92430 Assessment And Therapeutics In Health Care 1

92430 Assessment And Therapeutics In Health Care 1

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92430 Assessment And Therapeutics In Health Care 1

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92430 Assessment And Therapeutics In Health Care 1

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Course Code: 92430
University: University Of Technology Sydney

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Country: Australia

Question:

The intent of this assessment is to prepare students to be able to-

Identify and differentiate between normal and abnormal vital signs.
Develop an awareness of clinical practice and a beginning understanding of clinical reasoning. ?
Assess and utilise academic and evidence-based resources.

Students will be required to watch two short videos. Students will then need to complete a table and answer critical thinking questions based on the videos.
Video A:

Video B:

 
Complete the following table using information from the assessment resources and Video A.
Consider the patient situation
Collect cues and/or information
Complete the following table using information from Video A

Cue
(vital sign)

Definition
Use your own words supported with references

Factors that may affect this cue
Use your own words supported with references

Normal range (adult)

Terminology used to describe abnormal cue

Patient’s vital sign

Respiratory rate

 

 

 

 

 

Oxygen saturations

 

 

 

 

 

Heart rate (pulse)

 

 

 

 

 

Blood pressure

 

 

 

 

 

Temperature

 

 

 

 

 

Critical thinking questions
Assessment is a key component of nursing practice, required for planning and provision of person centred care. The Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice (2016) consist of seven standards and Standard 4 – Comprehensively Conducts Assessments states: “RNs accurately conduct comprehensive and systematic assessments. hey analyse information and data and communicate outcomes as the basis for practice”.
 
Identify four (4) errors made by the nursing student in Video B and describe how these errors may contribute to inaccurate measuring and recording of patient vital sign

Outline the importance of accurate documentation and how it relates to Standard 4 of the Registered Nurse Standards for Practice (2016)
What have you learned from this assessment? How will it inform your clinical practice?

Answer:

Clinical reasoning
A.

Clinical Reasoning Cycle

Consider the patient situation

In this section, provide a relevant and concise description of your observation of the context and patient situation.  

The patient is Sandra Smith, a 33-year-old female who presented with per vaginal bleeding. She has an IV cannular in her left hand with a normal saline IV fluid running at 125mls per hour. She has menstrual pads in situ and has been on bedrest since admission.

Collect cues and/or information

Review
Record current information (eg handover, patient history etc,  

She is passing 500mls of bleed per hour. She has a past history of endometriosis, hypotension and childhood asthma. Previous procedures included laparoscopic incision of endometrial tissue, colonoscopy, and appendectomy. On assessment important positives included elevated heart rate at 100 bpm, respiratory rate at 29, temperature of 38.50Cand a pale diaphoretic appearance with pain of 8/10. She also has not passed urine since admission.

 Collect cues and/or information continued

Gather new information – In the video, the nursing student gathers the current vital signs – record this information
Recall knowledge – What do the vital signs measured by the nurse in the video mean

Cue
(vital sign)

Definition
Use your own words supported with references

Factors that may affect this cue
Use your own words supported with references

Normal range (adult)

Terminology used to describe abnormal cue

Patient’s vital sign

Respiratory rate

This is the measure of a persons breathing per minute with one respiration being an inspiration and a corresponding expiration (Flenady, Dwyer and Applegarth, 2016)

Metabolic acidosis due to inadequate perfusion causes a hyperventilation as the patient tries to eliminate excess acid (Mikhail, 2015).

12 -20 breaths/minute

Hyperventilation
Hypoventilation

29 breaths per min

Oxygen saturations

This is a measure of the amount of oxygen in blood hence the level that is delivered to tissues (Jubran, 2015).

The metabolic acidosis make is hard to maintain a high oxygen saturation
(Fein, 2014).

97 – 100%

Hypoxemia

95 %

Heart rate (pulse)

This is the measure of the how fast the heart is beating with one cycle being diastole plus the corresponding systole. It is measured by palpating the radial artery for radial pulse (Oh, Hong & Lee, 2016).

Due to blood loss and low perfusion, there is a sympathetic nervous system stimulation which causes the release of catecholamine; adrenaline and norepinephrine (Kreimeier, 2016). This causes vasoconstriction, increased heart rate (above 100 bpm) and increased heart contractility. With this, there is adequate cardiac output which increases the tissue perfusion.

60 -100 bpm

Tachycardia
Bradycardia

110 bpm

Blood pressure

His is the measure of the pumping force of the heart against the resistance of the blood vessels (Guyton, 2015)

The blood pressure remains normal as compensation is occurring. There is activation of the renin-angiotensin-aldosterone system that leads to increased anti-diuretic production which in turn causes water retention. However, with increasing blood loss the pressure will fall as vasodilation due to anaerobic respiration occurs (Hinkle & Cheever, 2013)

130 to 90/85
 

Hypertension
hypotension

100/60 mmHg

Temperature

This is a measure of the bodies hotness or coldness and gives an indication of the bodies core temperature (Kushimoto et al, 2014)

Brain hypoperfusion due to haemorrhage resets the core body temperature imparing normal thermoregulation (Balk, 2015).

36.5 to 37.20C

Hypothermia
Fever
 

38.50C

Critical thinking questions
Identify four errors made by the nursing student.

Error 1

During blood pressure measurement, the student placed the blood pressure cuff below the cubital fossa, at the upper forearm instead of the required position just above the cubital fossa. This error leads to overestimation, underestimation or even guessing of values since the correct sounds cannot be heard correctly (Handler, 2009).

Error 2

During pulse rate measurement the thumb was used to measure which is incorrect. The thumb having its own pulsation interferers with the pulse being measured making the reading inaccurate (Glynn and Drake, 2014).

Error 3

The method of measuring respiratory rate was incorrect as she made the patient aware of the process. The awareness of breathing by the patient makes the reading inaccurate compared to if the rate was counted while the patient is un aware (Glynn and Drake, 2014)

Error 4

Inappropriate documentation protocol as the student did not record her results after every measurement but waited till the end of the assessment to do so. This is not standard practice as she could forget the correct readings and instead document incorrect figures (Fuller, Fox, Lake, & Crawford, 2018).

Importance of accurate documentation

The standard 4 provides for comprehensive assessment to guide decisions. Inappropriate documentation of assessments will impair this principle. If an assessment is done but not documented accurately, it renders the assessment inaccurate and an inaccurate assessment should not be used to inform nursing practice (Stevens & Pickering, 2010).  The assessment won’t be holistic, relevant or accurate (Collins et al, 2013). As a general rule in nursing, something not documented is considered not done. Good documentation is also crucial for clinical communication. Working in partnership with others to assess, prioritize and manage patients is required by the standards of practice no 4. This involves handover reports, patient information, previous assessment and results. This ensure continuity of care without loss of information (Stevens & Pickering, 2010). Another requirement of the standard is the assessment of resources available to inform planning. This involves accurate documentation of all available resources, the management of this resources and their use.

What have you learned from this assessment? 

The lessons learned in this assessment are numerous. The first important lesson is the use of the clinical reasoning cycle in the approach and management of a patient. This systematic approach as used in this assessment is more holistic, appropriate and simple to follow. The cycle follows eight simple steps that if applied to different clinical scenarios help in the management of patients. The second lesson is the importance of vital signs measurement in the assessment of patients, the identification of normal and abnormal vitals, and how errors in the measurement can greatly affect these readings. From this, good clinical skills in the measurement of vital signs need to be learned or improved to provide quality measurements. Also, the importance of vital signs will not be underestimated. The third lesson is the importance of accurate documentation in provision of quality nursing care and meeting nursing standards of practice. With this information, implementation of good, concise and regular documentation shall be a priority in the clinical setting. The final lesson is the use of evidence-based research in clinical practice and the importance of evidence-based resources in clinical nursing. This will help inform my clinical reasoning in the clinical area. 

References
Balk, A., (2015). Pathogenesis and management of multiple organ dysfunctions or failure in severe hypovolemia and hypovolemic shock. Critical Care Clinics, 16(2), 337–351
Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship Between Nursing Documentation and Patients’ Mortality, American Association of Critical-Care Nurses, 22(4), 306-313.
Fein, A. M., (2014). Acute lung injury and acute respiratory distress syndrome in sepsis and septic shock. Critical Care Clinics, 16(2), 289–313.
Flenady, T., Dwyer, T., & Applegarth, J. Accurate respiratory rates count: So should you! Australasian Emergency Nursing Journal, 20(1), 45-47.
Fuller, T., Fox, B., Lake, D., & Crawford, K. (2018). Improving real-time vital signs documentation. Nursing Management, 49(1), 28-33.
Glynn, M. & Drake, W. (2014). Hutchinson’s Clinical Methods: an integrated approach to clinical practice. London: Elsevier.
Guyton, A. C. (2015). Textbook of Medical Physiology. (13th ed.). Philadelphia: W. B. Saunders
Handler, J. (2009). The Importance of Accurate Blood Pressure Measurement. The Permanente Journal, 13(3), 51-54.
Hinkle, J.L, Cheever, K.H. (2013). Brunner and Saddarth’s Textbook of Medical and Surgical Nursing, (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Jubran, A. (2015). Pulse oximetry. Critical Care, 19(1), 272.
Kreimeier, U. (2016). Pathophysiology of fluid imbalance. Critical Care, 8,2: S3–S7
Kushimoto, S., Yamanouchi, S., Endo, T., Sato, T., Nomura, R., Fujita, M. et al. (2014). Body temperature abnormalities in non-neurological critically ill patients: a review of the literature. Journal of Intensive Care, 2(1), 14.
Oh, D.-J., Hong, H.-O., & Lee, B.-A. (2016). The effects of strenuous exercises on resting heart rate, blood pressure, and maximal oxygen uptake. Journal of Exercise Rehabilitation, 12(1), 42-46
Stevens, S., & Pickering, D. (2010). Keeping good nursing records: a guide. Community Eye Health, 23(74), 44-45.

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