Introduction
This essay is focused on the signification of health evaluation throughout the nursing procedure for a circumstance of patient (Mr Lee) who identified as having severe exacerbation of COPD and communicate how health analysis and emergency assessment help to plan a suitable nursing look after Mr Lee.
Background
Firstly, let's describe of Mr. Lee's health position.
Mr. Lee, aged 70, graduated from high school, retired. He have a boy and coping with wife and child. He had smoking habit (2 packages / day), but have been quit just lately. He also has drinking behavior (2 beers per week). He has allergic record of medication - Sulfonamides.
For days gone by background, Mr. Lee got myocardial, hypertension, left-sided heart and soul failing and fractured ankle. He also recently diagnosed with emphysema.
Mr. Lee accepted clinic with wheelchair at 23:30 hour on 23 Jan 2014 by grievance of increased cough and laboured deep breathing at home for past 24 hours. Pain ranked 4/10 (10 has been the most severe) with coughing and mucus sputum. Dyspnoeic respiration, breath sounds listened to on the bilateral lung field.
Vital signs checked out: temp 37. 3 Ж, pulse 90/ min, respiration 22 /min, blood circulation pressure 130/84 mmHg, SpO2: 95% on room air. Urine test outcomes normal.
General condition reasonable and conscious, feelings stable but demonstrated anxious and case had insomnia. Mr. Lee is obese: BW 84kg, Elevation 1. 6m (BMI 32. 8), he also offers oedematous on both ankles (size ++). His perspective and reading are normal.
Mr. Lee speaks Cantonese with clear communication. Desire for foods normal with denture which placed by patient, special diet: low sodium 4g should get to patient. Reduction is normal, colon pattern usual habit once per day. For the ability to move part, Mr. Lee ambulates separately with fairly stable gait. He didn't have impairment but need to assist the self-care ability.
Medical orders
At 01:30 of 24 Jan 2014 MO (Dr Chow) went to see Mr. Lee and approved some medical orders as below:
Prednisolone (steroid, 80mg po daily) improve respiratory function and oxygenation by reduce inflammation. However sever adverse effect may occur by taking dental steroids, such as hypertension, water retention, GI upset, restless etc. Nurse need to determine and close screen BP, in/out put, sentiment and give low sodium diet for patient.
Due to Mr. Lee have MI background, Aspirin (Salicylate, 80mg po daily) prescribe for inhibit platelet aggregation avoid MI relapse. Nurse need to examine coagulation function and liver organ function.
Prescription of two bronchodilators: Atrovent (2 puffs t. i. d. ) and Ventolin (2 puffs q6hr prn) are for COPD treatment by make bronchial easy muscle rest. Nurse need to evaluate the technique of inhalation and difficulty breathing.
Furosemide (diuretic, 40mg po daily) prescribe for removes the stimulus of sodium, chloride absorption because of Mr. Lee has oedematous on both ankles. This medicine causing a profound upsurge in urine output, Nurse need to assess the in/result balance and electrolyte level.
Metoprolol (Beta-blocker, 50mg po daily) leading to vasodilation to take care of hypertension and prevent coronary attack. Nurse need to assess the BP and heart rate before given.
Mr. Lee has left-sided heart failure history, MO prescribes Digoxin (cardiac glycoside, 0. 125mg po daily) which help maintain normal heart tempo and improve blood flow. Nurse need to examine the apical rate make sure >60/min before given.
To make sure the above drugs are safeness administer to Me. Lee, not only spot the special precautions of every drug express as above and apply three check five right in supplying medication, nurse also should give assessment for patients' health background especially allergy record; general study such as essential indications q4hr and p. r. n. , I/O graph; physical analysis e. g. respiration style and follow lab results (CXR, CBP, R/LFT, ABG, Urinalysis), assess and identify any unnatural finding before medicine given, examine the drug efficiency and side effect after receive drugs.
Oxygen therapy
Except oral medicine, Dr Chow also prescribes oxygen to Mr. Lee with maximum 4L/min to keep pulse oximetry90%. During administering air, hanging notice near Mr. Lee, let everyone know he's on oxygen remedy and the movement rate. Nurse should be understanding that COPD patients can cause respiratory system depressive disorder or acidosis (pH<7. 35) when receive incorrect level of oxygen. Nurse must determine the medical prescription is safe and appropriate.
Nurse should ensure the setting up of air delivery is soft, on the right type i. e. low-flow devices; and method i. e. nasal cannula or simple face mask.
Assess and screen pulse oximetry level and respiratory rate carefully. Keep perspective observation of demonstration of Mr. Lee such as SOB. Follow the medical review and the ABG consequence which may have an effect on the need and level modification of oxygen.
Assessment of SOB
Base on the principle complain of laboured breathing for Mr. Lee, nurse need to pay more attention on his professional medical demonstration. If patient battling short of breath (lack of oxygen and/or excess carbon dioxide in the blood) medical indications include: respiration rate become faster and shallow, tachycardia, struggling to speak long sentences, cyanosis, use accessory muscles of respiration. Patient also may have chest pain or getting confused.
Besides, nurse can apply diagnosis tool 'COLDSPA' requesting the symptoms of SOB as below:
Character: Ask Mr. Lee to describe the difficulty respiration. Onset: Ask whether the onset of difficulty deep breathing is rapid or progressive. Location: Ask have chest pain or not and the manifestation and fixed or moves. Length of time: Ask how long the SOB will last, does it appear when walk or doing activities. Seriousness: Ask how much it bothers Mr. Lee. Structure: Ask what cause SOB being better or worse. Associated factors: Ask will there be any symptoms arise with it and does indeed it impact patient.
Physical assessment also can use to determine SOB includes four parts:
Inspection to provide observation of skin area (shin pores and skin, cyanosis), body weight (fat, oedema), breathing style (faster respiratory rate, using accessories muscles), chest wall structure (barrel breasts).
Palpation mainly concentrate on the degree of growth of upper body, COPD patient may symmetrically reduced lung expansion.
Percussion which to tap the lung and produced tones. Different types of sound mean the chest filled up with air, substance or sturdy. Mr. Lee with SOB may have filled with air in the lung, the tapping audio will be hyper resonant.
Auscultation is use stethoscope to pay attention the audio of respiration. Mr. Lee with SOB, the breath sound would be wheeze and crackles.
Nursing action on N shift
Base on the assessment, the nurse should keep close observation of Mr. Lee scientific demonstration, pulse Oximetry and essential sign monitoring. Give Ventolin puff if patient SOB. Arranged NS stop for used. Chart I/O for the liquid balance. Pend investigations such as CXR and blood taking as quick as possible.
Important information hand over to A transfer nurse
The information of Mr. Lees' health record, general review and physical analysis and the nurse action done at night switch should be give to A switch nurse. Also informed the nurse that Mr. Lee dyspnea during the night, advise chasing laboratory results, suggest doctor order sputum ensure that you Peak circulation rate checking.
Important medical condition identification
To identify the main issue of Mr. Lee, nurse need to compare the objective and subjective data of the below groups.
Oxygen: (subjective data) Mr. Lee grievance dyspnoeic gradually, increase coughing with mucus sputum, labored breathing at home 24hours. Record of smoking 2 packs/day, quite just lately. (Objective data) Mr. Lee diagnosed severe exacerbation of COPD, GC fair, dyspnea during the night shift, pulse Oximetry from 95% reduce to 88%, Heart Rate from90/min increase to 110/min and Respirations are difficulty at 30/min with right lower lobe crackles and wheezing bilaterally.
Fluid (subjective data) Mr. Lee have denture kept by himself, drink 2beers/week. No complaint of eating and drinking, (Objective data) He is fatness with BMI 32. 8 excessive level, there also oedematous on both ankles. At night Mo prescribe Furosemide (40mg Po QD) and provide special diet (low sodium 4g). His I/O is positive balance, NS block set up and voiding per urinal.
Safety of physical and internal (subjective data) Mr. Lees' eyesight and ability to hear are normal, non impairment but pain rated 4/10 (10 is being the most severe) with cough. He also boasts insomnia. (Objective data) Mr. Lee doesn't tolerate get up to restroom need to use voiding per urinal. For range of motion, he ambulates independently with fairly steady gait but self-care ability need helped. He has hypertension background BP 130/84, Metoprolol (50mg po daily) prescribed for him. His mental stable but feeling shows restless. He suffers dyspnea at night with Pulse Oximetry 88%, Fast HEARTRATE 110/min and RR 30/min.
Comparison with three organizations' data, the most important health problem for Mr. Lee is Gas Exchange, Impaired related to improved oxygen resource and the data already confirmed above. Although Mr. Lee also offers excess body smooth and threat of security problems, but the challenge goal should be meet up with the physical needs of the individual, and then consider other degrees of need. Problem of oxygen source is immediate danger to life may cause dysnea or brain hypoxia etc, and need to take immediate action to resolve it. Besides fluid retention is an indicator of severe exacerbations of COPD and anxious relates to the dyspnoeic, so if the Gas Exchange, Impaired solve, the other problems may improve.
To improve Mr. Lee's condition, A change nurse need to have some essential assessment and actions perform for him.
Give general examination including: monitor vital sign and notice any unusual reading which immediately represent metabolism, oxygenation and circulatory functions; Keep an eye on O2 saturation where Mr. Lee vulnerable for desaturation; Assess skin area color and perfusion for development of cyanosis; Communication such as any changes in orientation and patterns.
Use IPPA to check on lung condition i. e. use accessory muscles, lung sound, expansion of upper body, noting any signs or symptoms of SOB or airway amount of resistance, also pay attention to breathing style, respiration rhythm and dept can reflex lung function such as cut down lung volume and ventilation. Nurse can also use peak expiratory circulation rate to assess airflow blockage,
Follow the laboratory survey of CXR, ABGs etc and be aware changes. Measure the setting of Mr. Lee to note any physical effort on oxygenation. Also determine patient's ability to coughing effectively to clear airway secretions. Note the number, color, and uniformity of sputum.
After assessments, nurse need to equate to the normal specifications, noted any excessive finding which help to give ideal measures.
The methods includes keep continues evaluation and screen which point out on above. Setting of patient, eating and sipping assist avoid dehydration. Medication should get as prescription and examine any side effect seem. Also use stress scale to check the feelings then give emotional care to lessen the stress level.
The expected result in the A move for Mr. Lee is free from difficulty breathing by demonstrated as maintains pulse oximetry90%, normal ABGs result and alert responsive, reduce troubled level. However there might occur undesired situation such as patient's condition continue to be unchanged even become worse. In that way, nurse need to recharge the data and reassessment patient's health condition to modify the aim and treatment to meet up with the need of patient.
Important information give to B switch nurse
A switch nurse should hand over the info of Mr. Lees' health background, general survey and physical assessment, Mr. Lees' condition in A transfer and the nurse action done at A move.
In conclude medical assessment is a process with planning, purposeful and systematic and run through hold nursing process of Mr. Lee. It can help nurses collect information to understand health of patient. The evaluation provides evidences to nurse research, judgment and present proper nursing attention, which improve the accuracy of nursing diagnosis and the management, fit the health needs of the patient more specifically.
