Acute Nursing Care
Essay Preview: Acute Nursing Care
Report this essay
The assessment of patients forms a major component of the nursing role. It allows the nurse to gain vital information to base the planning and implementation of prioritised care on. A systematic method of assessment is required, that ensures that all areas of assessment are covered and that the assessment and subsequent interventions are as effective and efficient as possible. One method that can be followed for patient assessment is the primary and secondary surveys, with an additional assessment replacing the secondary survey post-operatively. This essay will display the implementation of these methods in the assessment of a trauma patient throughout the peri-operative period. The case study of Mrs Lily Flowers, as outlined in Appendix A, will be used to demonstrate the use of the primary and secondary surveys both pre and post-operatively, commencing with the pre-operative primary survey first.
The first stage of the primary survey is airway management with cervical spine control. Mrs Flowers has a patent airway, signified by her ability to speak to the nurse (Cole 2004). The nurse must immobilise the cervical spine until they can confirm definitive clearance, by the Emergency department, of any spinal damage (Miglietta, Levins & Robb 2002). As Mrs Flowers has a patent airway, is not displaying any signs of airway obstruction and the cervical spine has been cleared of any injury, the primary survey now progresses to the assessment of breathing.
Breathing is assessed by observing the chest wall and pattern of breathing, including the rate and depth of respiration, symmetry of chest wall movements, the use of accessory muscles, rib retraction, nasal flaring, position of comfort and patient colour (OReilly 2003). Audible sounds, such as wheezes, stridor or gurgling are listened for and the lungs auscultated for breath sounds and bilateral air entry (OReilly 2003). Mrs Flowers respiratory rate of 32 breaths per minute indicates severe tachypnoea (OReilly 2003), which can be related to pain, anxiety and/or shock (Cole 2004). Reassurance must be given to Mrs Flowers to help reduce her anxiety, whilst assessing oxygen saturation and administering oxygen through a non-rebreather mask with a flow of 15 litres per minute (Cole 2004: Pruitt & Jacobs 2003). With oxygen therapy in place, circulation would now be assessed.
To assess circulation, the patients pulse must be palpated for rate, strength, regularity and quality. Other observations would include blood pressure, capillary refill, skin temperature and diaphoresis (Ahern & Philpot 2002). Mrs Flowers is tachycardic, with a heart rate of 120 beats per minute (Cole 2004). She would have a weak, rapid pulse with possible irregularity. Her blood pressure is 90/60, with a history of hypertension, this indicates extreme hypotension (Crisp & Taylor 2001). Capillary refill time would be slower than two seconds and her skin is pale and clammy (Cole 2004). These observations along with tachypnoea; restlessness and feeling faint indicate hypovolemic shock., An IV cannula has been inserted in the Emergency department, however crystalloid fluids and possibly fresh frozen platelets should be infused, which will require two large bore catheters to be inserted (Cole 2004; Kelley 2005). Therefore the nurse must get in immediate contact with the treating doctor to organise this. A maximum rate infusion is normally preferred, for patients with hypovolemia, however patients with cardiac disease need the fluid rate “titrated to response to avoid complications” (Kelley 2005, p.9) and use of “aggressive fluid resuscitation in uncontrolled haemorrhage” prior to the bleeding has been controlled is not recommended (Cole 2004). A urinary catheter should be inserted (Cole 2004) and the patient positioned in a modified Trendelenburg position, to encourage blood flow from the feet to the vital organs (Smeltzer & Bare 2004). An ECG would be conducted now due to a past cardiac history. Once circulation has been assessed and fluid resuscitation commenced, disability and dysfunction needs to be assessed.
Disability and dysfunction covers a rapid neurological assessment, conducting a Glasgow Coma Scale (GCS), observing pupil size and response. With no signs of neurological deficit and possible pupil dilation related to the hypovolemic shock, a pain assessment would be completed to assess the need for pain relief. An order for pain relief should be requested when the doctor is ordering the fluids and/or blood. This will be followed by an assessment of exposure and environment.
Exposure requires the inspection of the patients body, looking for obvious injuries, wounds or external abnormalities. Environment requires care to prevent hypothermia due to exposure, which can impair the clotting and oxygenation processes (Cole 2004). Mrs Flowers is not displaying any signs of extreme heat or cold, however is covered to maintain privacy and dignity during the examination. This now concludes the primary survey, with a more thorough assessment of the patient being completed in the secondary survey.
The secondary survey progresses through four stages, beginning with Fahrenheit. Fahrenheit requires the measurement of the patients core body temperature measured by oral or tympanic thermometer (Crisp & Taylor 2001), looking out for hypothermia due to fluid replacement and shock (Kelley 2005). Mrs Flowers temperature is 36.8oC, which is within the normal range (Crisp & Taylor 2001, p. 670). Get vitals requires a repeat of all vital sign observations, looking out for signs of oedema or fluid overload. With vital signs stable, a thorough history and head-to-toe assessment should be completed.
Using the mnemonic AMPLE, the patient history is taken. AMPLE stands for allergies, medications, past health history, last meal and events/environments related to the injury (Urden, Stacy & Lough 2002). Beginning with allergies, the patient is asked for any known allergies and the reaction if any. Mrs Flowers has no known allergies and her medications would be likely to include an anti-platelet agent (which reduces thrombi formation); an ACE inhibitor (which reduces hypertension); a beta-blocker (which reduces the oxygen demand of the heart) and a statin (which lowers lipid levels in the patient) (Banas 2004; Bryant, Knights & Salerno 2003). The patient should be asked about her use of alcohol, nicotine and other illicit drugs. Mrs Flowers states that she has been a smoker for 35 years and currently smokes 25 cigarettes per day. Mrs Flowers is then asked about her past and current medical history.
Further details regarding the patients history of hypertension and unstable angina would be asked, along with other