Discuss about the Management of Critical Illness for Neurological Systems.
Critically ill patients normally have altered psychological states and this puts them at a huge risk of experiencing deteriorating conditions. According to Subbe & Welch (2013), these deteriorating conditions gradually develop over numerous hours. The conditions can be suspected if abnormal vital signs start showing in the patient. These abnormalities start showing once the respiratory, cardiovascular, and neurological systems start failing (Tinker & Rapin, 2013). It is important to detect these psychological abnormalities soon enough to prevent the escalation of the condition into a more critical situation. A nurse is the most suited individual when it comes to the observation and assessment of the patient. The nurse then intervenes to prevent health deterioration (Silva et al. 2015).
The number one priority for nurses and health practitioner is the safety of their patients especially the critically ill patients. Morton, Fontaine, Hudak, & Gallo (2017), ascertain that it is the responsibility of the nurse to detect a patient’s worsening conditions and intervene promptly to prevent unintentional harm to the patient. A health practitioner needs to observe and document the patient’s physical conditions that may cause hemodynamic instability. An effective nursing observation is, therefore, vital when it comes to the identification of any signs and symptoms of medical. (Michelle Aebersold & Dana Tschannen, 2013). The aim of this essay is to discuss a nurse’s role in efficient patient care. The essay further addresses any potential complications that Mrs. Beverley Smith might encounter due to her conditions. We will then analyze the possible interventions that the nurse can use to counter Mrs. Smith complications.
Nurses have become more focused on recognizing and responding to patients’ deteriorating health conditions in the recent past. A patient’s declining health conditions may in some cases fail to be recognized early enough to enable prompt intervention. This failure can escalate to critical illness if a response is not initiated soon enough (Douw et al., 2015). Below are the methods of assessment used to recognize declining clinical conditions.
Patient assessment is very significant in identifying the deteriorating clinical conditions of the patient. It enables the nurse to identify the worsening health conditions in a timely manner and respond to them appropriately (Tinker & Rapin, 2013). Observation and recording of the vital signs such as the rate of heartbeat, temperature, respiratory rate, and blood pressure are important in assessing the patient and recognizing deterioration (Curry & Jungquist, 2014). Studies reveal that alterations in the vital signs of the patients are enough indicators of declining health conditions. There are two types of assessment that include the primary assessment and the secondary assessment.
Primary assessment is used during the initial stages of assessment. It can also be referred to as the ABCDE approach that means the Airway, Breathing, Circulation, Disability, and Exposure approach (Munroe, Curtis, Considine & Buckley, 2013). The primary assessment has several aims that include saving lives, breaking down complicated clinical situations into ones that can be managed with ease, granting the healthcare providers adequate time to develop a final diagnosis and treatment plan, and serving as an assessment and treatment algorithm (Munroe et al., 2013).
The letter A is an acronym for Airways. It requires a nurse to assess and treat the obstruction of air. Obstruction of air is either partial or complete. Partial obstruction is characterized by noisy breathing, difficulties in breathing, and a changed voice. A chin-lift and a head-tilt maneuver are used to remove airways obstruction. According to Odell (2015), failing to treat air obstruction may lead to reduced levels of partial pressure of oxygen and oxygen saturation. From the case study that we are presented with, Mrs. Smith’s oxygen saturation is 89%. The normal oxygen saturation, however, is 95-100% (Odell, 2015). This situation may, therefore, prompt the attending doctor to add Mrs. Smith more oxygen.
An assessment of her breathing must be assessed to ensure that it is sufficient. This is represented by an acronym B. This assessment is used to inspect the respiratory rate, movements of the chest cavity, and the value of SpO2. From the presented scenario, we can notice some abnormal readings such as SpO2 of 89% and respiratory rate of 32 breaths per minute. As Adam (2017) confirms, broken ribs may incapacitate the lungs and cause cyanosis which results in inadequate oxygen transfer in the body. An assisted ventilation may, therefore, be recommended.
Circulation represented by C is the next step in primary assessment. This assessment is used to inspect the pulse rate and the blood pressure. It may be necessary to perform skin inspections to notice any symptoms of poor circulation. A blood pressure of 95/50 mmHg may be a sign that Mrs. Smith has hypotension. The patient should, therefore, be placed in a supine position before the nurse can obtain an intravenous access to infuse saline. Hypotension is one of the indications of poor blood circulation in the body (Brown, Edwards, Seaton & Buckley, 2017).
The next step in the primary assessment is D which is an acronym for disability. It is used to assess the level of consciousness of the patient (Adam, 2017). An assessment should be done to confirm whether Mrs. Smith is alert, voice responsive, pain responsive, or unresponsive. Acronym E represents exposure which is commonly used to inspect the body temperature. A tympanic temperature of 37.8 is slightly higher than normal. A thorough physical examination should be used to assess Mrs. Smith or any signs of bleeding or trauma (Vaughan & Parry, 2016). There are two other steps represented by F and G. F is used to assess the fluid balance. Mrs. Smith has a reduced urine output as revealed by the case study. Acronym G stands for glucose and it is used to assess the blood glucose level.
Secondary assessment includes an assessment of the head, thoracic region, abdominal region and long bones. Brown et al. (2017) ascertain that the physician is required to observe the face and ears of the patient for any kinds of abnormalities. An observation of Mrs. Smith lips may also be important to identify any symptoms of cyanosis particularly due to the fact that she has fractured ribs which may incapacitate the lungs.
The next step is the assessment of the thoracic cavity. During this assessment, the practitioner checks whether chest expansion is symmetric or asymmetric. According to Vaughan & Parry (2016), asymmetrical movements of the chest may be an indication of fractured ribs like in Mrs. Smith’s case. A suitable intervention is then initiated post this assessment. The next step is the assessment of the abdominal region which is done to check for any signs of wounds, injury, and bruises. The nurse can easily notice the large skin tear on her right arm during this assessment. Finally, the long bones are assessed to check for any signs of swelling or discoloration (Vaughan & Parry, 2016). Discoloration may be due to of cyanosis.
The revelations from the case study indicate that Mrs. Smith fell and fractured her ribs. The nurses recognize her deteriorating clinical conditions upon her admission to the hospital. The nurses make several observations that include a blood pressure of 95/50 mmHg, a pulse rate of 110 beats per minute, a respiratory rate of 32 breaths per minute, and a tympanic temperature of 37.8º C. Furthermore, she has an indwelling catheter in-situ. An assessment of these observations indicates that Mrs. Smith’s condition is crucial and it may lead to several other complications. Below, we will discuss some of the potential complications.
Hemodynamics is common during intra-hospital transfer of the critically ill patients like Mrs. Smith and it should, therefore, be handled with extreme care. Normally, when a critically ill patient is transferred from one section of the hospital to the other, their blood pressure may drop substantially. This decrease in the blood pressure may be accompanied by an increase in the rate of the heartbeat of the patient. Morton et al. (2017), additionally confirms that the use of an indwelling catheter can contribute to hemodynamic complications.
From Mrs. Smith’s assessment, we are informed that her blood pressure is 95/50 mmHg which is extremely low when compared to the normal blood pressure. If we compare her pulse rate with the normal rate which is 60-100 beats per minute, we realize that her pulse rate is slightly higher at 110 beats per minute. An assessment of Mrs. Smith’s respiratory system reveals that the bilateral entry of air has been reduced in addition to having an indwelling catheter. She is also on a cardiac monitor that helps in checking the rate of her heartbeat.
The above assessments prove the possibility of complications due to hemodynamics. A postoperative intra-hospital transfer causes cardiac instability among the critically ill patients. This is enough to establish that Mrs. Smith is at a risk of encountering a hemodynamic complication.
Using an indwelling catheter for extended periods of time is a major cause of Catheter-Associated Urinary Tract Infection (CAUTI). This infection is one of the most common complications. This complication due to CAUTI may result in increased septicemia, urosepsis, and mortality. According to Nicolle (2014), catheters act as an ideal environment that enhances the growth of bacteria. This is so because the biofilms of the bacteria adhere to the surfaces of the catheter system. After the insertion of the indwelling catheter into the body, bacteria quickly grow in colonies that rapidly adhere to the walls of the catheter system. Chenoweth & Saint (2013), confirm that the peri-urethral region is full of numerous bacteria and these bacteria main gain an access into the urethra at the time of the insertion of the catheter. It is also important to note that the inadequate drainage of urine may cause urine stasis. This urine stasis increases the risks of having bacteria in the urine thus increasing the possibilities of having UTI. Nicolle (2014), further adds that the presence of the catheter may cause mechanical irritation that may further encourage the growth of bacteria around the catheter region.
The bacteria responsible for CAUTIs may be introduced into the urinary tract through either intraluminal or extra-luminal means. Intraluminal contamination occurs as a result of bacteria traveling from a drainage tube, a contaminated catheter, or drainage bag. Extra-luminal contamination, the other hand, may result from the insertion of a catheter that may have been contaminated from another source. Extra-luminal contamination is the leading cause of bacteria causing CAUTIs among women. The bacteria can travel through the catheter to the bladder within 1 to 3 days (Meddings et al., 2013). The main symptoms of catheter-associated urinary tract infection are fever and confusion.
This condition may result from the body’s response to chemicals that have been released into the bloodstream to fight a bacterial infection. This complication is life threatening because it can proceed to a septic shock that causes dramatic drops of the blood pressure that may lead to death (Adam, 2017). From an assessment of Mrs. Smith, we notice that her pulse rate is 110 beats per minute. Additionally, her respiratory rate is 32 breaths per minute. Furthermore, the urine output is extremely reduced and her blood pressure is very low at 95/50 mmHg. These revelations are all possible signs of sepsis that is normally characterized by a reduced urine output, a respiratory rate above 20 breaths per minute, a pulse rate higher than 90 beats per minute and an extremely low blood pressure (Adam, 2017). The reduced blood pressure may lead to a septic shock.
Mrs. Smith could also possibly suffer from cyanosis from the revelations presented in the case study. Cyanosis is defined as the bluish discoloration of the nails, skin, and the mucous membrane. According to McMullen, & Patrick (2013), this condition is caused by the lack of adequate transfer of oxygen to the body organs. We are presented with a scenario where Mrs. Smith is said to have suffered a fall in the garden and broke four of her ribs. These fractures may incapacitate the lungs thus preventing the lungs from expanding competently which may lead to low oxygenation of blood in the blood vessels. There is two types of cyanosis namely central and peripheral cyanosis (McMullen, & Patrick, 2013). A patient suffering from central cyanosis can easily get an infection of peripheral cyanosis.
An oxygen saturation of 89% that is exhibited by Mrs. Smith is considerably low when compared to the normal range of oxygen saturation. As a result, the supply of oxygen to her body organs is inefficient leading to the circulation of blood lacking enough oxygen that is characterized by a bluish color. This may cause a development of a bluish discoloration of the lips, skin, the mucous membrane, and nails which are the signs and symptoms of cyanosis.
Proper nursing interventions are very important in preventing the aggravation of the complications mentioned above. These interventions guarantee the provision of quality patient care and at the same time prevent the decline of the clinical conditions of the patient. Below, we will discuss some of the best nursing interventions that can help in addressing complications in critical illness.
Permanent or temporary pacemakers are implanted to help in addressing hemodynamic complications. As Stolic (2013) affirms, a nurse should possess enough knowledge and skills to appropriately place this device. Additionally, the nurse must be knowledgeable enough on matters concerning asepsis, and the monitoring and care of a patient undergoing this invasive procedure (Stolic, 2013). Furthermore, the nurse must be aware of any complications that come with this invasive procedure including an accidental puncturing of some vessels, infections, mechanical failure like battery failure of the pacemaker, and bleeding (Fowler et al., 2014). The available types of pacemakers include the single chamber, dual chamber, and biventricular pacemakers.
Routinely changing the indwelling catheter at intervals of 4-6 weeks is recommended to help in preventing Catheter-Associated UTI. This process is better than the habit of only changing the catheter when it blocks because it produces better results (Meddings et al., 2013). Additionally, education of the nurses and other staff is necessary for the proper handling of the catheter (Chenoweth & Saint, 2013). Through this education, the nurses get the necessary skills required routinely check the catheter and thus prevent or reduce the possibilities of CAUTIs.
There are three approaches that have been recommended by the CDC to help in preventing infections that may lead to sepsis. Under the advisement of the doctor, it could be important to get vaccinated against flu and pneumonia that are considered as potential infections. Additionally, as a nurse, I have to ensure that the wound on Mrs. Smith’s right arm is clean to prevent infections (Adam, 2017). Furthermore, I must stay alert to any symptoms of sepsis such as a rapid heart rate, confusion, fever, chills, and rapid breathing and recommend immediate medical attention.
Cyanosis, on the other hand, may require surgery as a corrective mechanism. Sometimes, the nurse is advised to place the nurse in a continuous oximetry. This intervention is important in detecting the deviations in oxygenation (Wang, 2015). The normal operation of the body is sustained by oxygen saturation above 90% and it is thus important that the level never falls below 90. Furthermore, it may be necessary to prepare the patient for intubation. Mechanical ventilation and intubation are important in maintaining sufficient oxygenation and ventilation which ensures that an artificial airway is placed and maintained effectively (Tsui, Chen, Zhou, Hai & Wang, 2015).
Conclusion
Extensive care is a major necessity for the critically ill patients due to their high risks of experiencing complicated deteriorating conditions. These declining conditions are characterized by abnormal vital signs that may involve failing cardiovascular, respiratory and neurological systems. It is thus important for the nurses to observe and assess these signs in order to prevent worsening conditions of the patients. After an effective observation and assessment, the nurse can then make informed recommendations to ensure patient safety. Early recognition and prompt response to the deterioration of clinical conditions are vital in the nursing practice. The assessment of patients which includes, primary and secondary assessments help in the recognition of the deteriorations. Failure to recognize the declining health conditions and promptly responding to them can lead to other complications such as sepsis, cyanosis, CAUTIs, and hemodynamic complications. Appropriate nursing interventions can, however, prevent or reduce these complications.
References
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