If 3 to 4 jet airliners crashed every day over the course of a year how many days would it take before something would be done to address this public health crisis?

Not many and the news media would be covering it 24/7!

But when you put the current public health crisis of medical error and failure to rescue in context that results in over 250,000 patient deaths in the United States (Makary & Daniel, 2016), this amounts to about 700 preventable patient deaths every day, hence the jetliner analogy.

The upside to this current problem is that nurses can make a big difference and save human lives! As the nurse collects vital signs, in order to teach students to think like a nurse and recognize a potential complication EARLY, the respiratory rate must be noted, accurately recorded and not estimated by the nurse (Ju, et al., 2017).

Did you know that the most common alteration in vital signs that predicted cardiac arrest was tachypnea or shortness of breath that was present in over 40% of patients who coded in a hospital setting?

In last week’s blog, I discussed early signs of clinical deterioration that the nurse must recognize to save a life.

Today I want to build on that by discussing the WHY or rationale of the significance of tachypnea and why this is always a clinical red flag and what this compensatory change physiologically represents.

ABCs

Whenever there is a change in vital signs because of a complication the nurse must UNDERSTAND the significance of the body’s compensatory response and the significance of what this represents so that relevant clinical data is not missed but recognized in order to rescue.

For example, when a patient begins the slow slide of sepsis into septic shock, because of increasing oxygen demands and hypoventilation/perfusion to the tissue, the EARLIEST compensatory response to sepsis or any shock state is not tachycardia or hypotension but tachypnea.

Whenever a patient has an elevated respiratory rate or decreasing oxygen saturation this is always a clinical RED FLAG that must be recognized and addressed by the nurse.

If tachypnea is not recognized or documented then the next domino or progressive change is tachycardia. But do your students understand pathophysiology well enough to understand the significance of this formula applied to clinical practice…

CO=SVxHR

This foundational pathophysiologic formula must be deeply understood by every nursing student in order to think like a nurse.

Though this formula provides a calculation for how cardiac output is obtained it tells the nurse much more. If a patient has a declining cardiac output because of a loss of volume related to hypovolemia or septic shock, the earliest compensatory response by the body is to elevate the heart rate to maintain cardiac output which maintains a relatively normal blood pressure for a time.

This is why shock and septic shock is often missed early by the nurse. Once the blood pressure drops this is always a late finding and leads to a much higher likelihood of a bad outcome or even patient death.

Smoke Alarm vs Fire Alarm

Tachypnea or an elevated respiratory rate must always be recognized as a potential smoke alarm that must be recognized and addressed. Is there a fire present?

The nurse must immediately cluster additional data including oxygen saturation, and a change in temperature, pulse and blood pressure that may indicate a potential problematic fire. Put the fire out here and it does not have to burn to the ground.

Most patients (84%) do not suddenly code and go straight into cardiac arrest. Smoke is present. Observable evidence of vital sign instability and visible patient deterioration changes occur in most patients 6 to 24 hours before a full cardiac arrest.

Here is a clinical scenario that highlights what can happen when this VS is not recognized:

Joan B. was a healthy 62-year-old woman who was admitted to the hospital for cholecystitis and recently returned from the operating room having undergone a routine laparoscopic cholecystectomy.

After arrival to the med/surg floor her VS were:

• T: 99.5 (oral)
• P: 90 (reg)
• R: 24 (reg)
• BP: 135/84
• O2 sat: 95% room air

When Joan was rechecked two hours later, the nurse collected the following:

• T: 99.2(oral)
• P: 102 (reg)
• R: 32 (reg) labored
• BP: 145/90
• O2 sat: 91% room air

TRENDING relevant clinical data including respirations shows a deterioration that is obvious. But smoke was present initially two hours ago with tachypnea, that went unrecognized by the nurse.

Recognizing a change of status that is now a raging fire (but should have been identified two hours prior!), the beside nurse initiated a rapid response team and was emergently transferred to ICU.

Equation for Failure to Rescue

Failure to RECOGNIZE + Failure to RESPOND=Failure to RESCUE

The essence of failure to rescue is that the nurse fails to recognize relevant clinical data including the significance of tachypnea and as a result fails to interpret the data correctly and as a result fails to respond.

In order to get to the root of the problem of failure to rescue, nurse educators must make it a priority to help students deeply understand the importance of pathophysiology which lays the foundation for critical thinking.

Build on this foundation with clinical reasoning and provide students opportunities to think like a nurse using case study scenarios that emphasize this essential nurse thinking skill. Clinical reasoning must be practiced in order to be developed like any other skill taught in nursing education.

ACTION Step

1. Make sure your students understand the physiologic WHY of each RED FLAG assessment data to ensure that knowledge is being applied and not just cookbook nursing by looking at numbers alone.
2. Ensure that students always acquire a full set of vital signs that include respiration rate. In one audit the respiratory rate was missing in over 15% of all nursing documentation.
3. Provide practice of clinical reasoning using case-based scenarios in the classroom or simulation to ensure that students understand essential content in the safety of the classroom before they are released into the clinical setting to experience it firsthand.

In Closing

In order to think like a nurse, every student must not only recognize tachypnea or tachycardia but understand the rationale for these physiologic changes and the compensatory response that it represents.

It is only then that the gravity or seriousness of relevant clinical data becomes evident resulting in aggressive action and advocacy that can save a life.

Make it a priority to teach this essential content but first eliminate infobesity in the curriculum so students acquire a deep learning of what is most important.

To better prepare students for professional practice requires two things.

Educators must do their part to cut out the fat in the curriculum while students do their part to embrace the responsibility of deeply understanding essential content and what it means to be the few, the proud, the professional nurse!

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Relevant Past Blogs 

• What Educators Can Learn From Pilots to Help Students Think More Like a Nurse
• Why Students are Not Prepared for Practice
• Two Questions to Ask Students to Help Them Think More Like a Nurse

References

Ju, T., Al-Mashat, M., Rivas, L., & Sarani, B. (2017). Sepsis rapid response teams. Critical Care Clinics 34, 253-258.

Makary, M.A. & Daniel, M. (2016). Medical error-The third leading cause of death in the US. British Medical Journal, 353

What is Good about this Friday?

Do you ever wish that you could get a do-over and go back and do things differently in your life? Forgiveness is possible and your past no longer has the power to condemn you because God demonstrated His love towards you, that while you were still a sinner, Christ died for you (Romans 5:8). That is what is good about Good Friday!

To learn more, download the booklet For Your Joy by John Piper.

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