NURS2100 Nursing Fundamentals Online Tutoring

QUESTION 1:

A number of causes might be behind changing patient condition, recurrence or ill-treatment of pneumothorax, head injury, her history of diabetes, her obesity etc

After observing Joanna’s ISBAR and NOC, we have a very strong idea that a reoccurrence of pneumothorax might be the reason behind changes in her physiological parameters. Her physiological reading indicates tachycardia, tachypnea and low blood pressure which are the initial signs of pneumothorax (Zhigang Li et al., 2014).

There is a chance of chest tube complication that might have resulted in improper treatment of pneumothorax (Olesen et al., 2016). After initial chest tube insertion, blood was extracted. However, Chadwick (2015) defines in this article the proper check before and after removing the drainage. It is required for the drainage to observe swinging as with the rise and fall of pressure. Absence of swinging indicates that the tube is blocked or not placed in the pleural cavity (AJ Chadwick, 2015).

According to patient’s ISBAR, patient faced post traumatic concussion and disorientation after the fall. Her GCS is 14 which denote mild head injury followed by confusion but there is a chance that CT scan didn’t observe neurological injury after the fall (Marincowitz et al, 2018). There is a possibility of mild traumatic head injury that had an effect on the autonomic nervous system (Greenwald et al, 2017). Autonomic dysfunction might be the cause behind changes in patient’s NOC, as it causes mortality if left untreated.

Joanna has a history of Type 2 diabetes and is taking oral medication for it. There is a strong possibility that increase or decrease blood sugar might have an affect on patient’s physiological condition. Hyperglycemic state and injury might be the reason behind changes in patient’s NOC readings (Rutan and Sommers, 2012). A diabetes patient has been found to be more prone to accidental falls ( Marks R, 2014). Diabetes ketoacidosis might also be a reason as it is caused due to high level of sugar in blood and improper uptake of medication (Wolfsdorf et al., 2014). Wolfsdorf (2014) in his article indicates how diabetes ketoacidosis has a similar like tachypnea, tachycardia, low blood pressure, confusion etc.

The patient has been noted to have a BMI of 40 which is considered morbid obese. Such conditions pose a threat to trauma patients as it slows down their recovery period and further complicates physiological parameters (Ditillo et al., 2014). Proper care and management is necessary to control adverse events (Dieudonne et al., 2018).

Delay in hip fracture surgery might be one of the possible causes of sudden changes in patient condition (Carretta et al., 2011). That combined with diabetes is an important root cause that cannot be ignored.

The patient is showing quite early signs of clinical deterioration through her vital signs. The readings are considered mild and will progress to moderate and then to extreme if immediate action is not taken.

It has been observed in NOC the sudden rise in RR is moving patient towards deterioration. Patient is currently facing tachypnea and moving towards hypoxia. Tachypnea and hypoxia affect the amount of oxygen needed by blood to transport to heart and other organs, and may cause multisystem failure and death (Duran-Bedolla et al., 2014). In this review, Duran-Bedolla (2014) illustrated and defined how oxidative stress and malfunctioning of mitochondrial receptors resulted in multi system organ failure during sepsis or other illness.

It is further noted that the patient has diabetes, which has been found to decrease the cellular response to low oxygen in blood (Pereira et al., 2011). In this article, Pereira (2011) has defined through research the effect of hyperglycemic state on hypoxia in diabetes patients under stress. Patient suffered a blunt trauma that combined with her comorbidity, further increased the chance of fatality.

Tachycardia is the earliest sign of cardiovascular compromise and heart failure (Guptaa and Figueredo, 2014). Guptaa and Figueredo (2014) explained in their review how tachycardia is a reversible sign that if left untreated can cause cardiac myopathy. In order to pump oxygen through the body, heart pumps faster. Abnormal heart rate i.e. greater than 100bpm is considered an initial sign of deterioration. This will progress to cyanosis which is the bluish colouring of fingers and toes due to deoxygenated blood (McMullen and Patrick, 2013). McMullen and Patrick (2013) in their research explained the occurrence of cyanosis and its effect on the body.

Joanna’s ISBAR shows GCS of 14 with confusion. There is a chance of slow deterioration in central nervous system followed by hypoxia. The patient is already facing confusion. This will be followed by stupor if left untreated. Systemic hypoxia and stupor may also lead to ischemic brain injury (Howard RS et al., 2011). Howard (2011) in his article explained how hypotension and hypoxia are few warning signs that may progress and lead to brain ischemia and unresponsiveness.

QUESTION 2:

COMPARISON BETWEEN PRIMARY AND HEAD TO TOE ASSESSMENT:

ABCDE assessment is also called primary survey and Head to toe assessment is also called as secondary survey.
Primary assessment is used to register patient’s immediate complaint and to rule out any immediate life threatening events (Thim et al., 2012). Head to toes assessment is a detailed assessment that is done later to gain an in-depth picture of the patient’s physical and mental functions.
Primary assessment is crucial for preventing patient deterioration (Considine and Currey, 2015). Secondary survey provides additional help and a broader picture for the medical team to assess the patient’s needs.
Primary survey has to be done at regular intervals. Secondary survey is done at desired interval to check the changes.
Primary survey mostly consists of body and organ function such as airway, breathing, circulation, mental status, as compared to secondary survey. Secondary survey includes physical outlook such as bruises, skin appearance, facial and body structure, abdomen and bowel system, mobility, hands and legs appearance.

PRIMARY SURVEY: (ABCDE APPLICATION)

This thorough approach is adopted to target the deteriorating patients and also aid in maintaining proper management of the problem.

Airway:

In deteriorating patients, checking airway is the most important step. If the patient is conscious, inquiring and checking the movements of chest and abdominal area is done. Patency is ensured.
Patient is observed for any signs of movement or obstruction by feeling the movement
Checking the color of skin or listening to breathing sounds through stethoscope.

Breathing:

As breathing is the initial indicator of deterioration, it is imperative that the medical professional should be attentive and monitor it at regular intervals

Note the rate, depth and rhythm of breathing for 1 minute and observe the oxygen saturation of the patient. If it is moving towards abnormality then inform the seniors
Note the color of the skin and breath sounds
Feel the thoracic cavity if it is symmetrical or not

Circulation:

Heart rate and blood pressure are one of the major indicators of deterioration and therefore significant

Check patient’s capillary refill, fever and urinary output
Observe blood pressure through manual technique
Monitor pulse rate through checking it manually

Disability

Assessing patient’s level of consciousness. We can use AVPU scale to check patient’s responsiveness
Measuring patient’s blood glucose level. This step is critical for diabetic patients
Response of patient’s eye to light
Using pain scoring scale to detect pain signs in patients

Exposure

Assess patient body for any signs of wound, bruises or rashes
Investigate and observe patient’s history, breathing charts and monitor reading to catch any sign of adverse event
Document every detail in patient’s clinical notes

SECONDARY SURVEY: (Head to toe assessment and application)

This assessment is a deep inspection of body parts that target every physical part and organ. It is required to develop first confidence with the patient and caregiver before proceeding with the procedure. Respecting their wishes and complying, will aid in effective communication and inspection (AngelaJones et al., 2015).

General status:

This step requires the nurse to observe patient’s behavior, hygiene, body position, patient mobility and speech.

Head, eyes, ear, nose, throat:

Inspection of head and eyes
response of eye to light
Inspection of mouth and throat for moisture and color. Dryness indicates dehydration

Neck:

Inspect for facial symmetry as it will indicate neurological condition

Chest:

Inspect the expansion and retraction of chest. We do this to check the shape as different diseases change the symmetrical shape of the chest (Waisman et al, 2012).
Auscultate for breathing sounds and other disturbing sounds. Note the heart sounds
Palpate for normal lung expansion

Abdomen: