GNT1 - Task One
The case review presents a 73-year-old female patient who is brought to the emergency department after collapsing at her residence. Just prior to the incident, the patient is reported to have been acting “confused.” Upon arrival to the emergency department, the patient is having difficulty breathing with an increased respiratory rate and pulse. The nurse is unable to complete the initial examination before the patient becomes unresponsive and has increased work of breathing. At this point, it is necessary to active an emergency response team and begin advanced cardiac life support (ACLS) interventions. These interventions involve the initiation of an algorithmic approach to assessment and the initiation of emergency interventions necessary to stabilize the patient. A primary assessment of airway, breathing, circulation, neurological status and inspection of body must be initiated immediately. This assessment is rapid and requires little to no use of specialized technological tools. The case study indicates that patient “collapsed” in her backyard; therefore, cervical spine immobilization must be maintained at all times until the possibility of spinal injury has been ruled out. This rapid assessment begins with an inspection of the patient’s airway to ensure no obstructions exist. Possible airway obstructions include the patient’s tongue, loose teeth, foreign objects, vomit or blood. The airway must be cleared of any obstructions before proceeding with the assessment. The case study does not indicate the presence of any airway obstructions. Once the airway is deemed clear, an assessment of breathing occurs. This includes observing the patient for signs of spontaneous breathing, including rise and fall of the chest, rate of breathing, work of breathing and breath sounds. The case study reports the patient as both unresponsive and as having difficulty breathing. In an unresponsive patient, it is important to begin ventilation with a bag-valve mask using high-flow oxygen. It is possible that a more definitive method of airway management, such as endotracheal intubation, may be required. The patient is now assessed for circulation. This involves the palpation of central pulses, either carotid or femoral, assessing for strength and rate. Palpation of a radial pulse is consistent with a systolic blood pressure of at least 80 mmHg, which is adequate for short-term profusion to the brain and other vital organs. Other observations include skin color, temperature, moisture and capillary refill. The case study indicates the presence of a rapid pulse prior to the patient becoming unresponsive. In the absence of a pulse, chest compressions would begin immediately. Once airway, breathing and circulation have been assessed, a quick neurological assessment occurs. This includes determining the patient’s level of consciousness and assessing pupils for size, shape and reactivity to light. There are two quick methods for assessing the level of consciousness. The first is the AVPU scale, which is an acronym for alert, verbal, pain and unresponsive. The case study indicates the patient is unresponsive. The second is the Glasgow Coma Scale, which measures eye opening, verbal response and motor response. This scale is most commonly used when a traumatic brain injury is suspected, including stroke. Pupillary assessment is performed with the use of a penlight. In addition to noting size, shape and reactivity to light, it is also important to note if asymmetry of the pupils exists. Finally, the last observation assessment made is that of inspecting the patient’s body for any signs of obvious injury, including any head and/or pelvic injuries that may have been sustained in the fall. For an accurate assessment, the patient’s clothing must be removed. Once the primary assessment is complete, and all lifesaving interventions have been initiated, a more detailed technological assessment occurs. A 12-lead...
References: American Nurses Association. (ANA). (2001). Code of ethics for nurses with interpretative statements [PDF file]. Retrieved from http://nursingworld.org
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