NSB236: Case Study: The Deteriorating Patient


The rib cage and muscle protect the kidney, in case of any injury to the rib or chest area there are chances of acute kidney injury. Injuring or breaking of the bony structure of the pelvis is called pelvic fracture that includes any injury to the ischium, pubis, tailbone, etc.  And internal bleeding and bladder injury are a few major complications from this injury. In the case study of Mr. Charles Nobother who was admitted to the hospital after a motorcycle event, he had a left orbital and left rib fracture, fracture in the left superior pubic rami and inferior ischial rami, mesenteric hematoma, and abrasion in the left arm,  he was given orthopedic surgery, after 14 hrs of care Mr. Nobother has fine crackles bilaterally, hypoactive bowel and distended abdomen, he has blood in his catheter and he has extreme pain in his hand due to the pelvic fracture, in this essay, there will be a discussion about NSQH factor that is relevant to this case study and using evidence of NSQH standard we will discuss the how sometimes failure to recognize clinical deterioration occurs, and how evidence-based approach can help in reducing incidences of failure to recognize and respond to clinical deterioration for future delivery of clinical care. Using the evidence elucidate the pathophysiology of the disease, such as signs and symptoms, and will highlight two clinical nursing interventions to discuss priority problems.


In health system it is vital to maintain the safety of the patient and it is important to recognize and respond to the acute deterioration (Pagani et al., 2019), the purpose of NSQH (The National Safety and Quality Health Service) standard is to provide safe care and acute deterioration of care recipient is identified immediately and suitable action is taken by health professionals (Bell et al., 2017). Action 8.1 of this standard is about integral clinical governance which provides guidance about implementing policies and procedures for identifying acute deterioration, managing risk associated with it, using training experience to manage the condition. Action 8.2 is about applying a quality improvement system that comprises monitoring, making strategies, reporting progress, and outcome to manage the deterioration.  Action 8.3 is about partnering with customers in which the carer can involve the care-receiver in the care plan, discuss needs and ensure effective decision making. 8.4 And 8,5  action is about identifying acute deterioration action 8.6 to 8.9 is about escalating care and action 8.10 to  8.13 action in NSQH is about responding to deterioration (Twigg et al., 2013. As in clinical field it is been said identifying decline is patient health can help in improving outcome through suitable intervention, but many time due to failure in recognising and responding to the deterioration it put patient at risk, there are eight (8) factors associated failure in clinical deterioration-


Not monitoring physiological observations consistently, or not understanding changes in physiological observations

Knowledge deficit of signs and symptoms that could signal deterioration

Limited of awareness of the potential for a person’s mental state to deteriorate

Knowledge deficit of delirium, and the benefits of early recognition and treatment

Knowledge deficit of formal systems for responding to deterioration

Knowledge deficit of skills to manage patients who are deteriorating

Failure to communicate clinical concerns, including in handover situations

Attributing physical or mental symptoms to an existing condition, such as dementia or a mental health condition


Knowledge deficit of signs and symptoms that could signal deterioration is one such failure associated with the case study as crackles in sound indicated infection or inflammation of the small bronchi, active bowel sound indicated slow intestinal movement, etc. there will be brief discussion about this as we proceed. 

Task 1

Failure to recognise and respond to acute deterioration can increase the risk of adverse event for patient receiving care/treatment in the hospital. Nurses play vital role in this process as they are the one who are closely monitoring or caring for the patient, over the decade there where many incidence of failure to identify the on-set sign and symptoms of decline health of patient, putting patient at risk (Currey, 2017). (Hammoudi et al., 2017) in their study stated about 20 million cases occur every year across the world related to delay in responding to declining health.  Increasing awareness for nurses who care for patient who is deteriorating is helpful in mitigating risk, though, there is no specific reason or study which highlight the fact what cause this failure. Though it is been said that understanding patient sign and symptoms or overall decline in health are supported by four factor; a) assessing the patient, b) understanding the patient and their needs, c) education , d) equipment/tool.

As lack of consistent clinical monitoring, lack of organizational communication, lack of nursing knowledge and skills, and failure in escalating concern are few major reason of deteriorating health of the patient (Liaw et al., 2018). This can be improve by assessing the patient through monitoring their vital sign so that care can be modified as per their need, there are different cues which nurses must be aware about to assess patient effectively, knowing the patient help in building awareness for instance, medical history of the patient play a significant role in understanding patient health, and overcome the barrier in recognizing deterioration.  Education is very crucial factor in recognizing the declining health, training and clinical education key that enable nurses to recognize and respond the deterioration. For instance, nurses who had postgraduate degree are more confident and experienced to recognize the patient deterioration.  Using the specific equipment by nurses help in recognize deterioration in timely manner.  Nurses can respond to patient deterioration through three themes:

  1. Non-technical skills: effective communication skills, active listening, situational awareness, leadership and teamwork permit nurses to be more efficient and active in responding the deteriorating patient health (Kim et al., 2020)
  2. Negative emotional responses: negative emotional response is basically related to emotions such as feeling anxious, panic and fear, nurses who recognise these feeling of the patient help in recognizing and responding to patient’s deterioration (Triantaphyllou & Yanase, 2020)
  3. Access to support: seeking support from colleagues is vital in responding to patient weakening health, taking support from seniors or medical staff to grab their attention on patient health and actively consulting will help in avoid delay in patient care is an effective way to respond to patient deterioration (Anstey et al., 2020)

 Task 2

Two signs or symptoms of clinical deterioration associated with the pathophysiology of the patients’ presenting problem are: Blood in urine and less urine output and breathing issue are two major sign and symptoms of clinical deterioration which indicated that his rib injury and pelvic insufficiency injury has caused acute kidney injury. As kidney is protected by rib cage and back muscles Mr. Nobother rib injury has caused the kidney injury (Zhuang, 2018)(for instance, blunt trauma). Urinary tract system of human has two kidney, one bladder two ureters and urethra. Kidney are main body filter, they control many thing such as electrolyte balance, fluid balance, regulation of blood pressure, etc.  When there is any injury kidney might not function well as we see in the case of Mr. Nobother though urine output, breathing issue, fluid balance, etc. thus, the left rib fracture also indicates the fact of kidney injury in the accident through sign and symptoms. Abdomen distention is another reason that associated with blunt trauma, basically rib injury, abdomen, distention, effecting kidney hinting about renal injury is the reason of deteriorating health of Mr. Nobother. Mr. Nobother has history of extreme alcohol and drug misuse which indicated the side effect of those substance on lungs, and overall health of Mr. Nobother.  The blunt trauma I direct injury on the chest or back area where rib cage and muscle unable to guard the kidney in case of fall or accident (George & Al Busaidy, 2015), a bruised kidney is a serious condition where symptoms include vomiting (Chaudhary, 2016), blood in the urine, muscle spasms, inability to urinate (Ofri et al., 2017), as mentioned in Mr. Nobother case study.  The one prime problem in the Mr. Nobother case is breathing issue cause by rib injury. The thoracic structure protection the ribs are important in mechanisms of breathing and protecting kidney, as rib comprise two adjacent rib and three layer of intercostal neurovascular bundles, surrounded by facial layer and intercostal muscle, during inspiration ribs moves upward and outward when diaphragm contracts and it escalated the thoracic cavity volume, in expiration the ribs moves inward and downward, during the hyperventilation, intercostal muscles work as accessory respiratory muscles contract along with enhance diaphragm. Harm to the bony structure of the chest by rib and sternum breaks destabilizes the rib confine and impedes unconstrained breathing mechanics significantly. This condition is intensified by torment, which further lessens breathing capacity (Okamoto et al., 2019). Direct horrible harm to the lung (i.e., lung wound), in blend with a simultaneous increment in vascular porousness of the lung vessels in the harmed territory (Benyan & Korymasov, 2015), prompts extravasation of protein-rich liquid with an adjusted surfactant synthesis, in the end bringing about moderate yet dynamic respiratory failure. Thus, we can say that Mr. Nobother's injuries have affected each other and are the key reason for health deterioration.


Two nursing intervention for priority problem is surgery, and monitoring sign and symptoms of the patient, a kidney injury for instance, blunt renal trauma in the case of a fractured rib, though before the surgery to identify the severity of injury through conducting X-ray, urinalysis, and CT scan, and in case if the injury is severe it is vital to monitor patient sign and symptoms such as blood pressure, fluid balance, etc.  Both before and after surge to ensure effective management of the patient health. A wounded kidney is a genuine physical issue that frequently requires prompt clinical consideration. In the event that the injury was minor, it can take as long as about fourteen days for a wounded kidney to recuperate all alone. Indeed, even with gentle manifestations, kidney wounds can advance into genuine inconveniences and may cause internal bleeding. Monitoring blood pressure, heart rate, breathing rate, can help nurses to effectively monitor patient health after surgery (Thornburg & Gray-Vickery, 2016).


The rib cage and muscle protect the kidney, in case of any injury to the rib or chest area there are chances of acute kidney injury, in case of Mr. Nobother, he suffered an injury rib injury and pelvic injury after the incidence, using the National Safety and Quality Health Service standards we discussed how to provide safe care though timely recognizing and responding acute deterioration. In the case, knowledge deficit of signs and symptoms that could signal deterioration is one such failure associated with the case study as crackles in sound indicated infection or inflammation of the small bronchi, active bowel sound indicated slow intestinal movement, etc.  The primary breathing issue and urine output indicate the side effect of rib injury effective oxygenation and ventilation, the thoracic structure protection the ribs are important in mechanisms of breathing and protecting kidney. Two nursing intervention for priority problem is surgery, and monitoring sign and symptoms of the patient, a kidney injury. 


Anstey, M., Bhasale, A., Dunbar, N., & Buchan, H. (2020). Recognizing and responding to deteriorating patients: what difference do national standards make?. Retrieved 16 August 2020, from.

Benyan, A., & Korymasov, E. (2015). Features of thoracoscopic ribs osteosynthesis in patients with a closed chest injury. Endoskopicheskaya Khirurgiya21(6), 29. https://doi.org/10.17116/endoskop201521629-33

Chaudhry, R. (2016). Management and Outcomes of Pediatric High-Grade Blunt Renal Trauma. Journal Of Trauma & Treatment05(01). https://doi.org/10.4172/2167-1222.1000295

George, K., & Al Busaidy, S. (2015). Management of blunt renal trauma. Trauma17(4), 270-273. https://doi.org/10.1177/1460408615593975

Kim, C., Armstrong, M., Berta, W., & Gagliardi, A. (2020). How to identify, incorporate and report patient preferences in clinical guidelines: A scoping review. Health Expectations. https://doi.org/10.1111/hex.13099

Ofri, A., Malka, V., & Lodh, S. (2017). Horner's syndrome in traumatic first rib fracture without carotid injury; review of anatomy and pathophysiology. Trauma Case Reports8, 1-4. https://doi.org/10.1016/j.tcr.2017.01.007

Okamoto, K., Ueda, K., & Ichinose, M. (2019). Cardiac injury due to the rapid progress of the dislocation of rib fractures: A rare case that required urgent open reduction and internal rib fixation. Respiratory Medicine Case Reports27, 100840. https://doi.org/10.1016/j.rmcr.2019.100840

 Thornburg, B., & Gray-Vickrey, P. (2016). Acute kidney injury. Nursing46(6), 24-34. https://doi.org/10.1097/01.nurse.0000482865.61546.b4

Triantaphyllou, E., & Yanase, J. (2020). How to identify and treat data inconsistencies when eliciting health-state utility values for patient-centered decision-making. Artificial Intelligence In Medicine106, 101882. https://doi.org/10.1016/j.artmed.2020.101882

Zhuang, S. (2018). Epigenetic targeting for acute kidney injury. Nephrology23, 21-25. https://doi.org/10.1111/nep.13466

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