Unit 16  Observing the Patient’s Condition and Rescuing the Critical Patient

Chapter 1  Observing the Patients’ Condition

Contents of Observing the Patient’s Condition

Patient’s general condition

Development and bodily form  Development is judged by age, height, weight, intelligence. Anthropometric measurements are used to determine body dimensions.

Diet and nutrition  Rational diet is important in the course of treating illness.

Facial features expression  Commonly special faces are as follows:

●  Acute facies  These include red face, too excited, tachypnca, painful expression. They can result from lobar pneumonia, malaria and so on.

●  Chronic facies  Chronic diseases, for example, malignant tumors, tuberculosis, can result in chronic facies, pale or grey look.

●  Critical facies  The patient with serious shock, hypohydration, is hyposteatosis, indifferent expression.

Position  The patient’s position is intimately related to diseases. Different patient may be obliged to take specific positions because of different diseases. Semi-Fowler’s position provides chest elevation and is thus often indicated for patients who have cardiac and respiratory problems.

Posture and gait  Rocking when walking is called wadding gait, which could result from congenital dislocation of the hip, rickets, hypoalimentatiwww.med126.com/wszg/on and so on.

Sleep  The nurse should interview the client to obtain a sleep history.

Skin and mucosa  Skin and mucosa can reflect some diseases. The nurse should observe the color, temperature, humidity, elasticity and absence or presence of hemorrhage, edema, rashes (skin eraption), cysts, subcucmeous nodules and so on. Lips, nail beds and conjunctive of anaemic patients are pallor. Cyanosis is blueness of the skin due to a lack of oxygen in the blood. It often occurs in the conditions of cor pulmonale (pulmonary heart disease) and heart failure.

Vomitus  Emesis (vomiting) is a phenomenon that material in the stomach is spat out through esophagus and oral cavity. It is a highly unpleasant sensation and an important sign that there is something physically and psychologically wrong.

Secrections   Secrections include sweat, sputum, feces, urine and so on.

Vital signs 

States of consciousness

Consciousness is the state of perception to the surroundings. Disturbance of consciousness is the state of lacking normal response to the surroundings. It can be classified:

Somnolence  It is the slightest disturbance of consciousness. The patient keeps on the state of sleeping, but can be wakened by words or slight stimuli, and answer questions correctly and simply. Besides, the patient is slow in thought and reaction.

Confusion  The patient has partially or completely wrong orientation to time, place and person, slow in thought and reaction and use of simple, nontechnical words.

Stupor  The patient sleeps deeply and is difficult to be wakened. Strong stimulation can waken him and he will answer the question vaguely and even give an irrelevant answer. The patient will fall asleep at once after stropping stimulation.

Coma  It is the heaviest disturbance of consciousness. It can be classified:

Chapter 2  Cardiopulmonary Resuscitation

Relating to Concepts

Cardiopulmonary resuscitation (CPR):  Cardiopulmonary resuscitation is a technique that externally supports the circulation and ventilation (breathing) in a victim of cardiopulmonary arrest. It helps to provide oxygen to the brain, heart, lungs, and other organs, until advanced life support can be given.

Cardiopulmonary Resuscitation (CPR)

Assess lack of pulse and breathlessness

●  Unresponsiveness or unconsciousness

●  Breathlessness

●  Lack of pulse, especially carotid pulse

●  Pupils are larger than 5 mm.

●  Skin is pale or in cyanosis

●  Cardiac sound is disappear

●  Wound is never bleeding

ABC of CPR

It is typical for emergency situations to create high anxiety levels. However, the nurse can assess patients in any emergency situation in an orderly manner by using the following memory help:

  A = Airway

  B = Breathing

  C = Circulation

A:  Airway

Assess responsiveness  The person must establish unresponsiveness, shake the person’s shoulder, clear h医学.全在线www.med126.comis pupils, and shout, “Are you okay?”

Call for help  Call out for someone to help you. You may need (1) to turn to the person or (2) to call the emergency medical system (EMS).

Position the person  The person must be in a supine (back-lying) position, a hard surface, if you are to perform CPR.

Finger-sweep to remove foreign matter  Any foreign matter, vomitus, or liquids should be removed from the airway before resuscitation begins. If a foreign body can be seen in the mouth, it should be removed with the fingers. Do not finger-sweep a child’s mouth!

Open the airway  If a neck injury is not suspected, you can: open the patient’s airway by placing your hand close to the patient’s head on the patient’s forehead, pressing back and down; and placing the fingers of your other hand under the bony part of the patient’s chin and lifting it up.

B:  Breathing

Determine if the person is breathing  Several ways are used to determine if the person is breathing, such as: (1) look at the chest, to see if it rises and falls; (2) listen for sounds of breathing; (3) feel for any air exchange against your cheek. If the nurse determines that the patient is not breathing, rescue breathing must be performed.

Perform rescue breathing  With the head positioned to keep the airway open, grasp the nose with the fingers of your hand on the person’s forehead. The nurse should take a breath and create an airtight seal with his or her lips around the person’s mouth. Breathe into the patient’s mouth twice. The nurse takes a new breath before each rescue breath. The patient is allowed to exhale passively between breaths. Ventilate the adult patient 14 to16 times a minute. The child should be ventilated 18 to 20 times a minute. This is called mouth-to-mouth ventilation.

C:  Circulation

Check the pulse  The nurse should gently palpate the pulse for 5 to 10 seconds, being careful not to compress the artery, and avoid reaching across the patient to palpate the carotid pulse. Take the pulse of only one carotid artery at a time.

Resuscitation if the patient’s heart is beating  If a pulse is present, keep on ventilating the patient. Continue to monitor the pulse, because it may stop.

Resuscitation if the patient’s heart is not beating  If there is no pulse, external chest compressions must be applied.

●  Single-rescue CPR  Kneel at the side of the patient, using the hand closest to the patient’s feet, slide the first two fingers along the lower rib margin until you reach the notch where the ribs meet the sternum. Place the middle finger in the notch and the index finger just above the middle finger. The adult chest is compressed from 3 to 5 cm, at the rate of 60 to 100 times a minute, with a ratio of 15 compressions to 2 breaths. This is continued for approximately 1 minute. After 1 minute the pulse is checked for 5 seconds. If a pulse is not found, CPR is continued for 4 to 5 minutes before the pulse is again checked. If no pulse is found, resume CPR. Recheck the pulse every few minutes.

Standard for evaluating

●  Respiration is resuming and heart is beating again.

●  Pulse can be touched.

●  The color of face, lips, nails and skin turns red.

●  Sounds of breath can be heard during exhalation.

●  Dilating pupils reduces.

●  Consciousness resumes.

●  Urine appears.

●  ECG waveform alters.