NR 557 Week 5 Red Flag Case Analysis Example

Red Flag Case Analysis: A Counted Respiratory Rate of 28 With New Confusion in a Patient Who Says "I'm Fine", the Case for Waiting Stated and Answered, and Why the Decision Was Same-Day Evaluation

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College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

Red Flag Case Analysis: A Counted Respiratory Rate of 28 With New Confusion in a Patient Who Says "I'm Fine", the Case for Waiting Stated and Answered, and Why the Decision Was Same-Day Evaluation

The Item, Standing Alone

The red flag in this case is a respiratory rate of 28 breaths a minute over a complete 60-second count at rest, in a 78-year-old with COPD (chronic obstructive pulmonary disease) plus heart failure, together with new disorientation to day and month. Standing alone, a counted rate of 28 at rest in an older adult is abnormal under any published threshold and far above the 18 to 20 recorded at this patient's previous visits. It is believable because it was counted under stated conditions, at rest, seated, with the patient unaware of the count, and because it fits the patient's visible effort: use of neck muscles and pauses to breathe mid-sentence. Respiratory rate has been described as the neglected vital sign precisely because an abnormal rate often precedes serious deterioration and is often missed (Cretikos et al., 2008).

The new confusion adds weight. In an older adult, new confusion with infection can be the first sign of sepsis.

The Case for Waiting

Several elements of the case argued for waiting, and each deserves to be stated as someone arguing for it would state it.

Blood pressure is normal. At 128/74, it is within the patient's usual range. The patient is not in shock.

The patient says they are fine. The patient told me, "I'm fine, it's just my chest, I get this," and asked not to be taken to the hospital, recalling a long wait in the emergency department last year.

COPD patients often breathe fast and live with lower oxygen levels. Some people with COPD have saturations in the high 80s on good days, so 88% might not be alarming for everyone.

The daughter can stay. The patient's daughter offered to stay the night and call if things got worse.

Treatment could start at home. The patient's primary care practice sometimes prescribes antibiotics by phone for chest infections in known COPD patients, which would avoid a hospital visit.

These are reasonable points. A nurse who sent every breathless COPD patient to the emergency department would overwhelm it and distress many patients unnecessarily.

Answering Each Point

Normal blood pressure. Blood pressure falls late in sepsis. A normal pressure with a raised respiratory rate, raised heart rate, fever and new confusion describes a patient who may be compensating, not a patient who is safe. The quick sepsis-related organ failure assessment gives one point each for breathing at 22 or faster, a change in mentation and systolic pressure at or below 100; this patient scores two without any fall in blood pressure, and a score of two or more identified people with suspected infection who were more likely to die (Seymour et al., 2016).

"I'm fine." The patient is disoriented to day and month. A person with new confusion is not well placed to judge their own condition, and "I get this" describes past COPD flares that did not include confusion, fever or one-sided consolidation.

COPD baselines. This patient's baseline is known: 92% to 93% at rest. The concern is not that 88% is low for COPD in general, but that it is four to five points below this patient's usual level.

The daughter can stay. She can call if things worsen, but she cannot count a respiratory rate or recognize subtle changes in confusion overnight, and the patient is already sick enough that deterioration could be rapid.

Antibiotics at home. Oral antibiotics would take a day or more to act. The patient needs an assessment of oxygen requirement, blood tests and a chest radiograph to judge severity, none of which can be done at home today.

Ranked by Consequence, Not by Odds

The most likely explanation is pneumonia that might respond to treatment at home. But the decision rests on consequences, not only probabilities. If the patient has early sepsis from pneumonia and is left at home, the consequence could be death or a much sicker admission tomorrow. If the patient is sent for evaluation and turns out to be well enough for home treatment, the consequence is a difficult day in the emergency department. The CURB-65 severity score, which gives one point each for confusion, raised urea, respiratory rate of 30 or more, low blood pressure and age 65 or older, would already give this patient at least two points before blood tests, a level at which hospital-based assessment is suggested (Lim et al., 2003). The asymmetry of consequences favors evaluation today.

The Decision

The decision was same-day evaluation in the emergency department, arranged through the patient's primary care nurse practitioner, with transport by ambulance because of the oxygen saturation and the patient's difficulty walking. I explained the reasons to the patient and daughter in plain terms: the breathing is faster than it has ever been at my visits, the oxygen is lower than usual, there is a fever and the patient is more confused than usual, and together these can mean an infection that needs checking today. The patient agreed, reluctantly, once the daughter said she would come along.

The decision was documented with the counted values and the reasoning, so that anyone reading the note later would understand why a patient who said they were fine was sent to the hospital.

The Conversation With the Patient

The hardest part of the decision was the conversation. The patient did not want to go and was frightened of a long wait. I did not argue with the patient's feelings. I explained what I had found in plain terms, said that I would be worried if my own parent had these findings, and offered to call the nurse practitioner so that the decision would not rest on me alone. The daughter's support was decisive. The patient kept the right to refuse, and had the patient refused, I would have documented the explanation, arranged close follow-up and asked the nurse practitioner to call directly.

Conditions Under Which the Call Would Differ

If the respiratory rate had been 20 and the patient fully oriented, with fever and new crackles but saturation at the usual level, a same-day call to the nurse practitioner for antibiotics at home with a next-day visit would have been reasonable. If the blood pressure had been low, the decision would have been an immediate emergency call rather than an arranged transport. The analysis rests on the counted rate and the tested confusion; had either been estimated, the decision would have rested on guesswork.

References

Cretikos, M. A., Bellomo, R., Hillman, K., Chen, J., Finfer, S., & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Medical Journal of Australia, 188(11), 657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax, 58(5), 377-382. https://doi.org/10.1136/thorax.58.5.377

Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2016). Assessment of clinical criteria for sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762-774. https://doi.org/10.1001/jama.2016.0288