Tracy Folsom is a 28-year-old female who was brought to the Emergency Department by her neighbor. The neighbor stated that Miss Folsom was found lying semi-conscious in the shower. The patient was received in the ED by the on call nurse. The nurse’s performance with Miss Folsom’s management is reviewed in this article.
Emergency evaluation of a patient is supposed be in a systematic manner. A systemic approach prevents the examiner from missing out important clues that may point to a patient’s diagnosis. This approach is divided into primary and secondary.
As part of the Primary Assessment, the patient’s Airway, Breathing, Circulation and degree of Disability was evaluated, as per protocol. Miss. Folsom’s airway was patent, breathing was shallow, and her skin color was pink, indicating good perfusion. She was obeying commands and pupils were equal in size and reactive to light. It is also helpful to state the capillary bed refill time as part of the primary assessment. (Gilbert, Souza & Pletz, 2009)
The secondary assessment is carried out after the primary assessment. This is a systemic assessment and is complaint-focused. Relevant physical examination is conducted as well as a brief overall head to toe examination. The secondary survey may be done concurrently with the patient’s history. Points to note before initiating a secondary survey are: conducting a rapid trauma evaluation, immobilizing the spine incase of a spinal injury, evaluating the patient’s chief complaint, and finally calling for help. Next, an initial set of vital signs are noted. (Gilbert et al., 2009)
The patient’s vitals reflected tachypnea, with a respiratory rate of 26 breaths per minute. Pulse was 94 beats per minute, blood pressure was elevated to 145/75 mmHg and the patient remained afebrile. Oxygen saturation was 95% at room air. Analyzing vitals and oxygen saturation is a crucial component of immediate emergency assessment. The patient’s general look is also part of the immediate assessment and can provide valuable information related to the severity of the patient’s condition. Incase of any pain or tenderness, a scale of 0-10 is used to quantify the severity of the pain experienced. (Gilbert et al., 2009) This aspect was described later.
Next, the patient was rightly reassured by the nurse, an important step to relieve anxiety for all conscious patients arriving at the ED. Patients often enter the doors of a hospital with heightened feelings of stress, anxiety and vulnerability. The environment that meets them has the potential to exacerbate their original condition. Building in a processes and using mechanisms to customize and personalize patient experience is a key strategy for overcoming their fear, anxiety and stress associated with being at the hospital. (Canadian Medical Association, 2007)
The patient’s chief complaint should have been mentioned immediately after obtaining vitals and reassuring the patient. This aspect was described later in the section of head to toe examination, an approach that may be justifiable in the ED, since history and examinations are often conducted side by side during an emergency. (Gilbert et al., 2009)
A drug history, including drug allergies were highlighted earlier, which is an important point to note. This may be important in cases where patients need immediate life saving drugs or pain killers to relieve tachycardia. Miss Folsom is allergic to all Sulfa drugs and is currently taking metoprolol 25 mg. Asking the patient when she last took the drug would also be important to know, to rule out the possibility of Miss Folsom missing her last dose. (Swash & Glynn, 2007)
The next important step is to identify risk factors and existing co-morbids that may help alert a physician of the nature of the primary complaint. (Gilbert et al., 2009) Miss Folsom is a 28-year-old female, with a known case of Atrial fibrillation and Ulcerative Colitis. She is obese with a basal metabolic index of 41.1. She is also a smoker and an alcoholic who has undergone a right hemicolectomy and an ileostomy in the past. The duration of smoking and excessive alcohol consumption, which was not mentioned, is also relevant to her primary complaint. (Swash & Glynn, 2007)
Relevant examination was carried out next alongside with the patient’s history. Assessing Miss Folsom’s head injury is an important first step as part of this examination. The injury was secondary to a fall, which resulted in a laceration injury above her right eye and a right facial contusion. The patient was disoriented in place and time and could not recall how the injury had occurred. The patient also complained of a headache. The correlation of trauma and the development of a headache points to the need for prompt attention. (Swash & Glynn, 2007)
The patient’s primary complaint was severe epigastric pain radiating to the back, relieved in Flowler’s position. Details of the pain and incidents before the pain were not mentioned. Important points would be to inquire about the onset, nature, duration of the pain, and any factor that might have precipitated it. (Swash & Glynn, 2007) Even though Miss Folsom’s history is suggestive of intensively severe pain, with an acute onset, it could still have been possible that Miss Folsom had been experiencing a similar kind of pain, but lower in intensity, before this acute attack.
Details about the pain itself can point to important differentials. For example, sudden, severe and sharp pain that radiates to the back points to aortic dissection. Since the patient is a known case of Ulcerative Colitis and is an alcoholic, sudden sharp pain after a binge drink or food intake could also point to Acute epigastritis. Because of Ulcerative Colitis, the patient might have been taking occasional pain killers, which when used chronically, alongside alcohol, can cause severe gastric ulceration. A past history of off and on epigastric pain would also be necessary to favor this diagnosis. Severe pain that is relieved on sitting forward inclines one to think about acute pancreatitis, which seems most likely with Miss Folsom’s history. (Swash & Glynn, 2007)
Having addressed any immediate life-threatening injuries, a secondary examination (head to toe) aims to gather more evidence and helps to identify and treat other associated conditions. (Gilbert et al., 2009) On examination of the abdomen, guarding was noted and bowel sounds were hypoactive. There was no mention of rebound tenderness, which would provide evidence for peritonitis. Shifting dullness or fluid thrill could also differentiate fluid from fat. There was no mention of other systems, such as, the cardiovascular and respiratory examination. Mentioning pertinent negatives also provides valuable information. (Swash & Glynn, 2007)
All observations made need to be documented on the patient’s files, as done precisely by the nurse. Documentations demonstrate thought processes and prevent legal issues. The nurse’s approach was also systematic and priority based. (Gilbert et al., 2009)
The management of Miss Folsom is an example of a patient focused care. Patient focused or patient centered care is not a new concept, but its value has been overlooked in preference to the technology-based, disease-centered model that prevailed in medicine for the last 50 years. This mode of patient care utilizes four broad areas of intervention, namely, communication with patients and their families, health promotion and physical care with medications and treatment. This approach is specifically valuable for the management of patients who are non-compliant and show a high degree of irresponsibility in relation to their health. Patients suffering from chronic diseases or multiple health conditions are at a higher risk of displaying irresponsible health behaviors. The three Cs of a patient focused approach — communication, continuity of care, and concordance (finding a common ground) — summarizes the tools used in creating a patient focused model of health. Primary and secondary assessment of a patient is an important aspect of continuity of care. Continuity of care is necessary for building a high quality health care approach. (Canadian Medical Association, 2007)
Primary and secondary assessment is a tool used for disease management. Prioritizing pointers from a patient’s history can predict the likelihood of a particular diagnosis and can forecast likely complications in a given time frame. This assessment tool also holds the advantage of being comprehensive but adequate, a component that can greatly benefit patients arriving at the ED. (Canadian Medical Association, 2007)
In the emergency department, healthcare workers are faced with complex interactions among many factors, such as the emergency situation on its own, along with physicians, technology, policies, procedures and resources. With the interaction of these factors in an emergency situation, harmful and unanticipated outcomes can occur due to human error. A systematic assessment approach was designed to minimize the possibility of “misses,” or even “near misses.” (Reason, 2000)
The importance for primary assessment can also be demonstrated in an emergency situation outside a healthcare facility. Identification of danger, risk assessment, and calling out for help need to be carried out quickly and in a stepwise procedure. Panic can greatly increase the time duration. Knowing what to do when, and how to do it, minimizes panic Moreover, these assessments are based on recommendations and guidelines that have proven to be of benefit. (Dean & Mulligan, 2009)
In Miss Folsom’s case, her neighbor was the primary witness. With the first contact with a health care worker, it would be important to inquire about the scene and the situation in which Miss Folsom was found in. Before considering any rescue measures, it is important to move to the next step of secondary assessment to help analyze the patient’s risks. (Dean & Mulligan, 2009)
Analyzing risks are important before attempting to practice any hands-on assistance. This is so that the risk verses benefit debate may be conducted. In Miss Folsom’s secondary assessment, it was concluded that her head injury needed to be further investigated immediately, even though her primary complaint was severe epigastric pain. The case of Miss Folsom is a perfect example of the fact that the most obvious complaint may not be the most serious. The secondary assessment tool has been designed to review each system. Information about a secondary complication or more evidence to support a primary diagnosis can be achieved with a systemized approach. (Swash & Glynn, 2007)
Nurses form the largest healthcare workforce. A large part of the demands of patient care is centered on the work of nurses and hence, the care that they provide ultimately determines the quality and safety of the entire healthcare team. Based on different patient needs, nurses integrate their knowledge, skills and experience to care for various patients. Understanding the need for patient centered care, and engaging in strategies to improve its outcome, is paramount to higher-quality and safer care. High-reliability organizations that have cultures of safety and capitalize on evidence-based practice offer favorable working conditions to nurses and are dedicated to improving the safety and quality of care. (Reason, 2000)
Offering a supportive environment for nurses has a great contribution to make in providing quality care to patients. Factors involved in increasing the liability of error can be classified as early or late. Early factors may include missing important points or not understanding the big picture. Late factors include system errors, a heavy workforce, and the working environment. Leadership and staff organizations can create new latent factors through re-scheduling, inadequate training and outdated equipments. When the numbers of risks or hazards are traced down to its root case, it ultimately leads to latent defects in organization and the working environment. (Reason, 2000)
The working environment in a health care facility stems like the branch of a tree. The stem of the tree is the organization that creates protocols. Stemming from the main stem are many branches which comprise of different work groups, for example, technicians, laboratory assistance, radiologists, nurses and physicians. For each group is a leader who supervises workers working under them. For the management of a patient, a collaborative effort of all groups is needed. This urgent need for interaction amongst the various groups creates a gap for iatrogenic injury and management delay. (Lake, 2002) For example, if one technician was responsible for collecting samples for blood sugar and another was responsible for collecting samples for Complete Blood Counts, infections could result from multiple pricks.
Organizational factors have been considered the “blunt end” and represent the majority of errors. Therefore, to prevent such errors from occurring, the environment in which healthcare workers work need to be adapted to their cognitive strengths and weaknesses and should be designed to ameliorate the effects of whatever human error occurs. (Reason, 2000) Junior staff members should be encouraged to seek help and assistance from the main stem employees and should be supervised at all times. In an efficient system, each worker knows what to do and when to do it. For each emergency, first, second and third line respondents need to be assigned before hand. (Lake, 2002)
An ideal model of care should be able to provide nurses with a satisfactory working environment and should consist of a patient centered approach. According to the Institute of Medicine (IOM), safety of patients is dependant upon health care systems and organizations, and patients should be safe from injury caused by interactions within systems and organizations of care. (Institute Of Medicine, 2001)
Canadian Medical Association. (2007, July). Putting patients first Â®: patient-centred collaborative care a discussion paper. Retrieved from http://fhs.mcmaster.ca/surgery/documents/CollaborativeCareBackgrounderRevised.pdf
Dean, R & Mulligan, J, 2009, ‘Initial management of patients in an emergency situation’, Nursing Standard, vol. 24, no. 5, pp. 35-41, (Academic Search Complete).
Gilbert, G., Souza, P., & Pletz, B. (2009). Patient assessment routine medical care primary and secondary survey. San Mateo County EMS Agency, 1-5. Retrieved from http://smchealth.org/sites/default/files/docs/243322118Patient_Assessment.pdf
Institute of Medicine. (2001) Crossing the quality chasm. Washington, DC: National Academy Press.
Lake E. (2002) Development of the practice environment scale of the nursing work. Index.Res Nurs Health.134(6):264 — 7.
Reason J. (2000) Human error: models and management. BMJ. 320:768 — 70. [PMC free article] [PubMed]
Swash, M., & Glynn, M. (2007). Hutchison’s clinical methods. (22 ed., pp. 1-119). Edinburgh: Saunders Ltd.
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