imamura, H. (2017). Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single?center, case–control study. Acute medicine & surgery, 4(2), 172-178. 10.1002/ams2.252  . Assessment Of Injuries And Health Conditions Discussion Paper