Emergency Department Of Emergency Nursing Assessment Answer

Objective and subjective cues:

The different cues that have been identified is that she was shivering when the nurse was taking her vital signs. Moreover, she was continuously trying to pull her jackets that show she was feeling cold. The vital signs show high blood pressure of 150/70, respiratory rate of 24, and weak pulse of 100 and the temperature of 35.0c.

Categorisation of the cues and comparison with the previous records:

Subjective data can be described as the information that comes from the patient’s point of view. This includes their feelings, perceptions and concerned. They are mainly the symptoms that are observed by the professionals (Bikmoradi et al. 2015). The professional observed that she was shivering and that her hands and feet were cold. Moreover, she was also trying to put on her jacket. The objective data are observable as well as measurable data that are obtained through observation, laboratory and diagnostic testing, physical examination (Gorges et al. 2016). Therefore, the vital signs that had been noticed come under the objective cues. These are the blood pressure management, respiration rate, and pulse and body temperature.

On comparison, it was found that her previous blood pressure was 120/70 on both days that was normal whereas the present blood pressure has increased to 150/70 that is abnormal. Moreover, her previous pulse rate was between 78 and 80 but now it has become 100. However, normal pulse rate of old woman varies between 70 to 100 and therefore it can be seen to be normal for Rosy (Sabel et al. 2017). However, 100-pulse rate is considered weak. The previous temperature was between 36 and 37 degree Celsius that is nerabout normal but now it is 35 degree Celsius and that is abnormal. From the entire analysis, it can be found that the patient is suffering from hypothermia. Hypothermia can be defined as the medical emergency that is seen to occur when the body is seen to lose heat at a much faster rate than it can produce it (Kim et al. 2014). This causes dangerously low body temperature. Homeostasis is the system of the body that tend to keep the internal environment of the body stable and helps to adjust to conditions that are optimal for survival.  When the temperature of the core falls below stable condition, three mechanisms take place to help the body come back to normal. Shivering is done by muscle contractions to create more body heat (Tuponr rt al. 2016). Heart stops pumping blood closest to skin and this prevents loss of heat through skin. It only pumps blood to major organs that need heat and oxygen (Tretter 2016). So Rosy’s skin became cold. Respiratory system accommodates heart’s pumping of less blood by breathing slower so less oxygen is only required. In extreme situation as in Rosy’s case, homeostasis was failing miserably and this led to hypothermia. The body’s core temperature fall 25 times faster in cold water than in cold air and hence the temperature of individuals are seen to fall from 37 degree c to that of 35 degree c. In cold water, the skin begins to cool and therefore the body is seen to constrict the different surface blood vessels (Walter 2017). This is mainly done to conserve the heat for the vital organs to work properly. Hence, the blood pressure and the heart rate also increases. Therefore, the blood pressure of rosy was found to be high. Muscles are seen to get tensed and shiver at the same time as this helps the body to produce more heat and adjust to the condition (Oh et al. 2016). Therefore, the vital signs changed due to the be mentioned physiological symptoms.

Intervention:

Rosy should be immediately moved from cold areas to warmer areas and she should be protected from the cold wind that is blowing. She should be protected from the wind especially around the neck and the head. The patient should be insulated from the cold ground. The wet clothing should be immediately removed (Bikmoradi et al. 2015). The wet things should be immediately replaced with warm, dry blankets or coats. If further warming is required, arm, dry compresses can be used in the centre of the body like mainly in the neck, chest as well as groin (Zhou et al. 2017). Another option that can be used is electric blanket. If hot water bottles or chemical hot pack can be is needed to be used, then a towel should be wrapped around it before applying. The person should be provided with warm, sweet as well as non-alcoholic drinks (Tuponr et al. 2016). The warning should be done gradually taking time. The limbs should not be rubbed as that might lead to stressing the heart and lungs. Other cues that need to be collected are whether the person’s coordination is getting severely impaired or not. Often such patients are seen to become confused that accompanies incoherence irrationality (Boug et al. 2015). Her skin should be touched and seen that whether she is feeling lethargic or not. All these would help to understand whether her hypothermia is still progressing or not . As the hypothermia progresses such symptoms may proceed and in such situation, rectal thermometer should be used as that oral measurements may not provide information accurately. Numbness of the limbs, loss of dexterity as well as clumsiness may occur in mild hypothermic situations and this should be also known to help the person come back to normal condition by exercising effectively (Gorges et al. 2016)..

I entered the room with my mentor and saw that the patient was not comfortable and was continuously pulling the blanket towards her. I tried to make her feel comfortable by covering her with a comfortable blanket and asked her how she was feeling. She was shivering immensely and she could hardly talk. I tried to measure her vital signs and for measuring that, I took her consent. However, I suggested her to lie on the bed with one of their side in a position where they can flex their hop. To this, she said that she is not comfortable and did not allow me          to take her rectal temperature I tried my best to make her understand her and tried my best to influence her. She got irritated and turned to my mentor stating that she is not comfortable with my actions.

So what?

To this, my mentor took me to another side and stated that maintaining the dignity and autonomy of the patients should be our first priority as nursing professionals. This ethics allows patient to be unique persons who has the innate right to have their own opinions, values, perspectives as well as beliefs. Patients are encouraged to make their own decisions without any judgements or coercion from the nurses (Ar and Gozan 2018). The patient has the right to accept as well as reject any treatment and procedures. Therefore, from this situation, I learnt that I should focus primarily on autonomy and dignity of patients and would perform and plan my intervention according to him only. Therefore, I took her temperature orally as she was comfortable with that.

Now what?

From the entire situation, I learnt that I should always follow proper ethical guidelines when taking vital signs.  I should first describe my procedure of taking vital signs and its importance in treatment. I would then ask for informed consent. I should maintain autonomy and dignity of the patient first and then would plan my interventions or alter my working procedure is that patients feel respected and cared for.

References:

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