Case Study of Joanna

NursingrecognizingandRespondingtothedeterioratingpatient1 NursingrecognizingandRespondingtothedeterioratingpatient Studentsname- Universitydetails- NursingrecognizingandRespondingtothedeterioratingpatient2 Answer1.(1)AsthecasestudyshowsJoannafellfromtwometersonaconcretepath.Joanna wasnotrespondingatfirstbutafterfewminutessherespondsinaconfusingway.Joannahas severalinjurieslikeHaemopneumothoraxwhichisaseriousconditionofhavingbloodandair filledinthethoraxcavity,headlaceration,herribs3-6arefractured,herleftulnaandradiusare alsofractured,shefracturedherleftneckoffemur(NOF).Shealsoexperiencedgeneralized bruisingtothechestattheleftside,leftabdomen,thigh,temporalarea,leftarmandthigh.The twoimportantconditionsbywhichJoannawasseverelyaffectedarehypovoleamiaandpossible ICCblockageduetothebloodlosstrauma. Hypovolaemiaisaconditionoflowextracellularfluidvolumewhichissecondary combinedtowaterandsodiumloss.Hypovolaemiaresultstohypovolaemicshock;itisacritical conditionwherethebodylossesalotofthebloodorfluidwhichmakesheartincapabletopump bloodtothevitalorgans.Pathophysiologyofhypovolaemiainvolvesearlyidentification,which ismorelikelyhavingtheinvolvementofexternalhemorrhage.Hypovolaemiaiscausedby lacerations,bleedingfromotherinjuriesandinternalbleeding.Joannawashavingsevereblood losswhichresultsinhypovolaemia(Summers,2021). Anintercoastalcatheter(ICC)alsoknownaschesttubewhichputbetweentheribs. Insidetheemptyspacewhichissituatedbetweenthecavityofchestwall(pleuralspace)andthe lungs.Chesttubedrainsallfluidandairfromthepleuralspaceofthelung.Blockedchesttube drainisacardinalsignoffluidwhichremainswithinthetubeandfluctuatewithrespirationand coughing.Thisineffectiveformofdrainagewillleadtounresolvedorundrainedpleural collection.JoannaICCinstitute20cmofsuctionandthereisanabsenceofswingorbubbling. Tensionfrompneumothoraxleadtoongoingleakofairfromthelungs(Mehra,2020).Patientis stillinaclinicalconditionandsoonJoannaisshiftedtothegeneralsurgicalwardforthesurgical repairingfortheneckofthefemur. (2)IncaseofJoannafurtherdeteriorationcouldbepossibleasthecomplicationsassociatedwith thehypovolaemicshockandacutekidneyinjury.Sheisinverycriticalconditionandher conditioncanbefurtherdeteriorated. Hypovolaemiareferstodecreaseinvolumeofthebloodleadtolossofplasmafluidand blood.Hypovolaemicshockhappensastheresultofhypervolaemia.Hypervolaemiaiscausedby NursingrecognizingandRespondingtothedeterioratingpatient3 externalorinternalhemorrhage.Hypovolaemicshockoccursduetoanessentialamountofloss offluidorbloodwhichmeansthatbodyisnotcapabletotransportenoughoxygentovital organs.Hypovolaemiahasfourstagesbywhichapatientcanleadtoprogressareinitialstage, compensatorystage,progressivestageandrefractorystage.Hypovolaemicshockstartedto developintheinitialstageswhichgraduallyworsenifthereisanincreaseinhypovolaemia. Oncethehypovolaemiareachestothestageofrefractoryitbecomesirreversible(Australian CommisionOnSafetyAndQualityInHealthCare,2022).Joannawasexperiencing hypovolaemicshockasshelossesalotofbloodandfluid.Sheisstillinaverycriticalcondition. Acutekidneyinjury,refertoasAKI;alsocalledacuterenalfailure,refertoasARFisa suddenonsetofkidneydamageorkidneyfailurethathappenswithinafewdaysorhours.AKI causesaccumulationofwasteproductsinthebloodwhichmakeshardforthekidneytoregulate thebalanceoffluidinthebody.AKIorAcutekidneyinjuriesaremostlycommoninpatients whocareintheemergencyunit.Signsandsymptomsofacutekidneyinjuryincludeswellingin ankles,legsandaroundtheeyearea,confusion,shortnessofbreath,confusion,fatigueor tiredness,lowvolumeurineleavingthebody,pressureorchestpainandnausea.Joannahas conditioncanleadtoacutekidneyinjury.Acutekidneyfailurecanbetestedbymeasuringoutput oftheurine,bloodtest,urinetest,glomerularfiltrationrate,kidneybiopsyandimagingtest. Treatmentforacutekidneyinjuryincludedialysisorkidneytransplant. Answer2.TheABCDEassessmentmethodfocusesonimmediateandquickassessmentof patient.TheABCDE(Airway,Breathing,Circulation,Disability,andExposure)isasystematic approachwheretreatmentandimmediateassessmentisnecessaryforaninjuredorcriticallyill person(Amboss,2022).Itisauniversallyacceptableandapplicablestrategyforinitial resuscitationandassessmentofcriticalconditions.Whilevarioushealthpractitionersandnurses useheadtotoeassessmentcheckliststoconfirmthatthereshouldnotbeanymistakesoccurand thatnostepshouldbeskippedduringtheoverallphysicalexaminationofthepatient.The checklistofhead-to-toeassessmentisadocumentedformthatprocessesandreviewsthe patientsfunctionsandthestate. InABCDEanalysis,initially,airwaypatencyissecuredandassessed;breathingisoften analyzedconcurrentlyandshouldbetreatedwithcarebyrespiratorysupportwithparticular NursingrecognizingandRespondingtothedeterioratingpatient4 time-sensitivetherapy.Thenextstepisthecirculatoryassessmentandinitiatinghemodynamic supportimmediately.Arapidneurologicalassessmentisnecessarytoanalyzethealteredmental status,weakness,seizuresandothermaymoreneurologicalcomplications.Thefinalstepisa rapidexposureofthebodyofthepatienttoidentifyanyhiddensignsorcluesfortheunderlying causeofinjuryandremovingtheaggravatingfactors.Inthehead-to-toeanalysismethod, checklistsareutilizedbythenurses,doctors,EMTs,andtheassistantsofthephysicianthat performanddocumentedtheentirechecklistofthephysicalstateofthepatient(Kostiuk,2021). InthecaseofJoannahelpstothelife-threateningconditions,andmeasurestheeffectsofthe treatment(Linders,2021).Theprimaryobjectiveofthetreatmentinitiallyistokeepthepatient aliveandshowsomesignoffurtherimprovement.Thiswillbuysometimeforthediagnosisand thetreatment. ABCDEassessment Theairwayisclearairwayandpatientisverbalizing.Joannasrespiratoryrateis26;thereisan absenceofbubblingorswing,ICCInstitute20cmsuction.Hercirculationwasinitially200mls frankblooddrained.Theheartrateis120andthebloodpressureislowat95/55.Shefractured3- 6ribs,fracturedleftulna,andradius,leftneckoffemurisfracturedandthereisageneralized bruiseonshouldertemporalarea,leftchest,thigh,leftarm,andleftabdomen.Herexposureof chest,pelvicarea,andabdomen,leftsideofthelegandleftsideofthearm,x-rays,CTscanof thehead,anintercostalcatheter(ICC)isinserted5thintheintercostalspaceinthemidaxillary line,leftsideofthewristissplinted,leftsideofthelegistheexternaltractionandtwowidebore intravenouscannulaswiththeintravenous(IV)fluidisadministrated. Head-to-toeassessment Establishaprofessionalrelationshipwiththepatient-Firstly,thehealthpractitioneror nursemustdotheverificationtheidentityofthepatientandmakethepersonal relationshipofrespectandtrustwiththepatientandmakethemcomfortable. EvaluatetheequipmentandincludetheequipmentinthechecklistAllthehealth practitionersincludingnursesperformphysicalchecksshouldrequireasetofequipment thatcontains-athermometer,gloves,stethoscope,heightwallruler,bloodpressurecuff, watch,scale,tapemeasure,andotherobjects. NursingrecognizingandRespondingtothedeterioratingpatient5 Healthpractitionersshouldknowwhatistobelookinginassessmentthehead-to-toe. Respiratorydistressisasuitableexampleofanabnormalfindingifthereisanyvariations occurintherespiratoryrate.Thereisdrasticchangeintheskincolorwhichmightimply somediseases. Head-to-toeassessmentmethodincludesseveralsafetymeasuresandpatientprivacy concerns.Medicalworkersandnursesmustincludesomeitemsinchecklistofnursinghead- to-toeassessment,justbeforetheactualphysicalexaminationsare: Washhandsbeforegoingtopatientsroom,checktheroomandmaintainnecessary precautionsforthecontactwiththepatient,giveyourintroductiontothepatient. Verificationofthepatientidentificationbyaskingpatientsdateofbirthandnameof thepatient,searchforthecorrectequipment,explanationthecompleteprocessto patient,makesurethatprivacyanddignitytopatientandlistentopatientsqueries. Nursesshouldbesystematicandorganizedwiththeassessment,checkforthe importantsigns(Doforms,2020). Generalstatusofthehealthchecklistincludes: Vitalsigns Heartrate Patientorientation Temperature Pulseoximetry Respiratoryrate Bloodpressure Pain Answer3.(1).Respiratoryrateisthenumberofbreathsthatapersontakesinaminute.A normalrespiratoryrateforanadultis12to20breathsforaminute.Underthe12andover25 breathsaminuteduringrestingstateisabnormal(ClevelandClinic,2019).Respiratoryrateis vitalsignwhichissensitiveinvariouspathologicalconditionsexampleclinicaldeterioration, pneumoniaandadversecardiacevents.TheStressorsincludingthecognitiveload,heat NursingrecognizingandRespondingtothedeterioratingpatient6 emotionalstress,cold,exercise-inducedfatigueandphysicaleffort.Sensitivityoftherespiratory rateunderserioussituationsismoresuperiorascomparedtotheothervitalsigns.Still respiratoryrateisnotroutinelymonitored(Nicol,2020). Insomanycases,achangeinrespiratoryrateisimportantfirstsignorindicationof possibleworsening.SpO2alsoreferredtoasoxygensaturation,isafractionofsaturatedoxygen levelinthehemoglobinrelatetothetotallevelofhemoglobininblood.Respiratoryratemeasure themetabolicprocessofoxygenintakeandreleaseofcardiacdioxide.Therespiratoryrate measuressensoryinputsystem,neuralinputsystemandmuscularsystem.Causesforslow respiratoryratearenarcotics,alcohol,braininjuriesorstroke,metabolicissuesandsleepapnea. Causesforfasterrespiratoryratearedehydration,fever,chronicbronchitischronicobstructive pulmonarydisorder,emphysema,asthma. (2).Respiratoryrateisalsoreferredtobreathingrate.Itismeasuredasthenumberofbreathsa persontakeperminute.Themeasurementofrespiratoryratecanbedonebycountingthenumber ofbreathsthatpatienttakesinaminute.Stepsforgettinganaccuratemeasurementare: Washthehandswithwaterandsoapinordertoreducetheriskofinfection. Gettheconsentofthepatient. Makepatientsitinacomfortableposition.Makethetemperatureconstantinorderto preventshivering(MayoClinic,2020). Ifthepatientisaskedfornasalcannulaoroxygenmaskwhichisrightlypositionedand shouldberecordedonthebasisofrecordedrespiratoryrateobservationchart. Approximately20minutesbeforethemeasurement,allowthepatienttotakerest.Also considersomemedicationsthatmightaffecttherespiratoryrate. Observetherespiratoryfunctionofthepatientwhilepreparing. Itmightbefruitfultoassesstherespiratoryrateatthesametimeasoxygensaturationand thepulserate.Thiswillhelptoevaluatetheaccuratemeasurementoftherespiratoryrate. Withthehelpofawatchinthesecondhand,countthenumberofbreathsforaminute. Whileevaluatingtherespiratoryrate,notethecardiacrhythm,whichmightindicatethe signsfortheunderlyingillness(Liu,2019). NursingrecognizingandRespondingtothedeterioratingpatient7 Observethelipsofthepatientforsignslikehypoxia,cyanosis.Pulseoximetryisknown tobeavaluabletoolwhichishelpfultomeasuretheSpO2buttherearesomelimitations whentheperipheralcirculationofthepatientorconditionofthepatientiscompromised. Recordtherespiratoryrateandreportanykindofabnormalities. Checkforthepatientiscomfortable,washanddryhands. NursingrecognizingandRespondingtothedeterioratingpatient8 References Amboss.(2022).ABCDEapproach.Retrievedapril16,2022,fromAmboss: https://www.amboss.com/us/knowledge/ABCDE_approach/ AustralianCommissionOnSafetyAndQualityInHealthCare(2022,May).Hypovolaemia. RetrievedMay02,2022,fromAustralianCommissionOnSafetyAndQualityInHealth Care:https://www.safetyandquality.gov.au/search?keys=deteriorating+patient Burgess,A.v.(2020).TeachingclinicalhandoverwithISBAR.BMCmedicaleducation,20(2), 1-8. Campagne,D.(2021,April).OverviewofFractures.RetrievedApril19,2022,fromMerck ManualConsumerVersion:https://www.merckmanuals.com/home/injuries-and- poisoning/fractures/overview-of-fractures Chiew,L.B.(2019).Nursesperceptionandcomplianceonidentification,situation,background, assessmentandrecommendation(isbar)toolsforhandoffcommunicationintertiary hospital,Dammam.MalaysianJournalofMedicalResearch(MJMR),,3(4),26-32. ClevelandClinic.(2019).VitalSigns.RetrievedApril19,2022,fromClevelandClinic: https://my.clevelandclinic.org/health/articles/10881-vital-signs Doforms.(2020).Head-To-ToeAssessmentChecklist.AStep-By-StepGuideToUsing eFormsForPhysicalExamination.RetrievedApril19,2022,fromDoforms: https://www.doforms.com/head-to-toe-assessment- checklist/#:~:text=A%20head%2Dto%2Dtoe%20assessment%20checklist%2C%20or%2 0form%2C,of%20a%20patient's%20physical%20state.%20. Kostiuk,M.&.(2021).Traumaassessment.StatPearls[Internet]. Linders,M.B.(2021).AdherencetotheABCDEapproachinrelationtothemethodof instruction:arandomizedcontrolledsimulationstudy.BMCemergencymedicine,,21(1), 1-11. NursingrecognizingandRespondingtothedeterioratingpatient9 Liu,H.A.(2019).Recentdevelopmentofrespiratoryratemeasurementtechnologies. Physiologicalmeasurement,40(7),07TR01. MayoClinic.(2020,March23).Howtomeasureyourrespiratoryrate.RetrievedApril19,2022, fromMayoClinic:https://www.mayoclinic.org/how-to-measure-respiratory-rate/art- 20482580#:~:text=To%20get%20an%20accurate%20measurement,the%20course%20of %20one%20minute. Mehra,S.H.(2020).Theeffectivenessofsmall-boreintercostalcathetersversuslarge-borechest tubesinthemanagementofpleuraldiseasewiththesystematicreviewofliterature.Lung India:OfficialOrganofIndianChestSociety,37(3),198. Nicol,A.M.(2020).Theimportanceofrespiratoryratemonitoring:Fromhealthcaretosport andexercise.Sensors,20(21),6396. Summers,R.(2021).Pathophysiologyandtreatmentofhypovolaemiaandhypovolaemicshock. NursingStandard,36(6). Wedro,B.,&Nettleman,M.D.(2022).Hematoma.Retrievedapril19,2022,fromMedicineNet.