Prioritizingand Providing Nursing Care - Assignment Example

Prioritizing Question 1 To prioritize and provide nursing care for the four patients, the nurse will use the Airway, Breathing, Circulation, Disability, Exposure, Fluids, Glucose (ABCDEFG) approach in prioritizing their care. This approach is extremely important in prioritizing nursing care because it assists in identification of the most life-threatening conditions and instituting treatment to correct them (Lees &, Hughes, 2009). When providing nursing care to these patients, the nurse will need to first assess and provide care to the patient with airway problem because untreated airway obstruction can rapidly result to cardiac arrest and can also affect vital organs (Munroe et al., 2013). In this case study, Clara in bed 3 will be the first priority because she has an airway as well as breathing problem as indicated by the vital signs such as SpO2-91% where  the normal SpO2 levels are around 97%-100% and RR-22bpm where the normal RR rates are 12-20bpm (Thim et al., 2012). The patient is an 84 year old patient admitted with left Lower Lobe Pneumonia. The nurse should ensure that there is an oral airway, oxygen as well as suction set up because the condition of the patient can deteriorate quickly and develop to cardiopulmonary arrest. The nurse will then assess the patients airway to determine if it is patent because partial airway obstruction can cause air hunger and fast breathing, sever airway obstruction can cause cyanosis even loss of consciousness while complete airway obstruction can progress to suffocation and death. The nurse should listen to noises because in partial obstruction air entry diminishes and it is noisy. Some noises can help localize the degree of obstruction. The nurse also assess if the patient has any signs of respiratory distress such as sweating and using accessory muscles of respiration. The nurse should also count the patient respiratory rate because rising respiratory rates indicate that the patient’s condition can deteriorate suddenly. Finally, the nurse should secure the patient’s airway and place her in an upright position to promote airway passage and reduce airway obstruction (Clarke, 2010). The second priority will be John in bed 4 because he has circulation problem. John was admitted with rapid atrial fibrillation (HR 152bpm) and had one episode of chest paid. The nurse should examine the patient’s skin color especially the hand and digits and see if the skin is blue, gray, pink or pale. The nurse should also assess the patient’s limb temperature by feeling his hands to examine if they are warm or cool because temperature can determine if there is poor blood circulation by determining the patient’s perfusion. The nurse should also measure the patient’s capillary refill time as well as count his pulse rate (Albert, 2012). The nurse should then look for other signs of poor cardiac output like decreased consciousness level. The nurse should then reassess the patient’s pulse rate and blood pressure regularly as well as keep on monitoring his vital signs. George in bed 2 will be the third priority. The patient had an ERCP and removal of gall stones x 3 after persistent epigastric pain for 2 days and is currently complaining of nausea and mild right shoulder tip pain. The surgical wound needs to be monitored closely to ensure that the surgical area does not get infected. In addition, the patient needs to be assessed to determine the level of pain and nausea as well (Yeh et al, 2008). The shoulder pain is a very disturbing problem in patients who undergo ERCP and it is caused by the trapping of carbon dioxide gas against the diaphragm (Jorgensen et al, 2008). The nurse should try to manage the patient’s pain by administering the appropriate analgesics as prescribed. In addition, the nurse should also inform the head RN and doctor regarding the patient’s nausea and pain so that the appropriate antiemetic and painkillers can be prescribed. Finally, the nurse will attend Catherine in bed 1. Catherine was admitted with acute appendicitis through emergency department. She is o NBM and has IV 0.9% Sodium Chloride infusing at 125mls per hour and is complaining of abdominal pain and has a temperature of 39.1°C. Intravenous Metronidazole 500mg TDS and PRN I.V. 1gm Perfalgan STAT has been ordered for the patient. The nurse needs to monitor her medications closely especially the drug infusion to make sure the IV line is running correctly and there is no sign of infection on the cannula site (Wilkinson & Treas, 2011). The patient’s temperature is 39.1°C is this is an indication that she may be having an infection and hence the nurse should do a full blood count test to establish is the patient has any infection. Lastly, the nurse needs to inform the doctor regarding the patient’s abdominal pain so the pain killers can be prescribed to relieve the pain. Question 2 The action that should be taken would be informing the physician or the members of healthcare team responsible for George’s treatment to take the appropriate action such as prescribing the patient antiemetic or reviewing and assessing the patient to find out if the nausea is as a result of post-procedures complications and side effects. This is because the nausea the patient is experiencing may an allergic reaction to the iodine-based contrast dye that is used during the medical procedure. In addition, some medications used during the procedures may be causing side effects that include nausea. Still, the patient having nausea is also an indication that the patient might develop post-ERCP pancreatitis which is typified by symptoms such as nausea and abdominal pains (Yeh et al, 2008). The nurse can also make an antiemetic medication order for the patient in order to reduce his worsening nausea. As Evans (2012) explains, the antiemetic drugs are useful decreasing nausea which is common after ERCP procedure due to the side effects of medications and sedatives used during the ERCP procedure. Similarly, the can place a nasogastric tube in case the patient’s nausea is not relieved. After informing the respective physician and medical team, the nurse should monitor the patient for any signs deteriorating condition. During communication with the physician, the nurse should state the patient’s situation which is nausea as well as her assessment results and explain the likely causes of the nausea as well as other background information as this will give the physician the adequate information to take the correct and timely action to prevent the patient’s condition from deteriorating further (Yeh et al, 2008). Question 3 The patient looks greyish in color and he feels cool and clammy and does not have a palpable pulse. These signs indicate that the patient might dead. Therefore, the nurse should conduct a comprehensive physical examination to ascertain if death has occurred or not. The first examination should show a deathly pallor especially on the lips and face as well as relaxed facial muscles. This causes drooping of the lower jaw as well as open staring eyes. In addition, the nurse should conduct further examination that should encompass: Palpation of all major pulses Heart and lungs auscultation for more than one minute Eyes’ examination for fixed dilated pupils and lack of corneal reflexes, cloudy cornea and no eye tension Examining the trunk to identify if there is presence of post mortem staining due to hypostasis Examining muscle tone for rigor mortis and confirming lowered temperature (Henry & Wilson, 2012). After confirming the death of the patient, the nurse should call a family member and deliver the message. The nurse should then begin providing nursing care which should include preparing him for family viewing, making arrangements for how the body will be transported to the morgue and ensuring that there is appropriate disposition of his belongings. The nurse should document valuables and personal effects and give them to the nominated family member. In case there is a social worker present, the nurse should engage one so as to assist the family through provision of support and information to the family as this will have a positive impact on the family (Ellershaw & Wilkinson, 2010).. The nurse also will ensure that the family is comforted and supported and that privacy is maintained. The nurse will provide personal care after death to preserve the appearance, condition as well as the dignity of the deceased. The body should be handled with dignity and respect. During the personal care, the nurse should talk to family to determine the needed special arrangements because at time the family may want cultural/religious rituals (Henry & Wilson, 2012). If the family members wish to take part in personal care after death, the nurse should prepare the family members sensitively for changes to the body and advise them accordingly to reduce risk from manual handling and infection-control issues. The nurse should lay the body on their back and straiten limbs if possible and place a pillow under the head and close the eyes through lightly applying pressure for 30 minutes. The mouth should be cleaned and dentures replaced (Henry & Wilson, 2012). The leakages from the oral cavity should be contained through suctioning and positioned. The body should then be cleaned and dressed suitably. The nurse should then ensure that there is clear identification of the deceased on the wrist ankle. As long as there is no expected leakage and no risk of infection, dress the body using a clean gown wrap it using a sheet. The nurse should then position the body in a way that the family can be able to hold their hand. The nurse should then prepare the environment by removing all distractions from the immediate area so as the family can view the body appropriately. Additionally, the bed should be lowered and enough chairs should be provided to enable family members to sit and touch the body easily. The nurse can then bring in the family members to the deceased and spend some time settling the family into the experience because some of them maybe anxious and terrified and hence settling them may calm and comfort them (Ellershaw & Wilkinson, 2010). The last step will include documentation. Accordingly, the nurse should document the time of death and record the name of the healthcare practitioner who pronounced the patient’s death. The nurse should also note if the death is referred to the medical examiner and if autopsy is being carried out. All postmortem care provided should be documented and also it should be noted if there was removal of any medical equipment or not.as mentioned before, all belongings and valuables belonging to the deceased should be documented and the name of the family member who took and signed the valuables as well as belonging list be documented. All belongings that were left with the patient should also be documented (Henry & Wilson, 2012). Documentation of the disposition of the body and the name of the patient along with the name, telephone and address of the funeral home or morgue should be done. The names of the family members who were there and viewed the body as well as the name of the family member who was informed about the death should be documented. Finally, the nurse should record any care and emotional support that was provided to the family members (Henry & Wilson, 2012). References Clarke, J. (2010). Nursing management: Upper respiratory tract problems in Brown, D. &Edwards, H. (2010). Lewis’s medical surgical nursing: Assessment and management of clinical problems (2nd ed.). Chatswood, NSW: Elsevier Australia. Ellershaw J & Wilkinson S (2010). Care of the Dying: A Pathway to Excellence. Oxford: Oxford University Press. Evans, (2012). Complications of ERCP. Gastrointestinal Endoscop. 75(3). Henry C & Wilson J (2012). Personal care at the end of life and after death. Nursing Times; 108: online issue. Jorgensen G, Gillies R, Hunt D, Caplehorn J & Lumley T. (2008). A Simple and Effective Way to Reduce Postoperative Pain after Laparoscopic Cholecystectomy. Australian and New Zealand Journal of Surgery. 65(7): 466-469. Lees L & Hughes T (2009). Implementing a patient assessment framework in acute care. Nursing Standard. 24, 3, 35-43. Munroe B, Curtis, K & Buckley. (2013). 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