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The assessment of patients forms a major component of the nursing role. It allows the nurse to gain vital information to base the planning and implementation of prioritised care on. A systematic method of assessment is required, that ensures that all areas of assessment are covered and that the assessment and subsequent interventions are as effective and efficient as possible. One method that can be followed for patient assessment is the primary and secondary surveys, with an additional assessment replacing the secondary survey post-operatively. This essay will display the implementation of these methods in the assessment of a trauma patient throughout the peri-operative period. The case study of Mrs Lily Flowers, as outlined in Appendix A, will be used to demonstrate the use of the primary and secondary surveys both pre and post-operatively, commencing with the pre-operative primary survey first.The first stage of the primary survey is airway management with cervical spine control. Mrs Flowers has a patent airway, signified by her ability to speak to the nurse (Cole 2004). The nurse must immobilise the cervical spine until they can confirm definitive clearance, by the Emergency department, of any spinal damage (Miglietta, Levins & Robb 2002). As Mrs Flowers has a patent airway, is not displaying any signs of airway obstruction and the cervical spine has been cleared of any injury, the primary survey now progresses to the assessment of breathing.Breathing is assessed by observing the chest wall and pattern of breathing, including the rate and depth of respiration, symmetry of chest wall movements, the use of accessory muscles, rib retraction, nasal flaring, position of comfort and patient colour (Reilly 2003). Audible sounds, such as wheezes, stridor or gurgling are listened for and the lungs auscultated for breath sounds and bilateral air entry (Reilly 2003). Mrs Flowerâ€™s respiratory rate of 32 breaths per minute indicates severe tachypnoea (Reilly 2003), which can be related to pain, anxiety and/or shock (Cole 2004).
Reassurance must be given to Mrs Flowers to help reduce her anxiety, whilst assessing oxygen saturation and administering oxygen through a non-rebreather mask with a flow of 15 litres per minute (Cole 2004: Pruitt & Jacobs 2003). With oxygen therapy in place, circulation would now be assessed. To assess circulation, the patients pulse must be palpated for rate, strength, regularity and quality. Other observations would include blood pressure, capillary refill, skin temperature and diaphoresis (Ahern & Philpot 2002). Mrs Flowerâ€™s is tachycardic, with a heart rate of 120 beats per minute (Cole 2004). She would have a weak, rapid pulse with possible irregularity. Her blood pressure is 90/60, with a history of hypertension, this indicates extreme hypotension (Crisp & Taylor 2001). Capillary refill time would be slower than two seconds and her skin is pale and clammy (Cole 2004). These observations along with tachypnoea; restlessness and feeling faint indicate hypovolemic shock.
An IV cannula has been inserted in the Emergency department, however crystalloid fluids and possibly fresh frozen platelets should be infused, which will require two large bore catheters to be inserted (Cole 2004; Kelley 2005). Therefore the nurse must get in immediate contact with the treating doctor to organise this. A maximum rate infusion is normally preferred, for patients with hypovolemia, however patients with cardiac disease need the fluid rate titrated to response to avoid complications (Kelley 2005, p.9) and use of â€œaggressive fluid resuscitation in uncontrolled haemorrhage prior to the bleeding has been controlled is not recommended (Cole 2004). A urinary catheter should be inserted (Cole 2004) and the patient positioned in a modified Trendelenburg position, to encourage blood flow from the feet to the vital organs (Smeltzer & Bare 2004). An ECG would be conducted now due to a past cardiac history. Once circulation has been assessed and fluid resuscitation commenced, disability and dysfunction needs to be assessed. Disability and dysfunction covers a rapid neurological assessment, conducting a Glasgow Coma Scale (GCS), observing pupil size and response. With no signs of neurological deficit and possible pupil dilation related to the hypovolemic shock, a pain assessment would be completed to assess the need for pain relief. An order for pain relief should be requested when the doctor is ordering the fluids and/or blood. This will be followed by an assessment of exposure and environment. Exposure requires the inspection of the patients body, looking for obvious injuries, wounds or external abnormalities. Environment requires care to prevent hypothermia due to exposure, which can impair the clotting and oxygenation processes (Cole 2004).
Mrs Flowers is not displaying any signs of extreme heat or cold, however is covered to maintain privacy and dignity during the examination. This now concludes the primary survey, with a more thorough assessment of the patient being completed in the secondary survey.The secondary survey progresses through four stages, beginning with Fahrenheit. Fahrenheit requires the measurement of the patientâ€™s core body temperature measured by oral or tympanic thermometer (Crisp & Taylor 2001), looking out for hypothermia due to fluid replacement and shock (Kelley 2005). Mrs Flowerâ€™s temperature is 36.8Â°C, which is within the normal range (Crisp & Taylor 2001, p. 670). Get vitals requires a repeat of all vital sign observations, looking out for signs of oedema or fluid overload. With vital signs stable, a thorough history and head-to-toe assessment should be completed.Using the mnemonic AMPLE, the patient history is taken. AMPLE stands for allergies, medications, past health history, last meal and events/environments related to the injury (Urden, Stacy & Lough 2002). Beginning with allergies, the patient is asked for any known allergies and the reaction if any. Mrs Flowers has no known allergies and her medications would be likely to include an anti-platelet agent (which reduces thrombi formation); an ACE inhibitor (which reduces hypertension); a beta-blocker (which reduces the oxygen demand of the heart) and a statin (which lowers lipid levels in the patient) (Banas 2004; Bryant, Knights & Salerno 2003). The patient should be asked about her use of alcohol, nicotine and other illicit drugs. Mrs Flowers states that she has been a smoker for 35 years and currently smokes 25 cigarettes per day. Mrs Flowers is then asked about her past and current medical history.Further details regarding the patients history of hypertension and unstable angina would be asked, along with other past and current medical and family history. Past medical notes may need to be obtained. The time of her last meal will be noted and what the meal included (Urden, Stacy & Lough 2002). Mrs Flowers would also be asked about the events leading up to her admission. These details can assist with knowing what other injuries to look out for.
Following the patient history, the nurse conducts a thorough head-to-toe assessment.The head-to-toe assessment should begin at the head and progress to the toes, with careful assessment of each of the body systems. This should include a comprehensive assessment of the neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and integumentary systems. The head-to-toe assessment has not uncovered any further complications for Mrs Flowers, therefore the required investigations and interventions should now be reviewed.Investigations would include follow-up on blood test results (conducted in the Emergency department); abdominal x-ray or ultrasound (if requested); periodic ECGs, monitoring any cardiovascular changes due to the shock and subsequent fluid administration; hourly urine measures; urine analysis, looking for haematuria and any other investigations as that are requested by the treating Doctor and/or surgeon. Nursing interventions for Mrs Flowers would include 15â€“30 minute vital sign observations. A fluid balance chart maintained hourly, noting the increased risk of fluid overload in patients with pre-existing cardiac disease (Smeltzer & Bare 2004). Jugular venous pressure (JVP) measurement, looking for signs of continued shock or fluid overload (Smeltzer & Bare 2004). Cardiac and respiratory status must be monitored carefully, along with adequate pain relief to keep the patient comfortable. Pressure area care, psychological support and standard pre-operative preparations are also required. It is also essential for tall of the observations and interventions to be documented continually in the patients notes. The primary and secondary surveys have allowed the nurse to conduct a pre-operative risk assessment, using the information obtained to follow-up on areas of risk. Identified risks for Mrs Flowers include current hypovolemia; a past history and current medication for unstable angina and hypertension and potential complications associated with being a long-term smoker. All current medications should be continued (excluding warfarin and high dose ACE inhibitors), as they will â€œalleviate symptoms, improve prognosis and aid compliance during the peri-operative period (Sear & Higham 2002, p437).
The hypovolemia is being addressed with fluid resuscitation and the anaesthetist and surgeon should be made aware that Mrs Flowers is a smoker. Patient education regarding post-operative requirements including deep breathing and coughing can help to prevent complications associated with being a smoker, having unstable angina and enduring an emergency exploratory laparoscopy. These surveys have assisted with a systematic assessment of Mrs Flowers pre-operatively and will be implemented again post-operatively, when she returns to the ward.Prior to the patientâ€™s return to the ward, the nurse is given a hand-over from recovery staff, outlining the operative and recovery periods. On return to the ward, the nurse must obtain a baseline of all vitals which should be compared to those taken in recovery to identify any decline in her condition. Temperature elevation up to 38Â°C within the first 24 â€“ 48 hours post-operatively can be due to the normal inflammatory response (Brown & Edwards 2005). After the first 48 hours, a temperature above 37.7Â°C should be considered to signify possible infection. Vital signs and general observations would be repeated hourly for the first four hours and then every four hours, depending on the patientâ€™s condition (Crisp & Taylor 2001). With baseline vitals obtained, the nurse would now commence the primary survey, assessing for any decline in patient condition or development of post-operative complications. Commencing with the airway, Mrs Flowers is observed to be verbalising clearly, therefore her airway is patent. Her breathing may be shallow due to pain; however her respiratory rate is 16 breaths per minute, which is considered normal (Crisp & Taylor 2001). Chest movements would be observed, breath sounds listened to and the lungs auscultated for any changes or abnormalities (Cole 2004).
Mrs Flowers may have a cough and some expectoration of mucous following surgery, due to the hypersecretion of mucous caused by smoking (ANZCA 2001). On completion of the breathing assessment, circulation should now be assessed.Assessment of circulation reveals a blood pressure of 130/90 and a pulse of 82 beats per minute, both within normal limits (Crisp & Taylor 2001). Capillary refill would be checked and would be expected to be within normal limits. An ECG should be conducted now, due to Mrs Flowers being at high risk for post-operative cardiac complications due to her unstable angina (Rinfret et al 2004). Any abnormalities in the ECG should be reported immediately. If the ECG is normal, disability and dysfunction would be assessed by completing a Glasgow Coma Scale (GCS) and observing Mrs Flowers pupil size and reaction. Mrs Flowers GCS, pupil size and reaction would be expected to be normal.A pain assessment would be conducted at this point. Moving on to assess exposure and environment, the nurse would inspect the patient, looking at both the posterior and anterior surfaces, noting any abnormalities or changes to Mrs Flowers condition. Environment would ensure that the temperature and bed coverings were adequate considering the patients body temperature, and that the side rails were up, an emesis bowl and tissues near by and the buzzer within reach for the patient. This concludes the primary survey post-operatively. At this point, the post-operative assessment would be implemented.The post-operative assessment focuses on nine areas of actual or potential risk for the patient. The nine categories include pain management; wound care and skin integrity; diet and elimination; cardiovascular function; respiratory function; fluid management; mobility; personal care and discharge planning. The management of these areas are critical to patient recovery, early identification and treatment of complications and the successful discharge of the patient from hospital. The assessment will commence with pain management.Pain and discomfort should be assessed regularly, ensuring that Mrs Flowers has adequate pain relief at all times. A pain scale along with observations of behavioural signs of pain should be implemented. The patient may not be able to verbalise pain, however behaviours including rinkling of the face, clenched fists, moaning, diaphoresis or an increased pulse (Brown & Edwards 2005, p.410) can indicate untreated pain. Effective pain management promotes healing and helps prevent common post-operative complications including â€œatelectasis, deep vein thrombosis, and prolonged delays in return of bowel function (Faries 1998).
The nurse must note that as a smoker, Mrs Flowers may require increased amounts of analgesia due to enzymatic liver alterations caused by smoking (ANZCA 2001). With most analgesics ordered as PRN post-operatively; careful and regular assessment of the patients pain and comfort levels is imperative. Adequate pain relief can encourage Mrs Flowers participation in post-operative exercises and early mobilisation which is desired (Brown & Edwards 2005). Wound care and skin integrity is the next component.Regular assessment of the wound site, dressing and drains is required. The amount, type and odour of exudate or any changes to the surrounding skin including heat, redness and inflammation or pain at or around the site of the wound should be noted and reported immediately. These could indicate complications, including infection or dehiscence (Brown & Edwards 2005). Smokers are at an increased risk of complications and delayed wound healing, due to alterations in microcirculation and the bodyâ€™s immune responses (ANZCA 2001). Therefore close monitoring for signs of complications in wound healing will be required for Mrs Flowers. Skin integrity and pressure area care is another essential component here. With regular repositioning and massage of the posterior surface of the body required to encourage blood circulation and prevent skin breakdown due to prolonged pressure (Brown & Edwards 2005). Diet and elimination is the next area to be assessed.For patients who have had abdominal surgery, food should not be introduced until normal bowel sounds return. Introducing food before the bowel resumes its function can cause nausea, vomiting and stasis of the food, which may further delay the bowel from functioning (Brown & Edwards 2005). Intravenous fluids would be administered during the period that the patient cannot eat (Brown & Edwards 2005).
The nurse must auscultate Mrs Flowerâ€™s abdomen to listen for bowels sounds and ask the patient if they have passed flatus, which is a common sign of the return of normal bowel function, before allowing them to have food. Constipation should also be monitored, which is a common side-effect of high dose analgesia and immobility. Diet, exercise and increased fluid intake should be encouraged, with aperients used only if the constipation continues. Cardiovascular management is the next component of post-operative care and management.Cardiovascular complications can occur post-operatively. Mrs Flowers is at increased risk of complications due to coronary artery disease and being a current smoker (ANZCA 2001; Rinfret et al. 2004). Intermittent ECGs should be conducted and observations for shortness of breath and chest pain made regularly. A fluid balance chart and haemodynamic studies should be completed, monitoring both closely for signs of conditions that could precipitate cardiac complications, including impaired clotting times, reduced hydration levels, electrolyte imbalances and uncontrolled bleeding. Common cardiovascular complications involve the development of thrombi, which can lead to deep vein thrombosis and possible pulmonary emboli. Anti-embolic stockings; leg exercises (10 12 times per waking hour); sitting out of bed by day two and early ambulation help prevent these complications. The next component to be assessed is respiratory function.Respiratory complications are common post-operatively.
Atelectasis and pneumonia can develop rapidly, with the build up of mucous in the lungs causing collapse of alveoli in atelectasis and infection development in pneumonia. Smoking increases the risk of these complications due to the hypersecretion of mucous and the reduction of tracheobronchial clearance (ANZCA 2001). Deep breathing and coughing exercises are essential post-operatively. This opens the all of the alveoli, prevents collapse and assists with the expectoration of the mucous (Brown & Edwards 2005). Regular deep breathing, ten times per hour; incentive spirometry; change of position second hourly and early mobilisation all encourage mucous expectoration and thus prevention of respiratory complications (Brown & Edwards 2005). Fluid management is another component to be considered.Fluid management is critical, with care of intravenous therapy if it is continued post-operatively. Mrs Flowerâ€™s cannula site must be checked regularly, the fluid bag replaced every 24 hours with fluid orders followed and the cannula should be resited every 48 â€“ 72 hours, depending on patency of the line. A fluid balance chart should be kept for her, to observe for fluid overload or deficiency. If the IDC remains insitu, Mrs Flowers should have 0.5mL/kg per hour output within the first 24 hours (Brown & Edwards 2005). Any variation to this should be notified to the doctor. Mrs Flowers catheter would normally be removed within the first 24 48 hours post-operatively, when urination should be monitored, watching for signs of urinary retention. Post-operative blood tests on Mrs Flowers will also assist with assessing her fluid and electrolyte balance. Interventions to correct imbalances can then be put in place as required. The next post-operative component looks at mobility.Early ambulation is a key factor in patient recovery. Mrs Flowers should be encouraged to sit of bed by day two, with assisted ambulation as early as possible. Early ambulation will help Mrs Flowers to increase muscle tone; it improves gastrointestinal and urinary function; stimulates circulation; prevents venous stasis; increases wound healing and increases the vital capacity and normal respiratory function (Brown & Edwards 2005).
Personal care and psychological wellbeing are another important component post-operatively.Personal care relates to hygiene, mouth care and activities of daily living, including dressing and grooming. The nurse would initially assist Mrs Flowers with these tasks, encouraging her to do as much for herself as she could. Once Mrs Flowers is ambulating, independence with her personal care could be encouraged. Psychological wellbeing includes reassurance to reduce Mrs Flowerâ€™s anxiety, to assist her to cope with her limitations and current situation and to encourage a positive body image that may be disturbed due to the accident, the surgery and related treatments. Patient education and discharge planning must begin on day one of admission. This component of the post-operative assessment is covered in Appendix D. Essential to all patient care is the documentation of these assessments and the subsequent observations, with immediate reporting of any patient decline or deviation from what is considered normal for the patient and their circumstances. This now concludes the post-operative components of Mrs Flowers assessment. It by no means is an exhaustive discussion of the nurseâ€™s role in post-operative assessment and care, however outlines some systematic approaches that can be implemented throughout the peri-operative care and treatment of a patient.This essay has explored the use of assessment methods and associated interventions used throughout the peri-operative period of a trauma patient. Using the case study of Mrs Flowers, the primary and secondary surveys were implemented both pre and post-operatively. In addition to the surveys, a nine component post-operative assessment was introduced, to assess any post-operative risks and to plan for strategies to reduce the incidence of these complications. While this essay has not been an exhaustive discussion of the components of peri-operative care, it has attempted to display the need for systematic assessment methods that allow for the optimal care and treatment of the hospitalised patient.
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