Patient Assessment and Care Planning in Critical Illness

This assignment will discuss the critically sick case study of a 64-year-old lady, Mrs. Joan Evans who can be considered as a fictitious patient in a case scenario. Nursing a critically sick patient with complex consideration needs will be discussed in a detailed approach for clinical investigation, evaluation, appraisal, and implementation and these will be used to offer all patient-centered care in a comprehensive way to deal with clinical conditions of the patient. The underpinning pathophysiology of the disease condition will be discussed throughout the assignment along with the status of the patient for the right structuring of the care plan.


The assessment considers psychological, physical, pharmacological, social, and spiritual aspects of care, using ABCDE approach to guide the assessment of the case-patient. Based on the findings, the assignment appraises the most appropriate means of communication to enable collaborative working among patients, families, carers, and health care professionals. Finally, the assignment reflects on the legal, ethical, and professional issues raised by the case-patient, focusing on the issues of consent.

A stroke is a clinical condition where the supply of blood to certain parts of the brain is disrupted which demands urgent clinical investigation and treatment to prevent the mortality. With the rapid access to the treatment facilities, the extent of damage can be prevented (Party, 2012). There are mainly two reasons behind the stroke such as ischaemic and hemorrhagic (Mendelow, 2015). The cells of the brain cells need oxygen which is carried by the blood to the parts of brain. When the stroke occurs there is hindrance observed in the supply of the blood to the brain parts, therefore the cells of that part faces death (Party, 2012). The formation of blood clots results in a blockage in the supply of blood in about 85% of the cases considered whereas in the case of the hemorrhagic stroke where the blood vessel supplying the blood to certain parts of the cerebrum bursts and that region gets damaged (Mendelow, 2015). It is further distinguished between subarachnoid haemorrhage and the intra-cerebral haemorrhage depending on where the bleeding is occurring (Shiber, 2010). In case of subarachnoid haemorrhage the bleeding occurs in between the skull and the brain whereas in case of the intra-cerebral haemorrhage the bleeding occurs within the brain parts (Shiber, 2010). There is another related condition where the pathophysiology is differently known as a transient ischaemic attack (TIA) where the supply of blood to the cerebrum is interminably stopped. The arteries of the brain gets narrowed down due to the accumulation of fatty materials called plaque formation or atherosclerosis that reduces the speed of the blood flow by creating obstruction (Shiber, 2010). This particular condition is also known as mini or short-stroke that can last from a few minutes to one day. The condition acts as a potential warning signal as it alerts about a nearby full stroke in the future (The Stroke Association, 2018). Certain conditions act as risk factors for stroke such as hypertension, an elevated level of cholesterol, atrial fibrillation, and diabetes (Hisham, 2013). In case of hypertension, the blood vessels that supply blood to the brain get damaged. The elevated level of cholesterol contributes to the formation of atherosclerosis, thereby enhancing the chances of stroke. Similarly, too much of sugar within the blood makes an individual more prone to stroke (Deb, 2010). The blood vessels may turn stiff in nature, and the physiological condition also enhances the condition of atherosclerosis. Moreover, the condition of atrial fibrillation is considered to be a potential factor for stroke as the blood might not be appropriately pumped out of the heart and that may result in pooling of blood or formation of clot. Therefore, this clot can travel to the brain and elevates the risk of stroke among the individuals (Deb, 2010). The number of strokes is thought to be enhanced by 60% within the year 2015 and it will continue to rise by 34% within 2035 as reported by the study of Hisham, (2013). The sedentary life style of the people, improper diet regimen and lack of physical activity are contributing to obesity and also elevates the other risk factors like hypertension, elevated cholesterol and diabetes which in turn are increasing the number of stroke sufferers and it is assumed that it will continue to rise (Luengo-Fernandez, 2020). Nearly 1.5 million individuals suffered from a stroke in the year, 2017, 9 million are stroke survivors and 0.4 million individuals faced mortality across 32 countries within the UK (Luengo-Fernandez, 2020). The essential symptomatic manifestations of stroke are: Face- the face of the individual may drop on one particular side and the person may not be able to move one part of his face or smile; Arms – the individual who has suffered a stroke will not be able to lift both the hands because of fatigues or weakness on one side; Speech – the person will show speech problems with slurry speech and Time – the individual or their carers should act fast after recognizing the symptoms by dialling the healthcare emergency number (Mendelow, 2015).

The Early Warning Scores (EWS) are utilized within the hospital setting among varied countries as it helps to deal with the patients in an optimum manner to hinder the further deteriorating condition, morbidity, and mortality of the patients. Therefore, for the relevant management of the patient from a worsening condition, it incorporates a chain of events that starts with EWS and ends with the formulation of an accurate medical care plan (Downey, 2017). Furthermore, among the NHS hospitals setting in England the vital signs of the patients are monitored and detailed into the National Early Warning Score (NEWS). The NEWS score lies within the range of 0 to 20 where 0 refers to the reduced degree of severity whereas 20 refer to the highest level of severity (Smith, 2010). RCP had amended the NEWS framework to NEWS 2 framework in December 2017 as they were committed to upgrade the scoring framework (RCP, 2017). The NEWS2 framework enables the practitioner to gain a baseline level of vital signs. To explore it we had used the NEWS2 scoring structure which refers to the National Early Warning Score. NEWS 2 has now obtained proper underwriting from NHS England and NHS Improvement to turn into the early warning framework for Recognising intensely poorly patients over the age of 16 – also will highlight patients with sepsis – in acute hospital settings in England. The National Early Warning Score (NEWS2), first structured in the year 2012 and then re-evaluated in December 2017. Thereafter, NHS England had mentioned that all intense acute care medical organizations should embrace NEWS2 within March 2019. It should be noted that NEWS2 is intended for use for adults, who are aged above or equal to 16 years. NHS, England asked all the trust to adopt NEWS 2 to approach the sepsis cases with a new concept. NEWS2 is not suggested for use among children, during pregnant conditions or in case of spine injury. The assessment of children are done based on an adjusted form alluded to as the Paediatric Early Warning Score (PEWS), which has distinctive physiological parameter ranges. Numerous community-based administrations are building up a Community Early Warning Score which fundamentally follows bespoken physiological parameters from NEWS 2, even though the calling measures/intensification arrangement will vary depending on escalation forms within the community services (McGinley, and Pearse, 2012). The patient scores NEWS 0 for respiration rate; NEWS 3 (red score) for saturation level of oxygen; NEWS score 2 for heart rate; NEWS 0 for BP and NEWS 0 for temperature. The aggregate NEWS is found to be 5 which indicates a moderate level of clinical risk and demands urgent attention by the clinical team. In addition, a solitary red score in any of the fundamental signs is viewed as abnormal and it requests an urgent investigation by the ward-based specialist who is equipped in the field of evaluating critical condition (NEWS 2 Chart, RCP, 2018; McGinley, and Pearse, 2012).

It was seen that the "ABCDE assessment approach" which stands for the "Airway, Breathing, Circulation, Disability and Exposure" could be used for examination and the joined impact of NEWS2 observations and ABCDE examination approach was found to be useful for assessing patient's general condition and for the administration of best quality practice (Thim,2010). It is a methodical way to evaluate a patient and take into consideration an organized appraisal framework by spotting on urgent parameters and acting on them. Therefore, it can be applied in a healthcare setting with constrained clinical setup or in further developed regions such as the emergency department, wards Critical Care, and so on (Thim, 2010). Moreover, it is also advised for those patients whose conditions deteriorate without giving any warning signals and therefore ABCDE assessment along with the track and trigger tool elevates the level of identification of the warning signs. Therefore, healthcare practitioners should consider the ABCDE assessment with the aid of a structured communication tool for reporting the findings of the patients (Smith, 2017). However, according to scientific pieces of evidence, staff at the emergency setting generally use the ABCDE approach only for the extremely ill patients and not for the identification of vital signs and symptoms of all the patients. This indicated that the concept is still not clear among the health care staffs (Olgers, 2017; James, 2009; Smith, 2017).

Applying ABCDE to assess the patient

The brief development that is taken after the verification of the patient is the utilization of the ABCDE approach which is generally applied for the essential evaluation of critically sick patients. The significant mediations should be undertaken for the fatal issues by the healthcare practitioners that could in the long run bring about death or inability if not treated or recognized early within time. The procedure for airway assessment is to review any hindrance in the airway (RESUS, UK). The blockage within the airway passage can be partial or complete which can be evaluated based on the breathing noise and effort and the voice clarity of the patient (Jevon, 2010). A lower degree of consciousness can be indications of airway obstructions and in this case, Mrs. Evans shows an unconscious state along with speech problems (Hernández, 2012). Therefore, this assessment is significant for the patient concerned. The chest and the stomach of the patient are assessed for any kind of change in movement , via the Look, Listen and Feel (LLF) The respiratory rate of the patient is 14 breaths every minute, scored NEWS 0 therefore it is considered to be within the normal range. After the airway course examination, the patient is reviewed by the physical assessment approach. Mrs. Evans's head is tilted in a way to open the passage of the airway. This strategy is necessary for effective ventilation as obstruction can be fatal (Hernández, 2012). The airway of the patient is considered to be undermined because of dysphagia and facial weakness.

The Look, Listen, and feel approach (LLF) is used to check the breath of the patient. The breath is assessed for the significance, indistinguishable development of the chest on either side, and rhythm of the patient (RCP, 2018). The Respiratory Rate (RR) of the patient is 14 breaths per minute (normal breathing rate for resting human adult 12-20) and scores NEWS 0 for RR. The patient is observed to have low or shallow breaths and is noted to be using her accessory intercostal muscles. The saturation level of oxygen is noted to be 89% on room air (normal saturation level >96) scoring NEWS 3 (red score) which is seen as abnormal and it requires an immediate report to the health professionals and oxygen should be administered as prescribed (Resuscitation Council, 2011; McGinley, and Pearse, (2012). Supplemental oxygen is endorsed to maintain adequate oxygenation via reservoir mask as she is demonstrating shallow or thin breaths (drawing of minimal air within the lungs). Close by that the conveyance rate of the oxygen (L/min) is administered and the device is setup based on the doctor's prescription and following the regulations mentioned within the NEWS2 chart and as demonstrated by the oxygen saturation level along with the delivery machine flow rate, as per the guidelines of British Thoracic Society (RCP, 2018) within the monitoring chart of the patients. Peripheral cyanosis was observed in case of Mrs. Evans and along these lines following admission to the hospital, a target for the suggested oxygen saturation is identified at 88 – 92% and it is assessed using the SpO2 scoring scale 2 as referenced in the NEWS2 graph 2 principles (RCP, 2018). The decision is taken in the presence of clinicians and it is documented within the clinical records of the patient. Dependent upon the NEWS 2 for the respiratory rate of the patient, it is presumed that the repeated checking of the patient ought to be kept at a normal interval of half an hour (McGinley, and Pearse, 2012).

Using the fingers to palpate the pulse is used for Mrs. Evans and the examination of regularity, quality, and rhythm (McGinley, and Pearse, 2012). The beat of the patient is found to be abnormal or irregular by hand palpate measurement. The patient shows the signs of tachycardia with 120 beats per minute (normal heart rate- 51-90 beats per minute), scores NEWS 2 and the pattern is found to be irregular. The state of the patient is certified on a twelve lead ECG. Blood Pressure (BP) is recorded to be 185/100 (normal Systolic blood pressure- 111-219) where the patient scores NEWS 0. The report revelations of the patient included sinus tachycardia. The discoveries are recorded in the documentation and the doctors are called for the situation (Adrogué and Madias, 2010). The significance of ECG cleared the significance of varied assessments that raised red scores for the case patient and this technique moreover hindered the administration of any inappropriate medication or therapy to the patient (NICE, 2016). The BP of the patient is recorded to be 185/100, scoring NEWS 0, which was accounted to be typical as demonstrated by her age, anyway it is checked at routine intervals of 30 minutes. The temperature is 37 degrees Celsius (normal temperature 36.1 - 38.0) for the patient, scoring NEWS2 0. Be that as it may, the temperature is routinely observed to screen any warning notice such as to monitor the risk condition of sepsis.

Joan is presenting speech problems along with additional features for example extreme weakness in the right upper and lower appendages though it is not understandable that for what period she was facing this trouble. The mental state of the patient is found to be confused but she is conscious. The level of the glucose level of blood is within the typical range (scored C on ACVPU). The assessment of the consciousness degree of the patient is done using the Alert, Verbal, Pain, Unresponsive (AVPU). The patient responded to voice and conformed to some of the requests. From the outset, the evaluation is performed after standard intervals of half an hour to screen the mental state of the patients after the presumed cerebral insult (NICE, 2014). The use of GCS is significant for the airway patency and to monitor the condition of the patient. There is a correlation in between the GCS score and the airway protection as a GCS score 8 or lower than that prompts the healthcare professionals to take an appropriate decision for the protection of airway. Moreover, the AVPU scale also denotes the management of the airway and the risk related to aspiration or compromising the airway (Romanelli, 2020). The patient is able to respond to the eye and verbal response and the patient scored around 4 which indicatesindicate her disoriented or confused speech and mental state. The Alert status of the patient is determined by the response of the patient to the surrounding environment, eye responses such as whether the patient can open their eye or not spontaneously and whether able to track the objects (Romanelli, 2020). The patient score is 12 concerning GCS and the findings indicated the status of moderate brain injury or hemorrhagehaemorrhage in the case of Mrs. Evans. The clinical observations of the patient are completed at regular intervals of half an hour until the condition becomes stable when the monitoring changed to 24 hours interval (McNarry, 2004). The philosophy of ABCDE is repeated after the GCS score to monitor the on-going condition of the patient (McNarry, 2004). These observations were maintained to highlight any worsening indications in the patient's condition, which will be reported to the medical staff.

According to the NICE guidelines, an individual who is admitted to the A&E department of the hospital with suspected stroke should be rapidly diagnosed using an accurate validated tool such as ROSIER. It is also recommended that an individual with suspected TIA and with an elevated risk of stroke should be given with oral aspirin on an urgent basis under the guidance of specialist within the stipulated period of 24 hours and continuous monitoring is recommended to prevent the secondary relapse after the confirmation of the clinical condition by the physicians (NICE, 2008). Therefore, the patient is immediately administered with aspirin on an urgent basis and recommended for CT scan within 24 hours of observation. The patient is transferred to an acute stroke unit for intense monitoring.

Mrs. Evans has shown indications of dehydration, it is unknown that when she last passed urine. The capillary refill time (CRT) as observed to be three seconds. The significance of the CRT is to determine the state of shock and dehydration. A long duration of CRT is considered to be a indication of dehydration, shock and reduced level of peripheral perfusion. It is also taken as an indication of the peripheral artery disease (Pickard, 2011). A delayed CRT (>2 seconds) acts as an indication of the hypo perfusion of the skin (Pickard, 2011). The doctors decided that the patient needs to be cannulated to restore the condition of hydration. The fluid balance chart is completed every hour, to monitor urine output (Marik, 2006). . A urinary catheter is inserted as she may unknowingly pass urine and is additionally complaining of weakness in her upper and lower right limbs. The clinical observations are recorded between times of 30 minutes to an hour. The condition of the patient is instantly reported to the doctor. Ongoing clinical observations of the patient are discussed with the doctor in charge who reviewed the ongoing management of the patient (Marik, 2006).

The application of Situation, Background, Assessment, and Recommendation (SBAR) Tool is the form of communication that enables the transferring of the relevant clinical and background information accurately between two capable individuals before handing over the charge is considered. This is viewed as a basic activity in the field of nursing as giving over undertaking by a capable individual, to a picked skilled individual and empowering them to be a part of the present condition (NMC, 2015). This particular technique assists the healthcare professionals to have an effective communication while handing over the charge of the patient. However, scientific evidence has revealed that there is a need to comprehend the significance of capturing the information. With reduced level of communication and failures in the process of communication hampers the prolonged take care of patients. This tool assist the nurses during the time of shift change over, by handing over the charge of the patient along with effective information (Achrekar, 2016). The physician is briefed about the present condition of Mrs. Evans such as about her ABG report and also about her background history which would help in the process of decision making. I It was also reported to the physicians that she might be in the dehydrated condition as she did not pass her urine for a long period and inquired the physician about the administration of intravenous fluid to Mrs. Evans. A liaised plan between the MDT was to follow the plan for Joan's needs (Jin et al. 2015). The multidisciplinary team including neuro specialist, stroke authority specialist, physiotherapist, occupational therapist, dieticians, occupational therapists, and clinicians are considered for the plan. The patient is highly dehydrated and fluids are given as prescribed (Katsilambros, et al, 2011). 1 liter of crystalloid fluid therapy with 0.9% of normal saline is managed for an hour and on account of the symptoms of dehydration, 0.9% potassium chloride is controlled for the accompanying two hours. The fluids administered are recorded in the documentation and the skin of the patient is checked for the sign of oedemas a result of fluid over-trouble. When the patient is ready for home discharge the MDT will consider home safety for the patient (Zhang, 2013).

Within a nurse's scope of practice, they will administer the intravenous fluids as prescribed. CT scan for suspected cerebral insult as it is considered as the highest quality level to identify the status of the blood clot within the cerebrum and the collection of blood is also prescribed by the physician for further investigation of her condition. Blood samples are taken as ordered by the doctor. The investigations required from the blood count will be urea and electrolytes, clotting, full blood count, anti-coagulant study, CRP. This will establish clotting status, hydration, and infection ( Morotti, et al., 2016; Ganti, et al., 2013). A chest x-ray will also be required to check the condition that she has aspirated or not (Sørensen, 2013).

Communication of findings to support effective collaborative working

The age at which individuals in the UK are facing mortality is expanding and the numbers are rising consistently within the acute hospital settings. Therefore pieces of evidence have revealed concerns concerning accurate communication and about low quality of life care within the emergency settings, specifically concerning correspondence among staff and family members (Kondoh, 2015). According to carers the life care of the patient gets augmented with effective mutual communication with the healthcare staff (Ljungqvist, 2017). Without proper correspondence with the family members of the patient, their carers get confused about the process of treatment and remain dissatisfied with the adopted care approach (Kondoh, 2015). Moreover, effective communication with the other healthcare staff to achieve a multidisciplinary care assists to provide better care to their patients and in turn augments the day to day efficiency of the care plan (Frank, 2009). In this case, as indicated the patient is suspected cerebrovascular accident, it requires the input of a multidisciplinary approach (MDT). The neuro specialist is informed as a matter of urgency. The neuro specialist or a stroke specialist is called to evaluate the inexplicable symptoms of the cerebral attack. The specialist assesses the condition of the patient to determine the severity and the type of stroke (Nor, 2004; Kelley, 2009). He is also approached for the recommended interventions as in the case of Mrs. Evans she is advised for preparation for decompression surgery along with stroke rehabilitation physiotherapy, medication, and other lifestyle alterations (Kelley, 2009). The patient is identified as being obese therefore; the dietician is required to ensure the appropriate diet which will control her blood parameter such as cholesterol level (Alviarez, 2018). Referral to the speech and language team to promote normal speech and assess swallow ability (Clarke, 2015). The physiotherapistphysio is also involved in stroke rehabilitation of the patient and will complete a full assessment to meet the patient's needs. The sentiment of the patient is difficult to exhibit, as her mental state is altered, and is also showing signs of depression and anxiety. As evident, this is common for stroke patients to suffer from post-stroke depression (Ayerbe, 2013). To address the altered mental state of the patient after the pathological condition psychologists can be involved to make an assessment of the patient's mental health and to uplift her mental status (NICE, 2008). However, the patient is educated about her present clinical condition and is strictly advised to stop smoking in the future as it could be dangerous to her health (NMC, 2015). The patient has to comply with the treatment plan adopted and must also obey the lifestyle changes such as giving up on smoking and should carry out the physiotherapy for improvement in her condition. The daughter of the patient is informed about her condition and the care approach is discussed with her in non-technical terms so that she can understand the present condition and give consent for the treatment process. The condition of the patient is carefully monitored as there is a high chance of recurrence. The care plan is discussed with the patient and consent is gained also the daughter of the patient is educated about the treatment plan before starting the treatment which increases compliance with treatment and care approach (NMC, 2015). This approach is intended to give a steady mind to the patient by meeting her key needs (Hussain, Mooney, and Russon, 2013). This included adjusting the patient's treatment alternatives to the objectives of the patient by tending to the development care arranging and shared dynamic to determine the fundamental side effect to the family and carers of the patient (Van Biesen et al. 2015). Also physio and occupational therapists will liaise together when the patient is discharged to ensure safety in the home (Langhorne, et al., 2009).

Ethical Consideration for the case study

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Moreover, according to the ethical issues of stroke medicine, the physician or the stroke physician must be highly certain about the essential treatment decision which will depend upon the probability of degree of disability, death after the first attack, the impact of the interventions undertaken (Louw, et al, 2002). According to Beauchamp and Childress, the four major medical ethics related to patients are autonomy, beneficence, non-maleficence, and justice of the patient. Therefore, informed consent is extremely essential before starting the treatment of the patient (Lee, 2010). The treatment plan that is adopted is for the best outcome of the patient, Mrs. Evans as per the ethics of beneficence, and it is also taken into consideration that the least harm is accomplished during the treatment. While deciding upon the justice aspect of the treatment the dissemination of every possible resource for the betterment of the patient is considered to ensure justice to Mrs. Evans. A patient has the right to accept or disregard the care approach adopted so the healthcare practitioners must maintain this balance (NMC Code, 2015). Concerning the informed consent approach of Mrs. Evans, the treatment and care plan adopted for the patient are discussed with the patient and her family member, her daughter, and their views and opinions are also honoredhonoured before making the plan strategy with the clinical specialist (NMC Code, 2015). This part is in accordance with the professional consideration as per the patient-centered approach mentioned within the NMC code, 2015. As per the NMC, code, 2015 the details of the patient are discussed only with those healthcare professionals who are considered to impart better healthcare to the patient, i.e., to provide care on the account of best interest to the patient. Moreover, it is also mentioned within the NMC code, 2015 that patients like Mrs. Joan who are lacking the capacity of deciding due to altered mental status or disability, for them the healthcare practitioner can suitably take the decision which will impart the best care to the patient. The patient is indicating modified mental status, be that as it may, the communication was completed with the patient compassionately and enquired her about the challenges and furthermore taught her about the present clinical condition, medicine, and way of life changes. All through the exposition the character and classification of the patient are kept up according to NMC code, 2015. As a healthcare practitioner, a nurse should also the duty to provide dignity and respect to the patient and should maintain confidentiality throughout. Even the Mental Capacity Act (2005) offers the framework to the patients to make the necessary decision who have the required capacity, and also provide the arrangements for those patients who cannot take decisions on their own, i.e., it also detailed about the laws and legislations that anyone taking any decisions on behalf of the patient should be for the best interest for the patients. The making of decisions will be allowed on the behalf of the patients with the application of formal procedures such as the written format of advance making decisions, power of attorney, and the decision which has been approved by the court of protection (Johnston, 2007; Chatfield, 2011). All through the exposition the character and classification of the patient are kept up according to NMC code, 2015. As a healthcare practitioner, a nurse should also the duty to provide dignity and respect to the patient and should maintain confidentiality throughout.


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