You receive handover from the morning nurse on Amanda, who is expected to be discharged this afternoon. Amanda is a 39 year old female admitted with a DVYT who has responded well with treatment and will be transferred to Hospital in the Home (HITH). The nurse handing over reports that this morning Amanda complained of slight back and shoulder-tip pain, which was resolved with 1 g oral paracetamol. All paperwork for her referral to HITH has been completed and Amanda is waiting for her discharge medications before she can leave. When you enter Amanda’s room, you find her pale and complaining of dyspnoea and chest pain.

1. What is your first action going to be?
2. What do you think has happened?
3. What sign did the morning nurse miss?
4. What diagnostic tests need to be done?

ANSWER

Rapid Response to a Patient’s Deterioration: Assessment and Actions

Introduction

As a nurse, responding to a patient’s sudden deterioration is a critical and time-sensitive situation that requires immediate attention and action. In this scenario, Amanda, a 39-year-old female patient who was expected to be discharged, has complained of dyspnea and chest pain, which indicates a potential medical emergency. This essay will outline the first action to be taken, possible reasons for Amanda’s symptoms, identify the missed sign during the morning handover, and suggest diagnostic tests that need to be performed.

First Action

The first and most crucial action in this situation is to assess Amanda’s immediate condition and ensure her safety. Rapid response should involve the following steps:

1. Ensure Amanda’s Safety: Ensure Amanda is in a safe and comfortable position, preferably in bed, and free from any potential hazards.

2. Activate the Rapid Response Team: Immediately activate the hospital’s rapid response team or code blue team to provide prompt medical assistance.

3. Assess Vital Signs: Check Amanda’s vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. This assessment will provide critical information about her condition.

4. Administer Oxygen: If Amanda is hypoxic (low oxygen saturation), provide supplemental oxygen to improve her oxygen levels and ease her breathing.

Possible Reasons for Amanda’s Symptoms

Amanda’s sudden onset of dyspnea and chest pain could be indicative of various serious medical conditions, including:

1. Pulmonary Embolism: Blood clot(s) in the pulmonary arteries can cause chest pain and difficulty breathing.

2. Myocardial Infarction (Heart Attack): Chest pain and shortness of breath are classic symptoms of a heart attack.

3. Pneumothorax: A collapsed lung can lead to sudden chest pain and difficulty breathing.

4. Pleuritis or Pleurisy: Inflammation of the pleura, the lining around the lungs, can cause chest pain worsened by breathing.

5. Pericarditis: Inflammation of the sac around the heart can lead to chest pain and breathing difficulties.

Missed Sign During Morning Handover

The morning nurse reported that Amanda had complained of slight back and shoulder-tip pain earlier in the day, which was resolved with 1 g oral paracetamol. This was a significant sign that was missed during the handover. Such pain, especially in the context of a patient with risk factors such as deep vein thrombosis (DVT), could indicate the possibility of a pulmonary embolism. Therefore, it should have raised concerns and triggered further assessment.

Diagnostic Tests Needed

Given Amanda’s symptoms and potential differential diagnoses, the following diagnostic tests should be performed promptly:

1. Electrocardiogram (ECG): To assess for any cardiac abnormalities or signs of a heart attack.

2. Chest X-ray: To evaluate the condition of the lungs and check for signs of pneumothorax or other lung-related issues.

3. D-dimer Blood Test: To check for elevated levels, which could indicate the presence of a blood clot.

4. CT Pulmonary Angiography (CTPA): To confirm or rule out pulmonary embolism.

5. Blood Tests: Including cardiac enzymes and a complete blood count (CBC) to assess for cardiac and inflammatory markers.

Conclusion

When a patient like Amanda experiences sudden dyspnea and chest pain, rapid and appropriate action is imperative. The first step is to ensure the patient’s immediate safety, activate the rapid response team, and assess vital signs. Amanda’s symptoms could be indicative of several serious medical conditions, and a missed sign during the morning handover underscores the importance of thorough communication and assessment. Diagnostic tests, including ECG, chest X-ray, D-dimer, CTPA, and blood tests, are essential to determine the cause of her symptoms and initiate appropriate treatment promptly.