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Case Study 5 MCs Online Case Study Nursing Assessment

Case Study 5 MCs


Recognising and responding to clinical deterioration involves an accurate and appropriate record of a patients’ vital signs (Lambe, Currey & Considine 2017; Hancock & Hulse 2009; Mok, Wang & Liaw 2015). It forms part of the ongoing assessment and action in response to the changing health status that I use on a daily basis as a Registered Nurse (Dean 2007; Osborne et al. 2015). This case study introduces Joseph (pseudonym) who I cared for day three of his admission to the medical ward of a rural hospital. He was admitted with right-sided shoulder pain. I aim to acknowledge the importance of clinical reasoning and clinical judgment. I will also reflect on the impact on the patient when staff failed to observe changes to their vital signs and what insights I have gained from this experience.

Case Study

 Joseph, an 85-year-old male presented to the emergency department with ongoing pain in his right shoulder. He had a past medical history of osteoarthritis and hypertension. I was only handed over that there was no reason for this patient to in the hospital and that he was admitted for pain management yet only on his regularly charted Panadol Osteo. On initial assessment, Joseph was alert and orientated to time and place. He mentioned his pain was six out of ten and was showing signs of discomfort and described his pain as a ‘throbbing’ sensation. His blood pressure was 111/70 and trending down when asked; Joseph mentioned this reading was low for him. He mentioned he hadn’t been drinking much today and didn’t think he had been to the toilet.

I started to become concerned about my initial assessment. My primary issues were the uncontrolled pain, trending down of the blood pressure and the lack of input and output. I decided to phone the doctor for some extra pain relief and provide an update on Joseph. Ideally, I would have liked a review but being in a rural facility, the doctors work from their surgeries, so clinical judgment and early detection from nursing staff are critical. During this call, the daughter rushed out to the nursing station and notified me that the patient ‘didn’t seem right.’ I reassessed Joseph; he was agitated, unable to tell me where he was or who his visitors were. His vital signs had significantly changed – he was now hypotensive 92/65, tachycardiac - 111, febrile - 38.9, tachypnoeic - 25 with obvious shortness of breath and hypoxic - 89% on room air. I immediately called rapid response, commenced the sepsis pathway, applied a non-rebreather mask at 15L of oxygen, inserted a cannula, attended an ECG and collected an-i-stat. Joseph was transferred to a tertiary hospital as the hospital I worked did not have the facilities to treat him. He was later diagnosed with septic arthritis.


Sepsis is a life-threatening illness caused by the body’s response to an infection (Bhan et al. 2016). The mortality rate of sepsis is generally attributed to the growing incidence of chronic conditions in aging populations (Burrell et al. 2016). Sepsis resulted in 17.5% of in-hospital deaths within New South Wales in 2009 (Burrell et al. 2016).

Vital signs can often be overlooked within the ward setting due to nurses making the task part of a routine rather than identifying the significance of detecting deterioration (Mok, Wang &Liaw 2015). Early detection of deterioration could facilitate more timely interventions. These help to achieve positive patient outcomes in reducing care to higher levels such as intensive care unit and mortality (Ghosh et al. 2018). Sepsis can be identified by signs of extreme pain as well as a drop in blood pressure (Hammett 2017; Novosad 2016). The information obtained during my initial assessment identified Joseph had pain that was not controlled as well as blood pressure that was abnormally low for him. This is an example of the important role clinical judgment play in patient care and accurate and timely assessment (Hyun-Ju Kim1 2018).


Observation and response charts are used to record patient observations. They play a key role in triggering abnormal vital signs and escalation of care if necessary (Flabouris et al. 2015). The track and trigger system used on the chart allows staff to use clinical judgment in order to acknowledge a trend and escalate care (Smith & Aitken 2016). By identifying a change in Josephs condition, I was able to provide efficient and thorough clinical reasoning skills (Hyun-Ju Kim1 2018). Similarly, Lee et al. 2016 suggest positive patient outcomes are achieved through accurate and precise assessment skills. This is evident when reassessing the patient, gather new information and initiate an action such as identifying a change in cognitive state, hypoxia, and hypovolaemia while also activating and following the sepsis pathway (Levett-Jones et al. 2010).

Finally, the clinical reasoning cycle involves reflecting on outcomes (Levett-Jones et al. 2010). Although Joseph was sent out, I felt I was able to detect and respond to the best of my ability and with the resources available. This case study involved me to critically reflect upon the assessment skills required to detect a deteriorating patient. As previously stated, I work in a rural hospital which requires well-developed, precise and evidence-based assessment skills. This enables safe and effective care toward inpatients while also enabling the skills to detect deterioration early in order to prevent poor outcomes for the patient (Burrell et al. 2016; Hyun-Ju Kim1 2018).


Bhan, C, Dipankar, P, Chakraborty, P, & Sarangi, PP 2016, 'Role of cellular events in the pathophysiology of sepsis,' Inflammation Research: Official Journal Of The European Histamine Research Society ... [Et Al.], vol. 65, no. 11, pp. 853-868.

Burrell, AR, McLaws, M, Fullick, M, Sullivan, RB, &Sindhusake, D 2016, 'SEPSIS KILLS: early intervention saves lives,' The Medical Journal Of Australia, vol. 204, no. 2, p. 73.e1-7.

 Dean, 2007, 'The Importance of Vital Signs,' Fire Engineering, vol. 160, no. 10, p. 32.

 Flabouris, A, Nandal, S, Vater, L, Flabouris, K, O'Connell, A, & Thompson, C 2015, 'Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications, and Calls, to Acutely Deteriorating Adult Patients,' Plos One, vol. 10, no. 12, p. e0145339.

Ghosh, E, Eshelman, L, Yang, L, Carlson, E, & Lord, B 2018, 'Early Deterioration Indicator: a Data-driven approach to detecting deterioration in general ward,' Resuscitation, vol. 122, pp. 99-105.

 Hammett, E 2017, 'Recognising sepsis: Early signs and symptoms,' British Journal of School Nursing, vol. 12, no. 2, pp. 74-76.

 Hancock, A, & Hulse, C 2009, 'Recognizing and responding to acute illness: using early warning scores,' British Journal of Midwifery, vol. 17, no. 2, pp. 111-117.

 Hyun-Ju Kim1, h 2018, 'Applying Clinical Judgment Rubric for Evaluation of Simulation Practice for Nursing Students: A Non-Randomized Controlled Trial,' International Journal of Contents, vol. 14, no. 2, pp. 35-40.

 Lambe, K, Currey, J, & Considine, J 2017, 'Emergency nurses' decisions regarding frequency and nature of vital sign assessment,' Journal Of Clinical Nursing, vol. 26, no. 13-14, pp. 1949-1959.

 Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, S.Y.S, Noble, D, Norton, C.A, Roche, J & 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 Education Today, vol. 30, no. 6, pp. 515-530.

 Mok, WQ, Wang, W, &Liaw, SY 2015, 'Vital signs monitoring to detect patient deterioration: An integrative literature review,' International Journal Of Nursing Practice, vol. 21 Suppl 2, pp. 91-98.

 Novosad, SA, Sapiano, MP, Grigg, C, Lake, J, Robyn, M, Dumyati, G, Felsen, C, Blog, D, Dufort, E, Zansky, S, Wiedeman, K, Avery, L, Dantes, RB, Jernigan, JA, Magill, SS, Fiore, A, & Epstein, L 2016, 'Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention', MMWR. Morbidity And Mortality Weekly Report, vol. 65, no. 33, pp. 864-869.

 Osborne, S, Douglas, C, Reid, C, Jones, L, & Gardner, G 2015, 'The primacy of vital signs - Acute care nurses' and midwives' use of physical assessment skills: A cross-sectional study,' International Journal of Nursing Studies, vol. 52, no. 5, pp. 951-962.

Smith, DJ, & Aitken, LM 2016, 'Use of a single parameter track and trigger chart and the perceived barriers and facilitators to the escalation of a deteriorating ward patient: a mixed methods study,' Journal Of Clinical Nursing, vol. 25, no. 1-2, pp. 175-185.

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