➢ Using the ABCDE method to assess a particular patient.
➢ Managing the life-threatening issues before moving any other step of assessment.
➢ Establishing the point where you will require extra help so as to call for it early.
➢ Making use of all the team members so as to allow simultaneous series of interventions.
➢ Communicate effectively with the doctor in charge using SBAR.
Body
First steps
➢ To ensure personal safety, I wore gloves and an apron as appropriate (Dylewski, 2014).
➢ I observed the deteriorating patients in general to see his condition
➢ Since the patient was weak and awake, I asked him how he was feeling. Research shows that if a patient typically responds that means that he or she has a patent airway (Kalil, 2017). However, if the patient responds in short sentences, then it means that he or she may be having an issue with the breathing system (Lever and Mackenzie, 2007).
➢ I undertook these rapid look, listen, and feel tactics to the patient in approximately 30 minutes to as to ascertain whether we needed urgent additional help (Lever and Mackenzie, 2007).
➢ I went on to monitor vital signs by attaching a non-invasive blood pressure monitor, ECG monitor, and a pulse oximeter soonest possible
➢ I inserted the patient with an intravenous cannula so as to take a blood sample for further analysis by our laboratory department
Administration of the ABCDE Approach
i. Airway
Airway obstruction if untreated it may lead to hypoxia (Luo, 2013). Secondly, it may result in damage to the brain, kidney, heart, cardiac arrest, and in worst scenario cause loss of life (Richmond et al., 2008). With that in mind, I did the following activities:
a. Looked for any sign of airway obstruction
In the case of deteriorating patients depresses consciousness in many instances is the facts that lead to airway obstruction (Richmond et al., 2008). Additionally, the condition makes the patient to use accessory muscles of respiration. The patient also showcases paradoxical chest and abdominal movements. In advanced cases of airway obstruction the patient shows clear signs of central cyanosis while if there is partial obstruction the air entry is often noisy or diminished (Stucky and Kimmons, 2005).
b. Treated the airway obstruction with urgency
Since the patient under analysis had clear signs of airway obstruction I inserted him an oropharyngeal airway and when it failed I decided use of tracheal intubation (Stucky and Kimmons, 2005). I acted in this quickly because untreated airway obstruction can easily lead to hypoxemia or even the death of the patient.
c. Gave the patient oxygen at a high concentration
I gave the patient under analysis, oxygen at high concentration using a mask with oxygen reservoir because he had acute respiratory failure. In such cases it is always advisable to maintain an oxygen saturation of between 94% and 98% (Schrier, 2006). I also ensured that the oxygen flow was sufficient so as to avoid the collapse of the reservoir as the patient breathed in and out.
ii. Breathing
In the course of my immediate assessment of the patient’s breathing condition I diagnosed so as to treat immediately any form of threatening conditions such as tension pneumothorax, pulmonary oedema, and massive haemothorax. I did the following:
a) I looked, listened, and felt for the common signs that are related to respiratory distress. For example, abdominal breathing, central cyanosis, and sweating (Schrier, 2006).
b) I observed the rate of respiration to determine whether it was high, average, or low. An average rate is between 12 and 12 breaths per minute while a high one is that which is above 25 breaths per minute (Tarrant et al., 2016). Increase in breathing rate indicates that the patient condition may worsen (Tarrant et al., 2016).
c) I assessed the depth of each breath so as to establish whether the chest expansion was uniform.
d) I recorded the oxygen intake reading.
e) I listened to the patient’s breath sounds to confirm whether it was rattling or wheezing (Tarrant et al., 2016).
f) I percussed the chest to establish whether there were signs of pneumothorax (Lever and Mackenzie, 2007).
g) I auscultated the chest to determine whether there were signs of lung consolidation (Lever and Mackenzie, 2007).
h) I checked the position of the trachea so as to establish whether there was mediastinal shift (Bernstein and Lynn, 2013).
i) I felt the chest wall so as to detect crepitus or emphysema because they are signs of pneumothorax (Bernstein and Lynn, 2013).
iii. Circulation
Expert recommends that in all medical emergencies a nurse should hypovolemia as the leading cause of shock until proven otherwise (Kalil, 2017). At this level I did the following activities:
a) I looked at the color of the patient’s hands.
b) I assessed the temperature of the victim’s limbs by touching them to feel whether they were warm or cold.
c) I manually measure his capillary refill time by applying cutaneous pressure on a tip of the finger.
d) I assessed the state of the vein to detect signs of hypovolemia (Kalil, 2017).
e) I listened to the heart rate using a stethoscope.
f) I assessed the regularity of pulses.
g) I measured and recorded the patient’s blood pressure.
h) I auscultated the audibility of the heartbeat.
i) I investigated any sign of inadequate cardiac output.
j) I thoroughly checked the patient to identify any form of external bleeding.
iiii. Disability
Many factors cause a patient to get unconscious (Lever and Mackenzie, 2007). However, to ascertain the real cause of the affected the patient under analysis, I carried the following actions
a) Reviewed the ABCs but excluded hypotension and hypoxia to avoid making uninformed conclusions.
b) I checked the drug chart of the patient so as to identify reversible causes resulting from drugs earlier administered (Brijwal et al., 2015).
c) I thoroughly examined the pupils to establish their reaction to light, equality, and size (Brijwal et al., 2015).
d) I assessed the patient’s level of consciousness using a method known as AVPU.
e) I measure the degree of blood glucose so as to exclude hypoglycemia (Chendrasekhar and Ismail, 2013).
f) I nursed the patient in a lateral position so as to ensure that his airway was protected.
v. Exposure
a) I looked all over the patient’s body for any signs of injuries and rashes. That was when I noticed that he had undergone surgery a few weeks ago and the wound was not fully healed.
b) I checked the body temperature.
c) I cove
red him with a blanket for warmth and so as to respect his dignity.
SBAR Reporting
a. Situation
My name is Smith, and I am a nurse. A patient who is acutely ill was brought in the emergency ward number seven. The patient has signs and symptoms of general inflammatory response such as tachypnea, tachycardia, fever, and respiratory alkalosis. The patient had faster a breathing rate that was faster than the normal 20 breaths per minute. His name was John, and his home was four blocks away from the hospital.
b. Background
His medical record shows that he had a surgery a few weeks ago and the wound is still in the healing process. A few minutes ago, he became unconscious and unresponsive. I have also noticed that he is having difficulty when breathing.
c. Assessment
I am concerned that the patient is suffering from urinary sepsis as a result of the infected surgical wound that is slowly healing.
d. Recommendation
As I observed the patient, I noticed that he had additional signs such as dysuria, renal colic, flank pain, and renal angle tenderness. There was a dire need of administering so that to prevent further progression of the infection that could lead to the appearance of pulmonary edema with acute respiratory distress syndrome. That is why I recommend that you come and take a look at him straight away.
Conclusion
The Johns Model of Reflection
a. Scenario description
The significant advantage that I derived from the experience was that I got a first-hand experience in how to take care of a patient who needs emergency care.
b. Reflection
I was able to stabilize the patient. Hence, I saved a life.
c. Influencing factors
The factors that influenced my decision included knowledge acquired from nursing school and the instruction that I received from the physician in charge.
d. Room for improvement
In the future, I will use the knowledge that I acquired from the actions under analysis to take care of patients suffering from the same infection.
e. Learning
The situation influenced the level of self-awareness in the nursing field and made me a better nurse with more experience. your essay in here…