Acute Nursing Care

Topics: Patient, Assessment, Blood pressure Pages: 12 (3757 words) Published: August 2, 2006
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 (O'Reilly 2003). Audible sounds, such as wheezes, stridor or gurgling are listened for and the lungs auscultated for breath sounds and bilateral air entry (O'Reilly 2003). Mrs Flower's respiratory rate of 32 breaths per minute indicates severe tachypnoea (O'Reilly 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 patient's 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 Flower's 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...
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