ABCDE Approach in Clinical Emergencies for Instant Evaluation and Curing - Case Study Example

Prioritising Question 1 During the assessment, the nurse will use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to prioritise and care for the 5 patients. ABCDE approach is very useful in clinical emergencies for immediate assessment and treatment because it helps in improving outcomes by enabling healthcare providers to focus on the most life-threatening clinical conditions (Thim et al., 2012). Accordingly, to treat and care for the 5 patient, the nurse will focus on the patient with the most life threatening condition. In this case study, Steven will be the first priority. The patient had acute appendicitis and had an appendectomy and is complaining of abdominal pain and has temperature of 39.2° c. The pain and elevated temperature in an indication of an infection and such a condition can deteriorate very fast the reason the patient was given the first priority. If not treated fast, the patient can develop peritonitis in case the infection spreads to peritoneum and if treatment of peritonitis is not immediate the condition can deteriorate and lead to septic shock which is fatal (McFarland, 2011). As a result, the nurse should ass the patient’s level of pain and inform the surgical team to review the patient and prescribe an analgesic to relieve the patient’s pain. The nurse will also perform a full blood count and request for imaging to establish if the patient has developed infection. Peter, the patient who has cholecystectomy +3 (gallstonesremoval) and has had persistent epigastric pain for two day and complaining of nausea will be the second priority. The patient had an endoscopic retrograde cholangiopancreatography and thus the pain and nausea he is experiencing is as a result of this. ERCP is used in diagnosis and treatment of pancreatic duct conditions in including gall stones (Evans, 2012). The pain the patient is having could be as a result of pancreatitis because of the irritation of pancreatic duct by the ERCP device. Additionally, since the ERCP included removal of gall stones, the patient may be bleeding or perforation in the intestine could have occurred as hence the pain. The nausea the patient is experiencing could be due to the sedatives the patient was given during the procedure or the discussed complications (Evans, 2012). The nurse should inform the respective doctor as well as the medical team to review the patient to establish the cause of the pain and prescribe the appropriate painkiller to relieve the pain and antiemetic to alleviate the nausea. The third priority will be Phillip who was admitted for infective exacerbation of COPD. The patient is the third priority because COPD is normally accompanied by sudden deterioration of symptoms. For instance, the patient can suddenly experience shortness of breath and COPD can also cause further damage to the lung tissue. Additionally, deterioration of COPD can lead to high blood pressure within the arteries that supply blood to the lungs (Masuda, 2009). However, since the patient is due for IV hydrocortisone 100mg and Piperacillin with Tazocin IV, his condition is not that urgent because the medications are likely to control his condition but the nurse should monitor the respiratory rate of the patient closely to note in case the patient experiences shortness of breath and his condition deteriorates. The forth priority will be John who was admitted with chest pain via the Emergency department and is on IV heparin infusion and aspirin which needs to be kept between 50-75 seconds. The nurse needs to monitor the patient closely because anticoagulation drugs are high-risk medications and there is an extremely small window for therapeutic dosing where high dosage can lead to bleeding and low dosage can cause clotting. The patient is on heparin that needs close monitoring due to its narrow therapeutic index, elevated risk for bleeding and potential for heparin-induced thrombocytopenia (HIT) (Angelo, 2011). Therefore, the nurse should monitor the patient through head-to-toe patient assessments for potential side effects, as well as laboratory monitoring. The fifth priority will be Melinda who presented with sudden onset of severe headache. The patient’s CT scan revealed a Grade 1 subarachnoid hemorrhage from a cerebral artery aneurysm. Cerebral artery aneurysm is a localized blood filled balloon like swelling within the wall of a blood vessel (Tenner, 2010). The reason this patient is the last priority is because the aneurysm was treated successfully with coil at the radiology five days ago and also her GCS is 15 which is the normal range. Therefore, the nurse only needs to monitor the patient for any complication that might occur or in case the condition of the patient deteriorates. Question 2 In such a situation, the nurse should assess the patient and immediately inform the medical team and doctor to come review the patient because such symptoms may be as a result of bleeding or perforation in the intestines or an indication of side effects of sedatives that the patient was administered with during the procedure. The nurse should immediately make a telephone antiemetic medication order for the patient’s worsening nausea to control or reduce the patient’s worsening nausea in presence of an enrolled nurse or a registered nurse because she/he is only a new graduate nurse. Antiemetic medications are used in controlling and reducing symptoms of nausea and vomiting and also used in treating side effects of sedatives and anesthetics like the ones that this patient was administered with when ERCP procedure was being done (Evans, 2012). When informing the medical team and the doctor, as well as when making the medical order, the nurse should use ISBAR communication that will be very helpful to the nurse because it will provide the knowledge of prioritizing information during communication regarding the patient (ACSQHC, 2010). The nurse will first introduce him/herself and give the reason of communication and then provide the situation of the patient, which will be followed by the background of the patient and this, will consist of aspects such as status changes, presenting symptoms, admission date and such. The nurse will then provide assessment of the patient’s condition including the risks that the patient’s status presents and then make a recommendation on what needs to be done. This will ensure effective and immediate communication and hence ensure that the patient’s health and safety are not compromised (ACSQHC, 2010). Question 3 The patient’s APTT is higher than 150 and this shows that the patient is at risk of bleeding. Bleeding is a common side effect of heparin and in the patient can be presented in various ways including: epistaxis, gum bleeding, hemoptysis, hematuria, melena or hemorrhage. Basically, if bleeding in the patient is not diagnosied or controlled; it can cause cardiac tamponade or cardiovascular collapse for the patient. Therefore, the nurse needs to stop heparin infusion and only restart after 6 hours if the patient is no longer at risk of bleeding. If necessary, the nurse can administer protamine sulfate if the patient has major bleeding (Angelo, 2011). The nurse should monitor the patient closely for any sign of bleeding for instance the nurse can monitor hematuria by looking for blood in the patient’s urine whenever the patient goes to the toilet and also examining the patient’s gums to assess if there is any gum bleeding (Angelo, 2011). In addition as per the ward protocol, the nurse should obtain baseline labs, calculate and give initial bolus dose, order and assess anticoagulation labs and finally perform titration of heparin to therapeutic goal basing on the patient’s presentation and also on clinical algorithm. To successfully carry out the laboratory monitoring, the nurse should obtain and evaluate laboratory results after every 6 hours post a dose change until successive anticoagulation laboratory results are within target (Angelo, 2011). Question 4 Melinda is complaining of faint feeling on getting out of the bed and her blood pressure is 80/40 which means that she has hypotension. The patient has the faint feeling because according to the result of her CT scan, she had a small (grade1) subarachnoid hemorrhage from cerebral artery aneurysm which is bleeding within the brain and led to hypotension (80/40) which is contributing to the faint feeling (Tenner, 2010). The patient’s hypotension condition is due to side effect of Nimodipine 60mg a medication that the patient is currently taking. Nimodipine works by reducing the brain damage that might have resulted from the subarachnoid hemorrhage by narrowing blood vessels and hence reducing the rate of blood flow and thereby relaxes the narrowed blood vessel within the brain adjacent to the bleeding area facilitating eased flow of blood. The hypotension due to nimodipine has also contributed to the patient feeling faint (Tenner, 2010). The nurse should inform the doctor and the medical team in charge of the Melinda immediately regarding her blood pressure measurements and inform them what should be done. Since the patient had reveal cerebral artery aneurysm that is bleeding in the brain and also due to the effect of Nimodipine medication that the patient is taking, to ensure that the patient’s status does not deteriorate to a point of the patient losing consciousness, the nurse should closely monitor the patient’s neurological status as well as vital signs. The findings should be documented and the nurse should also inform the medical team on the findings. References Angelo, S. (2011). Anticoagulation Drugs: What Nurses Need To Know. Johns Hopkins School of Nursing. ACSQHC (2010).The OSSIE Guide to Clinical Handover Improvement. Sydney: Australian Commission on Safety and Quality in Health Care Evans, (2012). Complications of ERCP. Gastrointestinal Endoscop. 75(3). Masuda, H. (2009). Chronic Obstructive Pulmonary Disease in Primary Care. Melbourne: Sage. McFarland M, Witkin L, Nguyen T & Edward, G. (2011). Abscess After a Laparoscopic Appendectomy Presenting as Low Back Pain in a Professional Athlete. Sports Health. 3(1): 41–45. DOI:  10.1177/1941738110374637. Thim, T, & Henrik, N, Krarup & Lofgren. (2012).Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012; 5: 117–121. DOI:  10.2147/IJGM.S28478 Tenner S. (2010). Cerebral Artery Aneurysm. Philadelphia, Pa: Saunders Elsevier. Read More