Abstract
Medical personnel working in the emergency department encounter many cases of patients suffering from life threatening conditions. It is important, therefore, that the healthcare provider determines the exact extent of the injuries before the patient is committed to specialized treatment. In this case, a patient presents to the emergency department with a life threatening condition, renal failure. Assessing the vital signs of the patient is critical in ensuring survival, in addition to reducing or mitigating the extent of the injuries. The assessment was achieved via a primary survey of the patient, which involved assessing the airway patency, breathing and ventilation, circulation, disability including neurological status and exposure. In addition to the primary survey, it is imperative to identify factors that contribute to the deterioration of the physical status of a patient suffering from renal failure. Finally, the care provider should initiate nursing care relevant to a patient’s needs in an effort to stabilize the patient.
Keywords: Primary survey, assessment, injuries, nursing care
End-Stage Renal Disease
End-stage renal disease
End-stage renal disease (ESRD), also commonly referred to as kidney failure, is a chronic illness that leads to loss of functions of the kidneys over a period of time (American Kidney Fund, 2016). It is referred to as end-stage because at this point, the kidneys are completely unable to function, usually at or below 10% of normal functioning (John Hopkins Medicine, 2015). The condition develops slowly, usually over a period of up to 10 years after diagnosis with a kidney disease (McDermott, 2016). There are many factors that contribute to the development of ESRD, for example, long-term abuse of alcohol, and injuries to the kidney resulting from frequent infections (DiMaria & Leonard, 2016). Treatment strategies for this condition include dialysis and kidney transplant (DiMaria & Marijane, 2016).
Primary Survey
Primary survey of a patient is an assessment intended to determine the extent of the deteriorating patient on a patient (Kman, 2010). Primary survey is important in ensuring survival of the patient while awaiting more specialized treatment. Maintaining a patent airway, oxygenation, breathing, circulation, disability and exposure are the key aims of primary survey. The process of primary survey is carried out in four major steps; airway maintenance, breathing and ventilation, circulation, and disability and neurological status.
Airway Maintenance
When Mr. Miller presents to the emergency department, his initial assessment indicates scattered crackles bilaterally throughout the lung base. Crackles, according to McDermott (2016), are rattling and crackling noises emanating from one or both lungs of a patient. The crackles are as a result of excessive secretions in the airways, which may arise as a result of aspiration or lung infections such as pneumonia and chronic heart diseases. The crackles are an indication of edema in the lungs, and this contributes to the obstruction of the airway (McDermott, 2016).
An airway is described as not patent when the patient is deoxygenated, fails to ventilate, and/or fails to maintain patency (Canadiem, 2015). At this point, it is very important that the RN further analyzes the most suitable way to manage the airway obstruction in order to facilitate oxygenation and ventilation in patients. Some of the interventions for managing airways include jaw thrusts, supplemental oxygen, bag-valve mask, and suction (Canadiem, 2015). Sometimes, surgery may be required, but this demands for more advanced skills and knowledge.
Breathing
Breathing is another critical component for assessment during primary survey. The triage nurse indicates that Mr. Miller has a respiratory rate of 36 breaths per minute instead of the recommended 12-20 breaths per minute for an adult in a resting state (Blood Pressure UK, 2016). Ineffective breathing impairs the ability of the body to inhale enough oxygen, and may cause confusion and agitation in patients (McDermott, 2016), such as the case observed in Mr. Miller. Labored breathing is also exhibited by the use of accessory muscles, especially those on the neck. Examination is done when the patient is in a sitting position, and a pulse/oximeter reveals that his oxygen saturation is low.
The presence of the chest pain is an indication of an injury to the chest or the chest wall, and can also be a symptom of other illnesses such as cardiovascular diseases (NHS, 2015). In the case that the patient is not ventilating effectively, the RN must consider interventions such as suction to clear any obstructions. AdditionallyMr. Miller will be initiated on supplemental oxygen since his oxygen saturation is low and his airway is not patent (McDermott, 2016).
Circulation
Primary survey also includes the assessment of the aspect of circulation in the patient. Mr. Millers’ blood pressure is recorded as 180/110mmHg, which is very high compared to an adults’ ideal blood pressure of 100/70 mm/Hg to 120/80mmHg (Blood Pressure UK, 2016). Also, his heart rate is a little elevated at 116 per minute, compared to the ideal range of 60-100 beats per at a resting state (NHS, 2015). Factors that cause high blood pressure and respiratory rate include too much sodium, which in this case is as a result of the failing kidneys (John Hopkins Medicine, 2015). The increase in weight is another factor that can contribute to the high blood pressure. His skin color, capillary refill time, and the color of the mucous membrane are not compromised. Was there mention of these aspects in the brief – maybe you could say that you would assess these also for circulation??
There is no presence of bleeding, either externally or internally. However, Mr. Miller has a distended jugular vein, which shows an increase in blood volume (Healthgrades, 2013). The distended jugular vein is an indication of elevated pressure in the veins. The doctor will prescribe an ACE to lower blood pressure and reduce the distended jugular vein. ACE work by inhibiting Angiotensin II, which consequently reduce the amount of water reabsorbed by the kidneys and relaxes the veins (Blood pressure UK, 2016).
Disability or Dysfunction of Central Nervous System
Doing both tests is vital in ensuring that the patient is free from other complications such as heart disease. Alertness was determined by asking the patient his name, where he was and the time of the day, and asking him to explain how he felt, in an effort to assess his level of consciousness. To check for peripheral oedema, a physical examination was carried out. The peripheral edema can be reduced by elevating Mr. Miller’s legs, which will consequently improve circulation (NHS, 2016).
Exposure/Environmental Control
Communication
Effective therapeutic communication to the patient and family members reduces anxiety, and this will be achieved by frequently updating the family members on the medical progress of Mr. Miller and also reassuring them. Communication between the multidisciplinary team is also crucial, as it facilitates the management of the patient’s condition. During communication the ISBAR mnemonic tool will be used by the Multidisciplinary team. ISBAR – Identify, Situation, Background, Assessment and Recommendation - is a mnemonic created to improve safety in the transfer of critical information (SA Health, 2016).
The multidisciplinary team will mainly communicate via nursing notes, but will also incorporate face-to-face or telephone conversations whenever the need arises. To avoid legal/ethical issues that may arise, the RN should only initiate the interventions that are within his/her scope of practice. The RN should also adhere to the codes of conduct, code of ethics, and professional boundaries and competency standards as outlined by the Nursing and Midwifery Board of Australia (2016). The Nurse will be communicating with RN on duty, radiologists, lab technicians, non-medical staff such as the porter, and nephrologists (Johns et al., 2015).
Factors that Contribute to Deterioration of Patient’s Physical State
Hypertension and diabetes are some of the two major risks to ESRD (DiMaria& Leonard, 2016). Diabetes and hypertension increase the development of ESRD, in addition to heightening deterioration of the patient’s physical state. Pyelonephritis also complicates the patient’s physical state, and the RN should intervene to improve the quality of life of the patient by initiating the necessary interventions. MahboobLessan and Zohreh (2009) carried out a study to determine the quality of life of patients diagnosed with end stage renal failure. According to the study, patients not only suffer from impaired physical functioning, but they also experience psychosocial and mental suffering. adherence to treatment is another factor that contributes to deterioration of the physical state of a patient. Mr. Miller missed a dialysis appointment, and this could have contributed to his current situation.
The age of the patient is another factor that contributes to the deterioration of a patient’s physical state. Statistics indicate that the prevalence of ESRD continues to grow among the geriatric population (Wong, 2014). As a person ages, his/her immunity becomes low, and diseases such as ESRD only heightens the patient’s susceptibility of the patient to opportunistic infections. Contracting opportunistic infections deteriorates the patient’s physical state. Pain is also another factor that contributes to the deterioration of a patient’s physical state. Pain reduces the quality of life of patients with ESRD.
Finnegan-John and Thomas (2012) also carried out a study to assess the effect of psychosocial experiences on the quality of life of patients with ESRD. According to the study, the debilitating chronic condition requires dialysis for survival. The treatment and the condition itself put mental stress on the patients. Although Mr. Miller has the support of his siblings and wife, it is evident that his current state is stressingon him and the family. Finnegan-John and Thomas (2012) also states that patients suffering from ESRD developed a new sense of self, which was characterized by increased awareness of an uncertain future, dependence on machinery and medications for survival, and the demands of the illness. This awareness, according to Finnegan-John and Thomas (2012), contributes to the deterioration of the patient’s physical state.
Nursing Care that will Stabilize the Patient
The primary survey indicates that the patient requires interventions to stabilize him before he is placed in the high dependency unit for dialysis. His blood pressure is too high and stabilizing it is critical for the survival of the patient. To stabilize the blood pressure, enalapril, angiotensin-Converting Enzyme, will be prescribed by the doctor with the aim of relaxing the patient’s blood vessels. ACE does this by inhibiting the release of Angiotensin II (Blood Pressure UK, 2016). The controlled blood pressure is expected to also contribute to an almost normalized heart beat rate and respiratory rate. The patient will also be put on a no-sodium diet in an effort to further manage the high blood pressure. Mr. Miller will be initiated on a pain management medication to improve his comfort, as he complains of moderate to severe chest pain. He will also be closely and frequently monitored by hooking him on an observation monitoring machine (SSWAHS, 2010)
Conclusion
This paper carried out a primary survey of a patient suffering from ESRD. The purpose of the primary survey was to identify important aspects that should be given priority in ensuring the survival of the patient. Airway maintenance, breathing and ventilation, circulation, and disability and neurological status were the main aspects reviewed for the primary survey. The paper also identified factors that contribute to the deterioration of the patient’s physical state including age, medications and dialysis, pain, and mental distress due to the burden of the disease. Finally, nursing care was initiated to help stabilize the patient as he awaits transfer to the emergency high dependency unit for dialysis. This patient depends on collaborative care, which makes multidisciplinary team very crucial. However, with such a team, care should be taken to ensure the confidentiality and autonomy of the patient is maintained at all times. Frequent communication with the family members is also critical in alleviating their tension.
References
American Kidney Fund. (2016). Kidney failure/ESRD. Retrieved from
http://www.kidneyfund.org/kidney-disease/kidney-failure/
Blood Pressure UK. (2016). Blood pressure chart. Retrieved from
http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Bloodpressurechart
Canadiem. (2015). Basic airway assessment. Retrieved from http://canadiem.org/basic airway-assessment-easy-1-2-3/
DiMaria, C. & Leonard, M. (2016). End-stage kidney disease: What is end-stage kidney
disease? Healthline. Retrieved from Healthline Database
Ferner, R. E. et al. (2007). Guidelines for the diagnosis and management of individuals with
neurofibromatosis 1. Journal of Medical Genetics, 44(2), 81-88.
Finnegan-John, J., & Thomas, V. J. (2012). The psychosocial experience of patients with
end-stage renal disease and its impact on quality of life: findings from a needs
GCS at 40. (2016). Glasgow coma scale. Retrieved from http://www.glasgowcomascale.org/
Healthgrades. (2013). Jugular vein distention. Retrieved from https://www.healthgrades.com/symptoms/jugular-vein-distention
John Hopkins Medicine. (2015). What is renal failure? Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/
John Hopkins Medicine. (2015). What are the vital signs? Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P00866/
Johns, T. S., Yee, J., Smith-Jules, T., Campbell, R. C., & Bauer, C. (2015). Interdisciplinary
care clinics in chronic kidney disease. BMC Nephrology, 16(1), 1.
Kman, N. E. (2010). The approach to trauma. The Ohio State University. Retrieved from
CDEM Database
MahboobLessan, P., &Zohreh, R. (2009). Contributing factors in health-related quality of
life assessment of ESRD patients: a single center study. Nephro-Urology Monthly,
1(2), 129-136.
McDermott, A. (2016). What you should know about bibasilar crackles. Healthline.
Retrieved from Healthline Database
NHS. (2015). How do I check my pulse? Retrieved from
http://www.nhs.uk/chq/Pages/2024.aspx?CategoryID=52
NHS. (2016). Oedema. Retrieved from
http://www.nhs.uk/conditions/oedema/Pages/Introduction.aspx
NHS. (2015). Chest pains. Retrieved from http://www.nhs.uk/conditions/chest-pain/Pages/Introduction.aspx
SA Health. (2016). ISBAR: Identify, situation, background, assessment, and recommendation.
Retrieved from http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/clinical+handover/isbar+-+identify+situation+background+assessment+and+recommendation
Sydney South West Area Health Service. (2010). Retrieved from
http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/RPA-observations-policy-directive.pdf
Wong, L. P. (2014). Dialysis realities.Today’s Geriatric Medicine, 6 (5), 12
