Nursing Assessment: The Initial Stage Of Five Phases In Nursing Care

The Significance of Nursing Assessment in Patient Care

In nursing assessment, the initial stage of five phases in nursing care entails continuously and systematically collecting data, categorising them, interpreting and structuring the same data, and documenting and communicating it for further nursing interventions (Toney-Butler & Unison-Pace, 2018). Assessment is necessary for identifying potential risks, indicators, and symptoms of deterioration. Furthermore, assessment is crucial for developing patient-specific treatment methods accordingly. The nursing assessment incorporates gathering data on the patient's physical, psychological, sociocultural, and spiritual necessities, and it is the fundamental step in analysing an individual appropriately (Giovanna et al., 2019). This approach necessitates both subjective and objective data gathering. Information gathering is a part of the assessment, which requires taking vital measures like temperature, breathing rates, heart rate, blood pressure, and severity of pain using age or disease-appropriate pain scale. By facilitating the development of a nursing diagnosis, the assessment investigates the patient's ongoing and prospective care needs. When any case includes children, inquiries are made to the children's guardians who have noticed the indications. In the given case study, Ashanti, an indigenous girl, has struggled with diarrhoea for quite a few days. Ashanti has had all her vaccinations. There are no records of any surgery. An A to G evaluation of the patient must be performed (Cathala & Moorley, 2020). In Ashanti's case scenario, it is crucial to perform an airway evaluation.

When Ashanti was breathing, her airways appeared clear. It is followed by a breathing evaluation for determining whether there are any indicators of respiratory distress. The respiratory rate of Ashanti in the case study was 56. In the case of a child, a respiratory rate between the range of 50 to 70 is regarded as inappropriate. It falls into the SAPO chart's yellow zone. Ashanti's SPO2 level was 93%. It is indicated in the SAPO chart that oxygen saturation levels between 95 and 90 % lie in the yellow zone. Nurses must measure heart rate (HR), blood pressure levels, and capillary refill during the circulation evaluation. In Ashanti's case scenario, her capillary refill was unknown, her HR was 182, and her systolic blood pressure (SBP) was 68 mm Hg (CEC, 2013). In children, HR exceeding 170 and SBP under 70 mm of Hg are classified as red flags (CEC, 2022).

Following the evaluation of Ashanti's circulation, the nurse is required to examine Ashanti for any impairment, which includes assessing Ashanti's neurological condition. Ashanti was in discomfort, and she could barely walk. The power and mobility of her limbs were restricted. AVPU systems were employed to determine Ashanti's state of mind, and she was quietly speaking to her grandmother, which put her in the yellow zone (CEC, 2022). The nurse was required to examine exposure, which she did, and observed that Ashanti's body temperature was normal, she had a dry tongue, her lips were cracked, and her eyes were shrunken. Additional evaluations are required, like the Glasgow Coma Scale (GCS). As Ashanti had not voided for an entire day and she was not accepting fluid or diet, an additional fluid evaluation must be performed to determine output and input. It had put her in the yellow zone. Her blood glucose levels were checked and confirmed to be 3.1 mmol. At last, the nurse is required to record the assessment's findings, identify the next steps, and employ local procedures and clinical judgment (Pain et al., 2017).

How to Perform a Nursing Assessment

CEC suggests that if an individual has any red zone indications, they are required to be treated immediately (CEC, 2022). Ashanti's HR and SBP fall in the red zone. Her SpO2, RR, neurological condition and RR are placed in the yellow zone. These indicate that Ashanti requires an urgent, quick and timely response. Her other indications, such as inability to drink, shrunken eyes, lethargy, and reduced skin turgor, have matched the WHO's standards for acute dehydration identification. Diarrhoea has resulted in acute dehydration and hypovolemic shock, pointed out by the evaluation results like tachycardia, no voiding, hypotension, and tachypnoea (WHO, 2017).

Introduction: Hello, my name is Maria, and I serve at Wilcannia Clinic as a Registered Nurse (RN). Is this Dr B I am speaking with? I have called to inform you about a three-year-old indigenous child named Ashanti receiving treatment at Wilcannia Clinic.

Situation: My patient Ashanti has been in the clinic for quite a few days, and her primary complaint is diarrhea. Her condition is declining due to her SBP and HR being placed in the red zone. Ashanti’s urine output, RR, neurological condition and SpO2 have been put in the yellow zone. Additionally, she has displayed clinical manifestations of acute dehydration and probable shock due to diarrhoea.

Background: According to Ashanti’s mother, she is completely immunized and has no notable surgical or medical record.

Assessment: SBP 68 mm Hg, no voiding for an entire day, neurological status V, RR 56, minor pain, HR 182, SpO2 93 per cent, 13 kg bodyweight, and BGL 3.1 mmol were detected at the time of evaluation. I also noticed weaker limbs, shrunken eyes, sluggishness, dry tongue, and cracked lips, among clinical dehydration symptoms. Additionally, I gave oxygen, and complete blood count, lactate, and blood culture results are forthcoming.

Recommendation: I would want to have a quick response from you within ten minutes, and as I wait, would you like me to prepare or perform anything?

When a patient arrives at the healthcare facility, the nurse’s primary job is to perform a comprehensive examination, record the observations, and employ local guidelines and clinical judgement to undertake the necessary intervention (March et al., 2021). The first responder’s ability to identify and provide quick and appropriate treatment to the patients is crucial to their survival. Ashanti suffers from acute dehydration, hypovolemic shock or sepsis that has been induced by diarrhoea and necessitates rapid medical intervention. As a result, nurses must prioritise patient care and deliver prompt nursing intervention.

At the time of evaluation, the Australian standards advocate the reversible causes of patient deterioration. When the patient's oxygen saturation levels drop below 94 per cent, supplemental oxygen must be used (ARC, 2022). For enhancing saturation, the nurses are required to place the patient in the right position and deliver oxygen. The ward in charge and the attending Medical Officer (AMO) are required to be contacted by the nurses for immediate assistance after the nurses have identified the indicators of acute dehydration, yellow flags and red flags. There might be a possibility that intravenous treatment, AMO, and antibiotics may not be available at distant clinics. In that case, nurses are required to refer the patient to the closest hospital as soon as possible. On their way to the hospital, the child's mother is required to provide Oral Rehydration Supplement (ORS) sips to the child (WHO, 2017).

Case Study: Ashanti, a three-year-old indigenous girl suffering from acute dehydration and hypovolemic shock

Whenever AMO is present and there is the availability of antimicrobial or intravenous treatment, nurses are required to commence relevant medical intervention until the MO arrives for inspection. Nurses are required to open IV access immediately or intraosseous infusion when IV accessibility cannot be created. A third alternative is nasogastric. Once the IV access is opened, nurses, to make a diagnosis, are required to send blood samples to the lab for tests like total blood count, lactate, and blood culture (Strachan & Morris, 2017). Nurses are required to consult the AMO for recognizing the probable clinical diagnosis. When there is a septic shock or a case of sepsis arises, IV fluid and antibiotics should be given to the patient within one hour of diagnosis. In the case of a hypovolemic shock, the priority is arresting the fluid loss and stabilizing blood volume before the patient's health condition deteriorates. Before administering antibiotics, nurses are required to consult with the MO and abide by the antimicrobial treatment guidelines. A bolus of 20ml/kg 0.9 per cent sodium chloride should be given within five to ten minutes of fluid resuscitation. Nurses must reevaluate and record the patient's condition after providing the bolus. The bolus must be repeated up to 3 boluses of 60 ml/kg during the first hour until the indications of shock have resolved (Anigilaje, 2018). Suppose the patient’s health worsens after receiving therapy. In that case, the nurses are required to seek medical assistance and transfer the patient to the closest hospital, where there is a pediatric intensive care unit.

A 48-hour care plan must be provided to the patient even after the symptoms of shock have subsided. Other healthcare professionals like microbiologists, pediatricians, dieticians, MO, pathologists, social workers and so on are required to be involved in the continuing management (WHO, 2017). Continuing management aims to deliver regular IV rehydration therapy, maintain or discontinue antibiotics, evaluate, educate, deliver psychological help, schedule discharge and follow-up. Nurses must consult with pharmacologist and MO in rehydration therapy and initiate 0.9 per cent sodium chloride +5 per cent glucose +/- 20 mmol/L potassium chloride for more than 24 hours to correct the acute dehydration and maintain the fluid volume. While the rehydration therapy is in progress, nurses should consult with doctors to set the frequency of the assessment and execute and record the evaluation results. Close surveillance of the patient’s vital signs, examination results like BGL, lactate, keeping track of input and outflow, and the clinical symptoms of fluid overload or depletion like edema, weight loss or gain (Anigilage, 2018). Dehydration is indicated by a daily weight loss of 5 per cent, and excessive fluid in the body is determined by a daily weight rise of 5 per cent (WHO, 2017). Ashanti’s family must be encouraged to develop an oral feed that is age-appropriate, in addition to rehydration therapy and with cooperation with a nutritionist. Hospitalization and illness of a young individual lead to several emotional problems. As a result, nursing counselling or intervention must be tailored to assist the family in developing coping mechanisms by delivering emotional assistance and information (Sunderland et al., 2019). After continuous therapy at the hospital or the clinic, the MO, nurse or the paediatrician should evaluate the child’s condition to assess whether the discharge is safe. The condition of the patients must be reviewed at the time of discharge planning. A discharge plan is formulated after consulting with healthcare experts and social workers based on the assessment.

Nurses or clinical educators are required to inform the families of the patients about the risk variables of dehydration, diarrhoea, and signs of shock, and in this way, they can help themselves (Mataram, 2021). Ashanti's family must be educated about the need for follow-up and urged to attend follow-up so that the healthcare experts can monitor the child’s health.

References

Anigilaje, E. A. (2018). Management of diarrhoeal dehydration in childhood: A review for clinicians in developing countries. Frontiers in pediatrics, 6, 28. https://doi.org/10.3389/fped.2018.00028

ARC. (2022). The ARC Guidelines - Australian Resuscitation Council. Resus.org.au. Retrieved 13 April 2022, from https://resus.org.au/the-arc-guidelines/.

Cathala, X., & Moorley, C. (2020). Performing an AG patient assessment: a practical step-by-step guide. Nursing Times, 116(1), 53-5. https://www.nursingtimes.net/clinical-archive/assessment-skills/performing-an-a-g-patient-assessment-a-step-by-step-guide-06-01-2020/

CEC. (2013). Between the Flags - Clinical Excellence Commission. Cec.health.nsw.gov.au. Retrieved 13 April 2022, from https://www.cec.health.nsw.gov.au/keep-patients-safe/deteriorating-patient-program/between-the-flags.

CEC. (2022). Home - Clinical Excellence Commission. Cec.health.nsw.gov.au. Retrieved 13 April 2022, from https://www.cec.health.nsw.gov.au/.

Giovanna, A., Chiara, C., Chiara, T., Paola, F., & Chiara, F. (2019). The narrative interview for the assessment of the assisted person: structure, method and data analysis. Acta Bio Medica: Atenei Parmensis, 90(Suppl 6), 7. https://dx.doi.org/10.23750%2Fabm.v90i6-S.8640

March, C. A., Flint, A., DeArment, D., Gilliland, A., Kelly, K., Rizzitano, E., ... & Libman, I. M. (2021). Paediatric diabetes care during the COVID?19 pandemic: Lessons learned in scaling up telemedicine services. Endocrinology, Diabetes & Metabolism, 4(1). https://dx.doi.org/10.1002%2Fedm2.202

Mataram, S. T. I. K. E. S. (2021). The Importance of Health Education and Environmental Hygiene Practices in Overcoming Children Diarrhea: What Does Healthcare Professionals Need to Know?. https://www.atlantis-press.com/article/125956977.pdf

Pain, C., Green, M., Duff, C., Hyland, D., Pantle, A., Fitzpatrick, K., & Hughes, C. (2017). Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System. International journal for quality in health care, 29(1), 130-136. https://academic.oup.com/intqhc/article-pdf/doi/10.1093/intqhc/mzw132/17669166/mzw132.pdf

Strachan, S. R., & Morris, L. F. (2017). Management of severe dehydration. Journal of the Intensive Care Society, 18(3), 251-255. https://doi.org/10.1177%2F1751143717693859

Sunderland, N., Westbrook, J., Urwin, R., Knights, Z., Taitz, J., Williams, H., ... & CareTrack Kids investigative team. (2019). Appropriate management of acute gastroenteritis in Australian children: A population-based study. PloS one, 14(11), e0224681. https://doi.org/10.1371/journal.pone.0224681

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WHO. (2017). Diarrhoeal disease. Who.int. Retrieved 11 April 2022, from https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease.