Implications of the Assessment Skills Based on Emergency Management - Assignment Example

Critically discuss "The implications of your assessment skills" Based on emergency assessment and triage Introduction Introduction: The term emergency management traditionally refers to care given to patients with urgent and critical needs. The philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be. Large numbers of people seek emergency care for serious life-threatening cardiac conditions, such as myocardial infarction, acute heart failure, pulmonary edema, and cardiac dysrhythmias. Apart from these, the Accident and Emergency Department also caters services of emergency management of trauma (Subbe et al., 2006, 841-845). Usually the management is given under the guidance of a physician or an emergency nurse practitioner. The emergency nurse has had specialized education, training, and experience in assessing and identifying patients' problems in crisis situations. Along with that, the nurse prioritises, monitors, and provides continuous assessment of the acutely ill or injured patients. The role does not end there. She has also the role to support and attend to families, to supervise allied health personnel, and to teach the patients and families in a care environment that is time-limited and highly pressured. Nursing interventions are usually accomplished in collaboration with or under the direction of a qualified physician or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data and current evidence for appropriate measures (Brook and Crouch, 2004, 211-216). The emergency health care staff members work as a team in performing the highly technical care for patients in an emergency situation, where taking an important decision matters, and research evidence can serve as a guide to make confident decision (Gerrish and Lacey, 2006, 3-15). The Nursing process in the Accident and Emergency provides a logical framework for problem solving in this environment. Patients in the A and E have a wide variety of actual or potential problems, and their condition may change constantly (Lattimer et al., 2004). Therefore, nursing assessment must be continuous, and nursing diagnoses change with the patients' condition. Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones; often, both independent and interdependent nursing interventions are required (Sakr et al., 2003). Therefore, it becomes pertinent to find out quickly which condition demands immediate care, so the patient may benefit from early and aggressive medical and nursing interventions, and the outcome of the condition is improved. The authors establish their point from references from already existent researches with evidence that early goal directed interventions in the A and E before admission to the Intensive Care Unit would significantly improve survival. The challenge to the A and E nurses are those of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. Emergency nurses spend many hours learning to classify different illnesses and injuries to ensure that patients most in need of care do not wait to receive it. Protocols may be followed to initiate laboratory or x-ray studies from initial encounter while the patient might wait for a bed in the A and E if indicated (Hucker et al., 2005). The laboratory investigations are important in the sense that a quick and accurate detection of the pathophysiologic process needs to be detected before it becomes irreversible due to progression of the pathology, and it can be intervened at the earliest by different measures such as fluid resuscitation, correction of acid-base balance, pressor support, arrest of haemorrhage, respiratory support, or a multitude of other nursing interventions (Leman et al., 2004). Nurses in the A and E collect crucial initial data: vital signs and history, neurologic assessment findings, and diagnostic data if necessary. The conventional protocol, however, considers physiologic markers such as heart and respiratory rates, urine output, and other markers that may prove to be misleading in many clinical situations that present in the A and E. In such conditions, these markers are less reliable since they change late in the course of the illness (Corbally and Gallagher, 2006). Early and aggressive medical intervention can be indicated by early detection of metabolic abnormalities in A and E triage by the A and E nurses, and this has been demonstrated to be providing survival advantage when these markers were used in association with conventional assessment parameters to assist in the identification of these patients. Furthermore, these parameters can be used to guide A and E resuscitation process on presentation and detection in the A and E before the patients were admitted to the A and E inpatient or Intensive Care Unit (Leman et al., 2004). The current provision for level I and level II facilities that would be required to manage these patients are highly inadequate (Ferns, 2005), and this indicates a major source implication for the National Health Service (Department of Health, 2007). If in the level I, there would be provisions for metabolic resuscitations beds in the A and E to employ these tests and to initiate early resuscitations based on these studies, it could be cost effective and would be able to reduce mortality. If this indicates a change is practice, the hospital authority or NHS may create provisions for these tests and the beds that were suggested, and the A and E nursing care team must be a part of it (Crouch, 1994). To begin with the findings of the research would need to be presented to the authority to convince them about the benefits of such a change. After appraising some studies, it can be safely said that many nurses who face critically ill patients on a daily basis during their duties, must be creating enough reflecting ripples, as this author is experiencing. There would be some who will have to come forward with the zeal to implement the evidence provided by research studies, and some leader among these nurses would emerge who could lead the process. All they have to do is to assess the patient carefully and record the data, which they are already doing (Cole, 2004). All recent research and government guidelines emphasises on the nurses' professional accountability and places decisions about the boundaries of practice in the hands of the individual practitioners. Although there are questions from different stakeholders, the authorities sees it as a major step forward where there lies opportunities for individual practitioners where practice may be developed in the accident and emergency setting in the interests of patient care (General medical Council, 2005). In the A and E setting, for a nurse to be able to exercise her assessment capabilities, it needs an eye for legal implications and training requirements. Prior to this, due mainly to staff shortage and increasing patient loads, many experienced nurses would assess and treat patients with minor injuries and illnesses. This was an approach that indicated that A and E nurses could extend their roles through experience and on-the-job training from more experienced colleagues. When a patient presents or when a nurse encounters a patient in the A and E, the patients will have a presenting complaint. An assessment skill comprises of not only the clinical physical examination skill, also it involves skills in communication and skills in keeping records. The presenting complaint begins the history of the patient surrounding the event of illness (Jarvis, 2005). The person who provides the history for the patient must be noted. The previous relevant history must be noted specially involving previous A and E attendance. It may appear that the family and social history is less important in the A and E setting, but it is also very important from the point of view of future care of the patient. Many patients take prescription and nonprescription medications, and a detailed history of such should be accomplished either from the old records or from the attendants. Enquiry about allergies to medications should be made and findings must be recorded (Jarvis, 2005). While the intent of the health services is to improve the care delivered in the Accident and Emergency, it is a fact that the attendances are continuing to increase. There is a perceived need for facilitate the services, and adding to skilled professional manpower seems to be the key for that. Seven out of nine national patients' charter standards are specific for A and E departments. This directs to the immediate need for the development of novel strategies of care for the patients within A and E. Although this is a need, other factors hinder the implementations of such policies (General medical Council, 2005). There has been Government Strategies to reduce junior doctors' hours leading to further contraction of professional manpower available in the A and E. Furthermore, publication of Scope of Professional Practice for nursing, midwifery, and health visiting, has opened an area of practice that validates the nursing assessment in the A and E setting. This means expansion of the role of the nurse in the A and E Department. The question, however, remains how skillful the nurses can become in such situations to be able to deliver effective care. It is important to note that during assessment both verbal and nonverbal communications are important. Assessment is done by application of cognitive skills through critical thinking and clinical decision making. In this particular scenario, the assessment of nurses is not expected to differ much from that of the doctors. Measurement of vital signs and a thorough systemic examination, guided by the history can at least differentiate the patients who can have adequate assessment by the nurse and who will need a doctor (Lont, 1992). A high blood pressure, respiratory distress, hypoxic state, jaundice, anemia, fever, can all be detected by assessment. Nursing assessment is also necessary to make a nursing diagnosis which is important in nursing care plan for each and every patient (Jarvis, 2005). The basic skills that the nurses must acquire for an effective assessment are inspection, palpation, percussion, and auscultation. The four principles of physical assessment are the following, inspection, palpation, percussion, and auscultation. Even though the nurses will not use all these techniques for every organ system, they should think of these four skills before moving on to the next area to be evaluated. An inspection may include observation of body habitus, general appearance, state of nutrition, symmetry, posture and gait, and speech. Palpation is the use of the tactile sense to determine the characteristics of an organ system. For example, an abnormal impulse may be felt in the right side of the chest that could be related to an ascending aortic aneurysm. A pulsatile mass in the abdomen might be an abdominal aneurysm. An acutely tender mass in the right upper quadrant of the abdomen that descends with inspiration is probably an inflamed gallbladder. Percussion relates to the tactile sensation and sound produced when a sharp blow is struck to an area being examined. This provides valuable information about the structure of the underlying organ or tissue. The difference in sensation in comparison with normal may be related to fluid in an otherwise nonfluid-containing area. Auscultation involves listening to sounds produced by internal organs. This technique furnishes information about an organ's pathophysiology. The nurse must learn as much as possible from the other techniques before using the stethoscope. This instrument should corroborate the signs that were suggested by the other techniques. Auscultation should not be used alone to examine the heart, chest, and abdomen. This technique should be used together with inspection, percussion, and palpation. Listening for carotid, ophthalmic, or renal bruits with a stethoscope can provide lifesaving information (Jarvis, 2005). A skillful nurse having an expertise in clinical assessment can be of help from many angles in order to provide innovative services to the clients. The most commonly identified benefit would be a reduction in waiting time. While crossing the traditional role boundaries, this expansion of roles of the nurses is not possible only with policy changes or with the need for inexorable escalation in patient attendance and medical staffing shortfalls. This needs education, training, and skill development of the nurses for assessment of these patients in the A and E. It is to be remembered that since assessment has been traditionally the roles of the physicians, there is a potential professional threat posed by the view that the assessment roles of the nurses is a form of medical substitution. However, some authorities think that this role of the nurses need close collaboration between the nursing and the medical staff, both at introduction and subsequent development (Department of Health, 1990). Taking the care of a patient presenting to the A and E with pain or fever, an adequate assessment is a must. To be able to adequately assess such patients and to ultimately be able to manage them, it needs a degree of autonomy and increased responsibility inherent in the role. The issue of education and training is a concern. However, throughout the United Kingdom, there are noted great variations in the length, content, and academic level of the courses. This means there would be a paucity of educational provision for development of assessment skills. In certain cases in the A and E, the cases presenting may be complex, and assessment in these areas by the nurses may be quite a difficult task fraught with chances of error leading to compromise in the quality of care. Assessment at higher levels needs higher levels of training and continued supervision to develop acceptable levels of competence in the A and E settings (Walsh, 1990). The assessment should be complete enough to identify unexpected conditions, while focused on areas likely to be contributing to or responsible for disease. Unfortunately, many A and E professionals are challenged for time and act quickly, performing abbreviated physical examinations while relying on laboratory and radiologic studies. Although laboratory backup is necessary, it is always best for the nurse to do a detailed, problem-oriented assessment with an eye to the fact that important findings are not missed (Davies, 1992).. While doing such assessments, it is important that the nurse also concentrate on the associated organ systems that may have role in the presenting illness. In fact, establishing a comprehensive differential diagnosis for that patient's complaint and examining areas of the body that may contribute to the condition may allow the A and E nurse to prioritize the likelihood of other diagnoses causing the symptoms (Jarvis, 2005). While assessing the general appearance may reveal the most important elements of an illness. With experience, even a nurse can have a reasonably accurate idea about the illness. Vital signs are important for all A and E patients. A complete set of vital signs should be obtained and repeated during the A and E visit and stay. Often, the vital signs are obtained in triage and not repeated until many hours later when patients are placed in examination rooms. Many A and E have policies that vital signs must be repeated for patients in the waiting room. This is a wise strategy, even though abnormal vital signs may not require action. It is at this point in assessment, the nurses may play very vitals roles in the care of the A and E patients (Mallet and Woolwich, 1990). Nurses who have expanded their knowledge and skills to be able to perform an assessment in a very busy scenario like this, where staffing, perhaps, is the biggest problem of all, can really add to the service with no only skills, but also with care, compassion, and loyalty. Many actions in the A and E setting can be performed by the skilled nurses, and studies have demonstrated encouraging results (Pickersgill, 1996). In many cases, this implies reduction in waiting time, full coverage of triage by the nurses, at the very least review of one complete set of appropriate vital signs on every patient, and addressing each abnormal vital sign or considering why it was abnormal. These tasks were previously undertaken by the medical staff, now a large chunk of it is being carried out by the nurses (Jarvis, 2005). In terms of this role expansion of the nurse within A and E Department, there has been considerable controversies, and there is a continued debate as to whether these changes are appropriate in order to improve care in the A and E. Nurses can be skilled enough to exercise these extended roles, which involve tasks as simple as rechecking the vital signs. The scenarios may include heart rate in a patient with ACS or acute myocardial infarction, the respiratory and heart rates in patients with breathing difficulty, or the temperature of a child who experienced a febrile seizure (Solomon, 1990). However, most of the health authorities control the nurses' activities by established protocols. Nurses recognise that in an A and E situation, nursing practice must meet the needs of the patients first. In some cases, they need to take courses on physical examination and assessment in order to achieve certificates of competence. The Scope of Professional Practice highlights the need for nurses to have a broad area of knowledge and skills to meet the demands of the society (Department of Health, 1989), and therefore, they must demonstrate continual striving for knowledge and skills to provide safe and competent care delivery that is "sensitive, relevant and responsive to the needs of individual patients" (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), 1992). This is one of the six principles of professional practice. In triage, for example, it should be necessary for them to identify which patients, they would not be able to handle or assess appropriately. This means they need to recognise the personal limitations of skill and knowledge where their assessment role in the A and E must maintain continuity and safety of patient care (Tingle, 2002). Since the Code of Professional Conduct for nurses also highlights accountability of practice within standards of practice and care (NMC, 2006), now the nurses can identify the areas of benefits to the patients where they can use their skills. Since care and treatment would need assessment as the very first step, this should conglomerate with the UKCC principle that the nurses even in A and E while doing assessment as a part of their extended role must adhere to the safe standards of care and competence and must gain appropriate experience and education prior to practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), 1992). It is to be remembered that at any given point in time during the care in the A and E, nurses must be able to delegate work, and they essentially are parts of a multidisciplinary team. In the A and E, one of the most important consequences of nurses' assessments is advancement of nurse triage. Triage is defined as assessment of patients on arrival to prioritise care. In this system the priority 1 patients would need immediate attention, priority 2 must be seen by the medical staff within 1 hour of arrival, priority 3 can safely wait up to three hours, and priority 4 upto 4 hours have been assigned (Blythin, 1988). This system, as evident, would permit life-saving measures, initiation of diagnostic investigations, first aid as appropriate for individual cases. In many cases, this waiting can become very tedious, and many such cases can be effectively assessed and treated by the nurses (Denner, 1995). In addition, nurse-delivered assessment and care early on can alleviate anxiety and frustration by being prompt and by providing information to the relatives and friends of the patients. Even if this may not provide sufficient care, an accurate assessment can make the best use of resources available in the A and E by directing the patients to the most appropriate care area. Quality of care requirements recommends immediate assessment of the patients just on time of arrival. Although there are criticisms as to how it can be immediate given the current stature of services in the A and E, as an alternative it has been suggested by many practitioners that the best would be to undertake triage before registration of the patient, in which the triage nurse will execute a preliminary assessment of the patient near the waiting area (George et al., 1992). Just being a nurse would naturally not serve the purpose, the nurse must be skilled enough to undertake the assessment. The charter standard requires rapid and appropriate care to the A and E patients, and the nurse who performs assessments as a triage nurse would thus have responsibilities to record any assessments made in the triage area. However, on the other hand, some authors stress on the fact that it can take up to 10 minutes to document full triage assessment including history and physical assessment, which may deter the achievement of patient standards in the triage (Williams, 1992). A complete physical assessment includes a general survey; vital sign measurements; assessment of height and weight; and physical examination of all structures, organs, and body systems. It is very important to establish a baseline. In the A and E setting, often a focused physical assessment zeros in on the acute problem with assessment of only the parts that relate to the presenting problem. It is usually performed when the patient's condition is unstable, as a follow-up to a complete assessment, or when the staff is pressed for time (James and Pyrogos,1989). The focused physical assessment consists of a general survey, vital sign measurements, and assessment of the specific area or system of concern. It also includes a quick head-to-toe scan of the patient, checking for changes in every system as they relate to the problem at hand (Jarvis, 2005). This scan may reveal associated problems and help determine the severity of the problem. The physical assessment techniques used by physicians and nurses are essentially the same, but some critical differences do exist. These differences are defined by the focus and scope of nursing and medical practice. While the techniques are similar, the underlying rationale differs. Nurses must remember that nurses must diagnose and treat not only the symptoms of the disease, but also the patient's response to a health problem (Edwards, 1994). In this context, it has been argued that there might be difference between a doctor assessment and nurse-delivered assessment due to academic leverage. Studies have shown that within the limitations of academic abilities, the nurse-delivered assessment provides equivalent diagnosis in comparison to the doctors. At least, studies have shown that nurses can deliver diagnosis and treatment of minor injuries, referral to other health professionals, and health promotional activities (Brook and Crouch, 2004). Conclusion In conclusion nurses providing assessment is a matter of skill and academic learning. If nurses follow the professional standards of care within the A and E, these assessment skills have many implications. This would lead to earlier assessment, treatment, and discharge of some patients without the need for referral to a physician who can devote his time to more serious patients. This would lead to a more effective and satisfactory care for the patients in triage with resultant reduction of waiting time for some patients in certain categories. This could also lead to earlier initiation of diagnostic tests in some patients. Since nurses bank on health promotion, this could also lead to improved counselling and health promotion. 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