The following Assignment task refers to the assignment in 2014. The task in 2015 has a different scenario and slightly different requirements therefore students need to consider this aspect in developing their Aged Care Nursing Assignment in 2015.
Three exemplars representing different standards have been provided that address the 2014 assignment task. These exemplars may provide you with further insight in how to address the 2015 task in regards to how to most effectively develop the assignment structure, provide a substantiated discussion and reference appropriately.
This assignment was allocated a Grade of 6.
Assignment Question 2014
Students are to refer to the following scenario and address the assessment task. Students are required to research the current scholarly literature and present written work using APA 6 style.
Scenario
A confused man (approximately mid-sixties in age) presents to the Emergency Department in a dishevelled and unkempt state. He has been unable to coherently provide information about himself or his condition. On admission, his appearance and odour suggests that he has not washed for some time and he frequently scratches his right upper arm. He anxiously keeps trying to leave the department saying that he wants to get home for dinner, yet is unable to state his address. On examination, his breath has an acetone odour, he has a haematoma (50 cents size) on the right side of his forehead and he repeatedly states that he wants to pass urine.
Assignment A: 2,000 words
You are the Registered Nurse assigned to care for this patient. You are required to assess this patient and plan their care. In order to do this you will need to:
1. Detail, prioritise and provide rationales for the nursing assessment that you will undertake.
2. Prioritise and provide rationales for the planned care you develop for this patient.
Student Name: Jane Doe
Essay/Report Title: Nursing Assessment and Planning
Patient Care
Word Count: 2203 (2000 +/- 10%)
The Accident and Emergency Department (A&E) is a complex and dynamic working environment for all health professionals. It is a specialised unit where patients of all age groups attend for emergency care for acute health issues. There is, however, great concern for the growing A&E admission rates of elderly patients over the past decade. The purpose of the following essay is to discuss the types of nursing assessments and care provided for an elderly man (Mr X) admitted to A&E with confusion, amongst other symptoms. Initially, the atmosphere of the emergency department (ED) will be defined, including the role of emergency nurses. A brief description of the ageing population will occur, focusing on A&E admissions and the affect of the emergency environment on the elderly. Different types of nursing assessments will be discussed in relation to this elderly man, utilising primary and secondary survey techniques. To conclude, appropriate nursing care will be provided, ensuring patient safety, comfort and communication .
A&E provides 24 hour critical emergency care to all who are acutely ill or injured (Ryan, Liu, Awad & Wong, 2011). According to the Australian Bureau of Statistics (ABS), approximately 2.4 million individuals were admitted to an ED over a 12 month period in 2010-2011 (ABS, 2012a); equivalent to over 6,500 admissions per day. It is evident that A&E is one of the busiest units in a hospital setting. In addition, vary in gender, age, cultural background, socioeconomic status and the admission types clinical presentation (Australian Institute of Health and Welfare, 2012). Health professionals, therefore, must be equipped to adapt to the variety of patient attendance and provide emergency treatment for a diverse array of clinical presentations.
The ED process encompasses a variety of procedures, ranging from triage assessment, care planning, diagnostic investigations, inpatient admittance and discharge. The team, therefore, must consist of multidisciplinary professionals, who contribute complementary knowledge and skills to the overall care of the patient (Department of Human Services, 2009). A fundamental health professional involved in A&E are nursing staff. Nurses are responsible for a vast array of tasks including assessment, investigation, care planning and monitoring of patients’ conditions, while communicating with the medical team and the patient’s relatives (Curtis, Murphy, Hoy & Lewis, 2009). A&E units are designed to deliver immediate time-critical periods of care to manage medical emergencies (Department of Human Services, 2009). Time management is crucial in A&E; therefore, the emergency nursing roles must be prompt, accurate and meticulous.
Worldwide, there is an increasing ageing population. In Australia, the population structure is transforming to be characterised by a decline in the proportion of younger people as the older population increases. According to ABS (2012b) statistics, approximately 23% to 28% of the population will 65 years or older in 2056, compared to 13% in 2007. As a result, there will be a significant increased demand on the healthcare system, with older adults more frequently seeking acute medical assistance. This is evident in the 2010-2011 statistics (ABS, 2012a) indicating approximately 17% of adults aged 65 years and older visited an ED over a 12 month period .
The care provided by A&E nursing staff to older adults is extensively different to that of younger patients. Elderly patients presenting A&E typically require more complex treatment regimes due to multiple co-morbidities and polypharmacy (Peters, 2010), in combination with functional limitations and cognitive impairments (Rosted, Wagner, Hendriksen & Poulsen, 2012). Additionally, according to Peters (2010), emergency nurses must understand the expected changes of ageing and deviations from the norm; thus, influencing potential atypical or nonspecific physical symptoms and inaccurate diagnoses (Parke & Chappell, 2010 ).
The A&E atmosphere can negatively impact older adults’ physical and psychological health. The physical environment of A&E units consists of overcrowding, consistent loud noises, bright lights and cold temperatures (Kelley, Parke, Jokinen, Stones & Renaud, 2011). As a consequence, uncomfortable environment, safety risks, lack of privacy and interrupted sleep were experienced by many clients (Kelley et al., 2011). The social climate of A&E departments was also illustrated as ‘busy’ and ‘chaotic’ (Kelley et al., 2011). This type of atmosphere contributes to a lack of physical and emotional support, family reassurance, assistance in self cares and long waiting times (Parke & Chappell, 2010). It is evident that the A&E environment of can be very distressing to elderly patients. It is, therefore, paramount for emergency nurses to take into consideration these aspects when developing assessments and care plans for the older population.
It is an imperative responsibility of emergency nurses to perform a thorough assessment. A characteristic of A&E departments is the presentation of patients with undifferentiated diagnoses in a time pressured environment (Curtis et al., 2009). An accurate assessment is, therefore, critical to determine a potential diagnosis, establish a care plan and monitor a patient’s health status (Curtis, Lord & Ramsden, 2011). There are two types of nursing assessments; primary and secondary survey. According to Dean and Mulligan (2009), these provide an emergency nurse with a methodical approach to identify and prioritise care. The aim of primary survey is to detect and stabilise actual or potential life-threatening conditions (Curtis et al., 2009). It encompasses the ABCD mnemonic; airway, breathing, circulation and disability, or neurological function. In regards to the scenario, an initial primary survey should have occurred during the triage assessment to determine the severity of the condition. Reassessment by the emergency nurse assigned to Mr X is, however, paramount due to the risk of changing conditions or rapid deterioration in the A&E setting (Curtis et al., 2011).
Once the primary survey is completed, an ED nurse can continue with a more comprehensive assessment; a secondary survey. Its aim is to detect injury which was not identified in the primary survey (Dean & Mulligan, 2009). According to Curtis et al. (2009), secondary survey involves a methodical head-to-toe assessment technique, whilst incorporating history taking and diagnostic testing. In any emergency situation, an essential component is the assessment and monitoring of the patient’s vital signs (Curtis et al., 2011). This includes pulse, blood pressure, temperature, respiratory rate and oxygen saturations, as well as blood glucose levels and pain score. These results provide a baseline to identify future clinical deterioration (Rose & Clarke, 2010). In addition, abnormal vital signs are key indicators to the body’s compensatory reaction to illness or injury (Rose & Clarke, 2010); thus, guiding the implementation of further investigations and interventions.
The time-critical atmosphere of A&E results in prioritisation of the head-to-toe assessment to the body systems affected by the presenting signs and symptoms (Curtis et al., 2009). The clinical presentation of confusion and a head haematoma are two concerns, especially considering Mr X’s predicted age. The neurological system, therefore, is the first priority in this scenario. The Glasgow Coma Scale (GCS) would be the initial nursing assessment. Its purpose is to assess the level of consciousness in patients with a suspected head injury (Bethel, 2012), which is indicated by the haematoma on Mr X’s forehead. Bethel (2012) demonstrates that the GCS is a predictor for injury severity and subsequent intracranial haemorrhaging. In addition, assessment of the cranial nerves, focal neurological signs and neurovascular observations would be beneficial to assess for a head injury and concussion (Suadoni, 2009). A mini mental state examination and the confusion assessment method would also be conducted by the nurse. These two assessments are used to detect the presence of delirium and a variety of mental illnesses, such as dementia and psychosis (Sendelbach & Guthrie, 2009), which are indicative of the clinical presentation of confusion and repeated scratching.
The cardiovascular system would be next assessed. Cardiac monitoring is an essential assessment tool utilised by nurses in A&E, especially with the presence of confusion and falls risk in the elderly (Curtis et al., 2011). In addition, serology should occur. It is not within a registered nurse’s scope of practice to prescribe such laboratory testing; however, it is essential for nurses to understand the rationale of each and the significance of results (Curtis et al., 2009). Initial blood tests ordered for Mr X would be based on his clinical presentation, including a full blood count, urea and electrolytes, liver and thyroid function, alcohol and drug levels, and coagulation rates (Han & Wilber, 2013). Drawing blood and intravenous cannulation are not competencies of a regular registered nurse. Specific hospital protocol or additional training may be required; thus, allowing such tasks to be performed by a qualified A&E nurse in the department.
Assessments of the renal and endocrine systems are of high priority for Mr X, due to the presentation of urination frequency and acetone breath. According to Donahey and Folse (2012), this symptomatology and Mr X’s confused state are indicative of poorly controlled diabetes mellitus (DM) and diabetic ketoacidosis (DKA). An emergency nurse must conduct a variety of procedures to confirm or eliminate this potential cause. A simple and non-invasive nursing assessment is a dipstick urinalysis (UA). A UA examines a diverse range of urine substances, including glucose, pH, protein, ketones, specific gravity, nitrates, white and red blood cells, and albumin (Boyd & Barratt, 2011). Results outside of the normal range for each of these components can identify numerous disease states; for this scenario in particular, DM and DKA, infection, sepsis, dehydration, malnutrition and alcohol consumption. In addition, a nurse can observe Mr X’s urine output and its appearance of colour, clarity and odour (Boyd & Barratt, 2011).
The integumentary system is the last priority in the assessment of Mr. X. Ageing causes the skin to become drier, fragile and less turgor; consequently, predisposing elderly patients to an increased risk to skin damage (Hunter, 2012). The haematoma on Mr X’s forehead would create concern for additional skin damage to other parts of the body. An ED nurse should conduct a physical examination of Mr X to observe other haematomas, bruising, rashes, lesions and discolouration (Hess, 2008). In addition, the frequent scratching of the upper right arm should be monitored to eliminate further skin damage. The remaining body systems should be assessed at a later stage in the ED process to ensure a predominant focus on presenting clinical manifestation.
The care provided by the nursing staff directly affects patient wellbeing and clinical outcomes. In A&E, the main focus of nursing care is to provide life-saving action to diagnose and treat the presenting complaint (Shapiro, Clevenger & Evans, 2012). A review by Pearce, Rogers-Clark and Doolan, (2011), however, demonstrated the pivotal role of ED nurses in adapting the care to specifically meet older patients’ needs, while decreasing the development of additional complications and distress unrelated to their presenting illness. One crucial aspect in regards to the care of Mr X is safety. According to Hignett (2010), the incidence of hospital falls is three times more likely than community-dwelling older people. Potential risk factors for Mr X in an ED unit include an unfamiliar environment, lack of safety aides, equipment obstacles, and symptomatology of confusion and urinary frequency (Hignett, 2010). It is essential for a nurse to conduct a falls risk assessment. This will guide the implementation of simple fall prevention interventions; for example, attaching brightly coloured wristbands to identify high fall risk patients and providing anti-slip footwear (Krauss et al., 2008). Patient monitoring is a frequently utilised nursing strategy to maintain patient safety. This may include moving Mr X closer to the nursing station (Cumming et al., 2008) and providing a ‘special’ for close supervision (Krauss et al., 2008). Environmental modifications in A&E are important safety precautions. This may incorporate de-cluttering the patient’s room and surrounding environments, ensuring an obstacle-free and well lit pathway to the bathroom or providing a commode and urinary bottle (Krauss et al., 2008). In addition, the facilitation of hand rails usage, lowering the bed and ensuring the call bell is within reach (Quigley et al., 2009).
The promotion of comfort is another important nursing care role . The A&E environment is chaotic; therefore, minimising reactive stimulus can be beneficial to a patient’s recovery by reducing distress (Han & Wilber, 2013). Modifications to the environment are essential for a senior-friendly ED unit, including dimming bright lights, reducing auditory stimulation from cardiac monitors or intravenous infusion pumps, and limiting staff changes (Fong, Tulebaev & Inouye, 2009). A key issue ED nurses must consider is unnatural attachments and physical restraints not necessary for clinical care. Examples include intravenous lines, oxygen masks, monitoring devices and bed rails. According to Fong et al. (2009), such restraints decrease mobility, increase the risk of injury and infringe on patient autonomy and dignity. As a consequence, Mr X may be predisposed to high levels of anxiety and agitation, resulting in cooperation difficulties during the assessment, history taking and treatment processes. Han and Wilber (2013) suggest providing intermittent fluid dosages and vital sign measurements, instead of continuous treatments.
ED nurses acquire the responsibility to provide safe and high quality care to patients. Effective communication skills on several levels are essential; to the patient, family members and the multidisciplinary team (Curtis et al., 2011). Nurses must engage in holistic care of Mr X to promote a trusting nurse-client relationship, via open communication. This approach ensures a genuine connection and rapport (Curtis et al., 2011). Effective communication and a harmonious relationship, in combination with a calm and quiet environment, enables ED nurses to conduct further assessment of Mr X. Particular focus would include history of the presenting complaint, past medical history, medications, psychosocial status and availability of a collateral, which are vital comprehensive information in an A&E setting (Curtis et al., 2009). In addition, ED nurses are responsible for communicating and referring to other healthcare professionals, including the medical team, dietician, mental health clinician, physiotherapist, occupational therapist, social worker and community health nurses (Leah & Adams, 2010). These types of nurse-initiated interventions promote a diverse range of additional assessments to ensure optimal care for Mr X.
A&E is a complex and dynamic functioning environment. All medical staff must be able to adapt to the variety of patient attendance and clinical presentations. One population which is increasingly utilising the ED unit is the elderly. Nursing staff must understand the ageing process and the affect of the emergency atmosphere on older patients to ensure appropriate assessment techniques are used and quality care is provided. ED nurses should employ the primary and secondary survey to prioritise the type of assessment, in relation to Mr X’s presenting complaint. Life-saving treatments are vital in an A&E setting; however, nursing staff must incorporate care specific to Mr X’s needs. This includes patient safety, comfort and the development of trusting relationships, via open communication between patients and health professionals. This approach guarantees the opportunity for a senior-friendly ED unit.
References
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