Important Assessments and Forms for Admission
Question:
Discuss about the Implement And Monitor Nursing Care For Clients With Acute Health Problems.
The important assessments and forms that should be done as a part of the admission are as follows:
- Detailed medication and medical history
- Recording vital signs
- Additional measurements for their weight, height, circumference of the head and blood sugar levels.
- Advance directive (if any)
- Neurological assessments (Partridge et al., 2014)
- List of allergies and adverse drug reactions
- Consent for transfusion of blood and blood products
- Cross-match reports to decrease the risk of occurrence of all kinds of hemolytic reaction
- Visual examination- This will help in detecting abnormalities by carrying out an investigation of the thorax, while the patient breathes.
- Palpation- This is the first step of the assessment, where the patient will be touched. It will help to assess mechanical breathing problems (Miller, Owens & Silverman, 2015).
- Auscultation- It encompasses the process of hearing the breathing sounds using a stethoscope (Bohadana, Izbicki & Kraman, 2014).
- Percussing- It will be done over the intercostals space and the resonance shall be felt, by movement of the diaphragm.
- Radial pulse by exposing the patient’s wrist
- Brachial pulse by exposing the anterior elbow of the patient (Van Bortel et al., 2012)
- Carotid pulse by exposing the patient’s lateral and anterior neck
- Femoral pulse by exposing the lateral pelvis
- Skull X-ray for suspecting neural injuries and revealing the presence of calcifications, intracranial tumors and vascular markings
- CAT studies for providing a cross-sectional view of the skull that will help diagnose tumors, lesions and infarcts (Washington & Grubb Jr, 2012)
- Noninvasive EEG for diagnosing the presence of neuromuscular disorders
- Cerebral angiography for viewing the arterial blood flow, by injecting contrast medium (Sharshar et al., 2014)
- Malfunction of the anesthetic equipment during the surgery. Accidental leaks in the connective tubes will make the anesthetic gas to seep out, thereby exposing the patient and the operation staff to danger (Hill et al., 2012).
- Contact with blood and body fluids will increase the susceptibility of getting afflicted with hepatitis and HIV (Markovi?-Deni? et al., 2012).
- Death or brain damage may occur due to inadequate ventilation, difficult ETI or esophageal intubation (Pickering et al., 2013).
- Medication errors that occur while administering IV antibiotics can lead to adverse events.
- Aqueous-based iodophors like povidone-iodine (PVP-I), which contain iodine that forms a complex with solubilising agents. This solution is used based on iodine’s antiseptic property that destroys microbial DNA and proteins (Phillips et al., 2014).
- Isopropanol and ethanol based antiseptic agents that are inexpensive, short-acting and have broad-spectrum antimicrobial activity (Lamagni, Elgohari & Harrington, 2015).
- Allergies and hypersensitivity
- The reason for surgery and the procedure implemented
- Type of anesthesia that was administered (TIVA, GA or regional)
- Anesthetic or surgical complications encountered
- ASA and PMH scoring
- Preoperative activity level of the patient (MET)
- Preoperative cognitive function (Johnson et al., 2014)
- Intubation conditions (quality of bag, mask, ventilation, grade of view)
- Catheters and lines (foley chest tubes, CVSs, surgical drains, VP shunt and IVs)
- Medications that are due during PACU
Vital signs refer to the measurements of the basic functions that include pulse rate, body temperature, blood pressure and respiration rate. The frequency of recording vital signs range and vary from Q15 minutes*4, Q30 minutes*2 hrs, Q 1 hour*2 hours to Q 4 hrs, when the patient shows stability.
- Body temperatures are recorded based on the gender, food and fluid consumption and the time of the day. Temperature recordings are taken wither orally, rectally, axillary, or from the skin and ear.
- This is followed by pulse rate measurement, generally from the wrist.
- Respiration rate is measured at rest and the number of breaths is counted for a minute, by noticing the number of chest rise.
- Blood pressure measurements are then done using a stethoscope and a sphygmomanometer.
- Level of conciousnes- A recent sedation or administration of opioid analgesics often impairs consciousness in patients who are receiving supplementary oxygen via nasal cannulae or masks
- Oxygen saturation- This will help to determine the amount of blood that is being delivered to the cells and tissues.
- Respiratory effort- This labored respiration will show whether the patient uses accessory muscles of respiration accompanied by grunting, nasal flaring or stridor, following an obstruction of the airways (Carteaux, et al., 2013).
- IV fluids- This will help to check the electrolyte balance and hydration status of the patient
- Urine output- This will indicate proper functioning of the kidneys. It will act as an indicator for renal perfusion.
- Reportable blood loss- Assessment of postoperative bleeding can help to determine whether the stitches have come apart or some organs got injured. This will help in providing immediate treatment (Huang et al., 2014).
- Assessment of dressings and wound sites- Wound assessment will indicate formation of new tissues, hypoxia, cellulitis or erythrema, thereby indicate infection or pressure trauma (Elliott & Coventry, 2012).
- NGT in situ- It can be used to reduce the risk of rhinitis, esophageal erosion or pharyngitis (Pryor et al., 2015).
- Presence of drains- This will remove blood, fluids and accumulated pus from the wound sites.
- Pain and nausea score- Higher scores will result in selection of a prophylactic regimen to reduce the sufferings (Backes et al., 2013).
The 4 possible effects of untreated pain on her body might be:
- Cardiovascular side effects such as hypertension and tachycardia- This occurs due to continuous sympathetic discharge from the rearranged neuroanatomy, in which the memory of pain circuitry is embedded. The blood pressure also gets increased due to sympathetic activity (Botto & Devereaux, 2015).
- Increased oxygen consumption-The metabolic needs and amount of free fatty acids get increasedin severe pain, which in turn increases myocardial oxygen consumption.
- Inabilities to deep breathe or cough- This occurs because the pain can lead to compression of the lungs that fail to clear the airways. This leads to buildup of secretions and often causes atelectasis.
- Emotional suffering- This occurs when the person fails to recover and leads to formation of anxiety and fear.
- Moaning with restlessness and movement
- Low appetite and a reduction in nutritional intake
- Irritability, agitation, anger and aggression
- Guarding a particular portion of the body or a reluctance to move
- Questioning the patient the reason for such behavior and reassuring that all possible efforts shall be taken to provide her holistic care
- Responding to the verbal abuses in a polite manner and with firmness and using non-verbal communication skills such as, body posture, gesture of hands, eye contact and active listening, to make her understand that her concerns are being addressed
- Installing a bed safety alarm that will provide alerts as soon as she gets up from the bed. This will prevent in-patient fall
- Seeking order for restraint from the hospital administration if the situation worsens
- Proper hand-washing- The hands will be wet and an alcohol-based cleanser or soap and warm water will be used to clean the hands and the nails for 15-30 seconds. It will be rinsed well and dried using a clean towel.
- Removing old dressing- The tape will be carefully loosened from the skin, after putting on disposable gloves and it will be disposed of in a plastic bag and set aside. The hands will be again washed (Matatov et al., 2013).
- Wound care- A gauze or cloth soaked in normal saline or soapy water will be used to wipe the skin to remove all drainage and dried blood.
- Putting on new dressing- Clean packing tape or gauze pads will be put over the wound. The wound and spaces under the skin will be filled in. It will be covered by a large, dry dressing pad and rolled gauze or tape will be used to hold it in place.
Low respiratory rate or bradypnea occurs when the normal regulation of respiration gets disrupted in the brain. Opioids are powerful drugs that get attached to receptors in the central nervous system and relieve pain. An accidental overdose of morphine may result in low respiration rate and reduced oxygen saturation. Use of sedative or anesthetics during her surgery may also affect the brainstem that may result in bradypnea (Botto & Devereaux, 2015). Her old age and hypertensive symptoms may also be the possible causes. Insufficient alveolar ventilation is another rprobalbe risk factor that has predisposed her to the disorders (Mador et al., 2013). Furthermore, obesity also obstructs the airways in the lungs that lead to low oxygen saturation (Aron-Wisnewsky et al., 2012).
- Positioning the patient with her head elevated, and in a semi-Fowler’s position (the head of bed will be at 45 degrees).
- Turning the patient for every 2 hours. Regularly monitoring the saturation of mixed venous oxygen after turning.
- Positioning the patient at reverse Trendelenburg position at 45 degrees, owing to the obesity. Assessing the respiratory rate and depth for every 4 hours.
- Maintaining an oxygen administration device to keep the oxygen saturation levels at 90% or greater.
The cutting of skin during surgery stimulates the nerve fibers for signaling pain. Inactivity of the body after surgery, side effects of anesthesia and pain in the chest and abdomen contribute to the shortness of breath. Chest pain or shortness of breath can also occur when blood clots developed in the leg veins of an inactive person break off and travels to the chest (Kline & Stubblefield, 2014). This blocks blood flow to the lungs and may also block the coronary blood vessels, causing pain. Sever loss of blood during surgery can result in reduction in RBCs that fails to carry adequate oxygen to the lungs.
- Troponin tests will be performed at regular intervals to detect heart injury (Sato, Fujiwara & Takatsu, 2012)
- Administration of 0.4mg nitroglycerin (sublingual) for every 5 minutes until chest pain is relieved (Münzel & Gori, 2013)
- Administration of oxygen therapy via nasal cannulae
- Administration of anxiolytic medications for anxiety associated with dyspnea (Asmundson et al., 2013)
- Monitoring vital signs at regular intervals after the medications
- Avoiding smoking and consumption of second-hand smoke
- Moderate exercise and dietary modification that will help to lose weight and reduce complications
- Controlling blood pressure with proper diet and adherence to medications
- Avoiding strenuous activities and adhering to nitroglycerine medicine to prevent angina
- Assessing the patient’s airways to predict potential problems
- Taking spinal precautions to stabilize the neck, head, and back in neutral position. It will minimize movement that can injure the spinal cord
- Assessing the breathing to determine if it is adequate. Beginning rescue breathing by using mouth-to-barrier device, pocket mask or BM device in case of inadequate breathing.
- Evaluating signs of bleeding, central or peripheral pulses, temperature, and skin colour.
The equipments that will be needed at her bedside are as follows:
- 2-bag mask ventilation and oral airways
- Tracheostomy tubes of accurate sizes
- Catheters (on observing distended bladder)
- Electrocardiogram (ECG or EKG) kit
2 drugs found in the resuscitation trolley are:
- 1 unit of 300mg Amiodarone
- 3 units of 1mg Adrenaline
Amiodarone is administered for treatment and prophylaxis of ventricular fibrillation and unstable ventricular tachycardia. It is used intravenously. It helps in maintain normal heart beat (Kudenchuk et al., 2016).
Adrenaline is administered undiluted, either subcutaneous, or intravenous into anterolateral aspect of thighs. It narrows the blood vessels and opens airways. This reverses hypotension and wheezing (Dumas et al., 2014).
Possible Effects of Untreated Pain on the Body
The stinging sensation occurs due to the inflammatory process of wound healing, when the blood vessels contract leading to the formation of a clot. Increase in exudate levels around the wound due to homeostasis leads to heat, edema and erythrema (Edwards et al., 2012). Thus, formation of an infection at the wound site might have occurred. The stinging sensation can also occur due to shearing of the superficial nerve endings.
- Confirming for feelings related to malaise
- Fluid drainage from the incision area
- Hot and swelling at the incision site
- Assessing the size of the wound and tracing its outline on a paper
- Examining the edge of the wound
- Identifying presence of dark red granulation tissue to confirm infection expansion
- Recognizing presence of slough or eschar
Septicemia or bacteremia is a major bloodstream infection that occurs when some bacterial infection enters the bloodstream.
Treatment options include administration of antibiotics such as, ceftazidime, ceftriaxone, piperacillin or ampicillin. Most often they are given in combination with vancomycin (Mustafa & Ahmed, 2014).
- Widespread inflammation all over the body (sepsis) that can cause organ failure
- The released toxins can ead to septic shock or drastic reduction in blood pressure
- Acute respiratory distress syndrome (ARDS) where oxygen fails to reach the lungs
4 complications that can arise on her discharge are mentioned below:
- Pressure ulcer or bedsore development due to prolonged pressure to her skin that covers the bony areas of her body.
- Postoperative delirium due to action of drugs, electrolyte imbalance or immobilization.
- Unresolved pain that can add to her anxiety
- Constipation due to irregular bowel habits
The three supporting healthcare team members who can help her cope with these problems are:
- Pain specialist- They will play an essential role in evaluating and diagnosing the types of pain she experiences and will take her additional care to reduce the pain symptoms.
- Psychological counselor- They will help in identifying the underlying factors that contribute to delirium and will be able to reduce aggression or agitation by engaging in an effective conversation.
- Physiotherapist- They will formulate and review the treatment programs based on manual therapy such as, massage, electrotherapy and therapeutic exercises that will improve mobility.
References
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Equipment Needed for Nursing Care
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