Management Of Acute Deterioration Case Study Sample

Introduction Of Management Of Acute Deterioration

The definition of acute deterioration of health (ADH) refers to physiological psychological and cognitive changes that indicate the decline of a patient's health status (Tomašev et al. 2019). The primary sign of ADH refers to decline in function, increasing fatigue as well as declining oral intake and fluctuating consciousness and increasing pain. This is followed by changes in respiratory rate along with oxygen saturation, blood pressure, heart rate as well as temperature and mental state of the patient.

The identified intervention for the following patient refers to administrations of 0.9% NaCl IV by 1000 ml isotonic crystalloid at a slower rate of 83.33 MS per hour over 12 hours recommended at 10:30. In the following case study of Sam, he was diagnosed with CKD stage 3 and administered by using A to E assessment that resulted with the absence of fluid overload by considering the presence of comorbidities such as cardiovascular, renal and pulmonary diseases. While isotonic crystalloids are used to replenish extracellular fluid deficiency and manage extracellular fluid volume (Dinesen and Benson, 2022), Sam was fluid resuscitated with identified isotonic while performing OGD with four bleeding varices bindings.

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Besides, ADH for IV intervention for Sam was recognised at 10.30am with NEWS2 score that is used by the NHS to showcase early warning systems with the aim of identifying chronically ill patients (Barlow et al. 2020) and here, it refers to Sam being hypotension of 90/60 mmhg.

The following context is aiming at addressing the ADH pathophysiology that was negotiated with the identified intervention and demonstrating acute understanding of relevant NICE guidelines while evaluating nursing roll to ensure the management of intervention in an early and effective manner for the patient.

LO1: Physiological and Pathophysiological theory

This section is intended to focus on the critical evaluation of medical intervention during Sam's hypovolemic state by using his physiology and pathophysiology. The fundamental inciting context in the pathogenesis of upper GI tract bleeding (UGIB) consists of damage to the mucosal injury along with disruption of blood arteries that supply to the GI tract (Obonyo, 2020). In the following case study, Sam already has the medical history of "ALD Cirrhosis (ALD-CoL), Atrial fibrillation (AF), portal hypertension (PH), hepatic encephalopathy (HE), Asthma, CKD stage 3". In the UK, approximately 1.4 million people are suffering from AF, associated with worst patient outcomes (Chung et al. 2021). In this context, Tham et al. (2022) have managed to address the role of AF that is associated with increased risk of bleeding and causing intracranial haemorrhage and role of alcohol in terms of causing tissues being very sensitive and creating a substantial amount of bleeding by causing "Mallory Weiss tears". These factors are capable of increasing the necessity to induce IV intervention to treat Sam in the following case study. Besides, Ntoumanis et al. (2021) have mentioned the primary goal of treating UGIB refers to correcting shock and maintaining coagulation of abnormalities while stabilising patients for further evaluation. This includes intervention of IV fluids and transfusion of packed red blood cells are also important alongside the presence of high doses of proton pump inhibitors (PPI) in order to reduce the requirement of endoscopic treatment. Besides, Arrahmani et al. (2022) have mentioned the primary goal of fluid resuscitation intervention with the aim of increasing cardiac output and improving organ perfusion by stabilising the patient's condition. In the hemodynamically unstable state of the patients, the use of fluid intervention is effective to showcase the improvement in stroke volume while managing fluid administration. Therefore, it can be stated that, in the following case study the identified intervention is important for Sam's treatment.

In the following context, the new changes refer to the role of alcohol that can permeate all tissues in the body which resulted in alteration of the multi-systemic path of physiological changes of the patient. By supporting this content, Mauro et al. (2022) have managed to state that excessive consumption of alcohol is considered the third leading lifestyle related cause of death in the UK and it also impacts on the dose dependent relationship between alcohol consumption and the prevalence of PH, Ischemic heart disease and kidney problems. Approximately 3.4% of non-communicable disease are related to the alcohol consumptions where 5% of the overall populations face death and 2.4% of the population face difficulties in adjusting life which are attribute to the excessive consumptions of alcohol and living with the higher burden of liver cirrhosis and kidney disease (Antunes and Copelin II, 2022). In the following context, Sam has already suffered from stage 3 CKD which has shown his poor kidney functions with the Glomerular filtration rate (GFR) less than 25 along with high values of urea and creatinine. Metabolic acidosis is considered one of the most common consequences of CKD; it also prevails increasing declarations of GFR and that leading to the imbalanced acid and base levels in the body (Fernandez-Prado et al. 2023). Here, Copur et al. (2020) have stated the reduction of nephron mass that resulted in environment of the production of total renal acid excretion and leading towards positive acid balance among the CKD patient. Therefore, it can be stated that for Sam his progress on kidney disease and declination of J5 leads to the increased acid balance in the body which impacts on developing metabolic acidosis.

Pharmacological related factors

In this context, Mallah et al. (2020) have managed to address the use of epinephrine group of medications as the form of pharmacological treatment for the UGIB. This includes use of physical compressions of the blood vessels and addressing pharmacological treatment by medicine with the aim of managing diverticular bleeding. In the following case study, Sam has already instructed with IV Terlipressin which is considered a synthetic analogue of vasopressin. This medication is used as a vasoconstrictor in terms of predominantly splanchnic circulations along with treating GI tract bleeding and managing hepato-renal syndrome (Petersen et al. 2020). In this context, it can also be stated that this group of medication selectively impacts on extra-renal construction by stimulating V1 receptors. Besides, it is also effective in terms of restoring hypotension in shock along with improving haemodynamic and cerebral perfusion (Gouriou et al. 2021). Sam was already in hemodynamic conditions during the admissions and he was instructed on IV Terlipressin on admission and therefore, it can be stated that in the following ADH of Sam, this group of medication is used to manage his condition.

Physiology underpinning the mode of action

Crystalloid fluids are considered significant in terms of functioning to expand intravascular volume without disturbing the ion concentration as well as inducing significant fluid shift between intracellular intravascular and interstitial space (Kirkman et al. 2021). The identified intervention while administering isotonic solution is considered a similar volume to the blood which stays in the intravascular space and does not participate in osmosis while moving fluid between different spaces.

What extent the intervention addressed the pathophysiological problem

While addressing my participation in administering IV fluid perceptions in case of Sam, 0.9% NaCl is used while suppressing the hypovolemic stimulus in terms of releasing ADH while promoting excretions of dilute urine and rapid corrections of hyponatremia (Jansen, 2019) (Na-137). I was also instructed to manage the >0.1% concentration of solution in the case of hypervolemic hyponatremia and while maintaining the ratio <0.5ml alongside the rate of 83.3ml/hr in terms of ensuring Sam's kidneys are not overwork and reducing the chance of renal failure. Besides, as per the opinion of Casey et al. (2018), the risk of kidney injury and deaths are considerably higher with semi synthetic colloids in comparison to the crystalloids alongside associating with guided haemodynamic responsiveness by improving the patient's outcome which has been prescribed for the patient. I also feel the intervention is impactful for Sam while managing his comfortability throughout the treatment process.

Summary

While participating in Sam's admission and medicine administration, I felt I have managed to learn emergency work while practically using my knowledge and skills of maintaining hypovolemic condition and preventing kidney failures for the patient. This also includes justifying the intervention choice while continuing Sam's treatment to control UGIB.

LO2: Evaluation of the evidence base for the intervention given

NICE guidelines

As per the identified guidelines, the primary quality step refers to endoscopy within 24 hours for the patients who are hemodynamically stable and immediate endoscopy for people who are hemodynamically unstable (Lott et al. 2021). Besides, band ligation is recommended for oesophageal variceal bleeding with continuation of low dose of aspirin. In the following case study, Sam was immediately recommended endoscopic treatment, followed by band ligation and IV intervention by using Ramipril group in terms of managing blood pressure and preventing heart failure. On the other hand, people with severe UGIB and hemodynamically unstable, are given endoscopic treatment within 2 hours of optimal resuscitation (Nice.org.uk, 2023a). Here, Malbrain et al. (2020) have managed to address the use of this specific treatment in UGIB in terms of accessing information on the likely prognosis while facilitating the provision of haemostatic therapy. In the following case study, Sam was provided with the identified treatment in order to follow with urgent investigation and treatment. [Refers to appendix 1]. Besides, it can be stated that intravenous fluid composition is responsible for affecting kidneys by increasing risk of injury alongside the death of critically ill patients (Kang and Yoo, 2019). This includes the rate of death and kidney injury is higher in semi synthetic colloids in comparison to crystalloids. This also includes a responsible approach to use balanced crystalloid in the form of 2-3 litres per day (Casey et al. 2018) which is 83.33ml/hours for initial fluid resuscitation in the hypovolemic state while guiding the overall fluid administration.

On the other hand, NICE guideline on managing IV fluid therapy refers to provision of IV fluid therapy whose need cannot be met by using oral or enteral routes and requires to be stopped as soon as possible (Nice.org.uk, 2023b). In the following context, Sam was prescribed at the gastro ward to continue with only fluid therapy and his conditions are incapable of meeting his daily needs, therefore, he was instructed with IV fluid therapy. Besides, the important context refers to the type of fluid along with rate and volume of fluid to be administered, followed by a proper monitoring process (Soar et al. 2021). In this context, Miller, and Myles (2019) have managed to address the role of communication that can be maintained in the presence of the patients during fluid intake and take part in decision making by using signs and involving patient's families to maintain the care approach in fluid therapy. In addition, in the initial assessment by NICE, in the case patient being hypovolemic, it indicates the immediate and urgent fluid resuscitation and the indicators consists of systolic blood pressure <100 mmhg, heart rate >90 beats/min with NEWS score being 5 or more (Nice.org.uk, 2023b). These are followed by identifying the history of patients to understand the current needs of fluid therapy by previous limited intake amount, thirst along with quantity and composition of losses as well as comorbidities (Malbrain et al. 2020). As per NICE, clinical monitoring such as NEWS, Fluid chart and weight along with laboratory reports such as full blood count and urea, creatinine and electrolytes need to be done (Nice.org.uk, 2023a) and was continued for Sam. Besides, for the patients receiving IV fluid resuscitation, are required to go through ABCDE assessment in the form of "Airway, Breathing, Circulation, Disability, Exposure" (Nice.org.uk, 2023b) and for Sam, it was performed as well. Besides, patients receiving 0.9% NaCl concentration of fluid, their serum chloride concentration is needed to be monitored daily and resuscitation requires using crystalloids containing sodium with the range of 130-150 mmol/l over less than 15 minutes (Nice.org.uk, 2023b) which was again followed for Sam. For patients with renal impairment and cardiac risks (present for Sam), the fluid management requires 20-25 ml/kg/day (Nice.org.uk, 2023a). Besides, in comparison with 0.9% NaCl solution, the implications of Hartmann's solution (HS) may hasten the resolution of acidosis which can be severe for the patients (Elghazali et al. 2021). While both the NaCl and HS are considered deficit replacement in terms of managing plasma bicarbonate at similar rate, the "European guidelines on managing major bleeding and coagulopathy following trauma" has stated the preferability of the balanced crystalloid solution of 0.9% NaCL to be administered properly for managing major bleeding (Nielsen, 2023).

Limitation of the guidelines

The limitation of the identified guideline refers to reduction of capillary blood flow which is considered a significant reason for developing renal ischemia and is responsible for worsening kidney function (Kundra and Goswami, 2019). This includes causing "acute kidney injury (AKI)" and impacting myocardial infarction as well as damaging liver function. Besides, the role of improper fluid management can lead to delaying wound healing and is considered a risk factor for causing intra-abdominal hypertension. On the other hand, the role of crystalloids repletion during shock and hypovolemic conditions may lead to increased acidosis and impact on the patient's state (Naticchia et al. 2021).

Relevant research on clinical trials

Using established guidelines to modify the preparation of IV fluids and was linked with local chemistry records and nationally available patient data from NHS Scotland for specified medical emergencies. The primary outcome was abnormal bicarbonate rate and elevated range of sodium and potassium with the incident of AKI and the secondary outcome refers to no adverse impact on patient mortality and length of stay (Padhi et al. 2019).

Even though the use of established principles for IV therapy is considered here, not receiving adequate training on subjects which impact on performing common tasks while taking complex decisions on volume, rate and type of fluid (Jung and Moon, 2019). This also reported on "National Confidential Enquiry into Perioperative Deaths (NCEPOD)" that resulted in 1 out of 5 patients receiving IV fluid in hospital went through complications and morbidity due to inappropriate administration.

Findings

While the initial trial focused on complications during administration of IV fluid therapy, the next context justified the use of isotonic crystalloid along with prioritising 0.9% NaCL with a low rate to prevalent proper fluid administration that led to reduced post complication in the case of Sam.

LO3: Critical discussion of your role, in ensuring this intervention was given as early and effectively as possible

My role on ensuring effective intervention

In my opinion, implementation of early and effective intervention to patients requires the use of critical thinking and critical judgement. In this context, McDougall et al. (2022) addressed the role of registered nurses during the development of an initial care plan while using continuous reassessment process in terms of detecting changes and requiring change in the overall care plan.

In the following case study, while monitoring Sam's condition, deterioration of his state was recognised at 10.30 am and conducting NEWS score was done alongside identifying low BP and hypovolemic state. Here, Sam's NEWS score was 4 during admission and then it increased with a score of 10 and 11 at 10.30 and 11.15 am respectively alongside a BP of 90/60 mmhg, O2 saturation of 89% with CRP level of 20 which denotes the presence of mild inflammation in the patient. These situations were informed to the doctors, however, delay in prescribing fluid was noticed due to the doctors on board rounds and the morning shift was understaffed.

As a nursing staff, I managed to complete my role to act immediately in this condition. As per the NICE guideline (2018), I had to put out a rapid response team (RRT) while informing the outreach consultant on call. As per the NICE guideline, the typical rapid response team calling criteria consists of heart rate over the 140/ minute or less than 40 per minute along with the respiratory rate over 28/ minute or less than 8/ minute while blood pressure is either 180 mmhg or 90 mmhg (Nice.org.uk, 2023d). The roles and responsibilities of RRT is based on the patient's assessment criteria along with allowing the team to effectively and quickly document fundamental information during a medical emergency (Nice.org.uk, 2023d). In the following case study, I did the same while keeping an outreach consultant on the phone for further instructions in order to administer doses to normal saline before the consultant reached the spot and I complied with the instructions.

The next step consisted of the role of RRT to carry out the A to E assessment, investigation and blood tests for Sam to understand his present state. Here, Bailey et al. (2019) have pointed out the immediate action towards the patient refers to restoring the stability of the haemodynamic situation of the patient. By supporting this context, McDougall et al. (2022) have managed to address the role of nursing staff while performing rapid assessment, stabilisation along with identifying the severity of bleeding and potential sources and underlying conditions that can contribute to causing bleeding. I along with the medic team have managed to perform an A to E assessment while identifying Sam's condition as not being fluid overloaded and his co-morbidities and catheterised for monitoring urine output. These are part of the immediate action taken for Sam's hypovolemic state, secondary to UGIB and I feel the whole RRT has maintained the early and effective intervention in this case. Besides, this is effective in terms of planning to resuscitate the patient while administering his fluid management along with prescriptions for resuscitation while administering fluid to Sam. As the the updated NICE guideline (2017), the use of RRT in emergency helps with a prompt reaction while inducing early intervention for improved outcome (Lyons et al. 2018). It also helps with identification of unmet needs of patients along with an activation of RRT while assessing, intervening and managing patient triage. This also includes taking bloods from Sam while preventing him from facing a progressive stage of hypovolemic shock.

While hypovolemic shock itself is considered a life-threatening situation, the physiological responses to this condition refers to increasing heart rate along with elevating myocardial contractility as well as constructing peripheral blood vessels (Barannik et al. 2023). Besides, the fundamental goal of the physiological response consists of increasing the amount of fluid in Sam's body by using fluid resuscitation while maintaining his safety and improving the overall health outcome. Here, Zampieri et al. (2021) stated the therapeutic aspects of physiological treatments which have significant impact by using mechanical methods alone or using IV intervention in the hypovolemic state to increase the success rate of controlling situation among patients which was considered here.

Challenges

Medical interventions are considered significant in terms of measures to and improving health while altering the course of illness. Here, Tomašev et al. (2019) addressed the improper identification of initial symptoms and patient's circumstances which involved in causing delay to manage intervention for treatment. However, in the following case, because of the morning shift and understating, the delay of starting resuscitation made me feel that it was leading to response time which has potential impact on delay in starting hypovolemic appropriate treatment in patient care. Here, understaffed morning shifts and management of efficient intervention could have caused tension between the staff and employers while implying clinical guidelines in the following context. However, while treating Sam, I had to advocate for the patient while challenging doctors in terms of controlling his deteriorated state on time and making sure for continuing enough intravenous fluid on prescription while updating his drug chat by suspending anticoagulant as well as anti-hypertensive drugs in terms of managing his conditions during endoscopy. Besides, the referrals to the alcohol liaison team which was sent by the nurse followed by consulting with the patient in order to use clinical guidelines 100 with the aim of a withdrawal assessment tool for providing therapeutic action in order to associate Sam to withdrawal from alcohol. As per the NICE guideline (2018), the decision-making responsibility of nursing staff helps to determine the patients based interest while demonstrating their adherence for the improved outcome (Nice.org.uk, 2023c).

Expectations

As a professional body, it is important to consider the expectations of my nursing profession while being able to maintain clear and concise communications in the medical field. Here, while treating Sam's hypovolemic state, as the nursing staff, I managed to communicate with an outreach consultant to manage his emergency treatment alongside communicating with Sam to help him with his withdrawal. The next expectation as the professional body refers to consistent information to the public and family members of the patient (Seccombe and Sapey, 2018) and here, I was transparent and honest with Sam's family with his present conditions and communicated with his family regarding his complex health conditions and associating family to help Sam with his alcohol withdrawal while improving the quality care.

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Conclusion

In terms of summarising the overall context, it can be stated that the use of IV 0.9% NaCl and crystalloids fluid contain balanced electrolytes which is considered significant as the effective and fast acting ways of administering medication treatment in emergency situations. Besides being directly linked to bloodstream, this Intervention is considered the most effective way to manage the fluid proportion for the patients while providing treatment. In addition, it can also be stated that using this intervention provides the advantage of continuously measuring hemodynamic variables for the patients. However, in the case of absent physiological optimisation, this would lead to decreasing concentration of dissolved solutes in blood in comparison with intracellular space and thus causing complications in treatment.

While implying the evidence-based intervention for the given case, I feel this was well supported by using proper guidelines and research articles. This also addressed the positive outcome on mortality and hospital stay for the patient receiving the same treatment. However, in case of unsupported intervention, acid suppression is considered one of the effective interventions while treating patients with UGIB which provides options of treatment in the form of IV PPI every 12 hours with a continuous infusion.

From the overall context and the given case study, I have managed to imply theoretical knowledge into the practice field while using effective and early intervention for the patient and maintaining communication with the team and patients while involving them for decision making to continue the overall treatment. Besides, in my opinion, the overall process could have used the inclusion of a review process from the gastro section while implementing the practice in an effective manner.

While I was taught to communicate with an interdisciplinary medical team, treating Sam's case has given me the opportunity to use both verbal and nonverbal communication style while positively contributing to the management of his treatment procedure by using IV intervention. This is followed by closely monitoring the hemodynamic states of the patient which has helped me to identify the severity of the case alongside taking precautions to prevent any mishaps. I believe this will help me in the future to improve my practice in managing intervention processes and adding experience to maintain continuous IV training and monitoring in an effective manner.

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