ABCDE Framework for Nursing Assessment and Interventions

Introduction

When assessing patients in acute care, the ABCDE framework is essential for identifying risks and prioritising interventions. This case study explores Michelle’s condition, highlighting assessment limitations, evidence-based nursing and pharmacological interventions, and the importance of communication and person-centred care.

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Part A: ABCDE Framework for Michelle

Please use dot points in this section

Limitations/Omissions must be supported by literature

Assessment Undertaken

(What did you see happen)

Limitations/Omissions

(What aspects of the assessment was not completed in full or was omitted)

Airway

· Airway was noted to be clear by the nurse, and Michelle was able to communicate (Elliott et al., 2021).

· No examination of the upper airway was performed (for example no inspection of the mouth and throat).

· As for suctioning and further checks of possible obstructions, no data were provided.

· There is a great need to assess other parts even if the assessment of the airway seems to have been completed, due to noticeable swelling or blockage.

Breathing

· Respiratory rate recorded at 24 breaths/min.

· Oxygen saturation measured at 93% on room air (Shenoy et al., 2020).

· Several other lung exams like checking equal chest expansion or for features of respiratory trouble were not performed.

· Development of early respiratory complications should be auscultated to ensure the right interventions are taken (Kim et al., 2022).

· Further respiratory assessments like auscultation were omitted.

Circulation

· Blood pressure recorded at 100/60 mmHg (Munira Khusainova Alisherovna, 2021).

· Capillary refill and peripheral pulse assessments were omitted.

· Other tests of perfusion were not performed, besides blood pressure and heart rates (Rasche et al., 2020).

· A complete assessment of the circulatory system involves assessment of skin colour, temperature and the time taken for the capillary beds to refill after compression.

Disability

Heart rate recorded at 115 bpm (tachycardia).

· A neurological examination could help understand her current level of consciousness, and identify any signs of developing neurological disorders.

Exposure

· Michelle was alert and able to communicate.

· No assessment of skin or body temperature mentioned.

· No assessment of her skin for rashes, bruises or infection was performed and the patient’s temperature was not checked.

· An exposure assessment is necessary in order to notice any changes on the skin that might be suggestive of an inner problem.

Part B: Nursing and Pharmacological Interventions (Prioritisation of Care)

Please complete the below table and in order of priority choose three examples where the A-E assessment* was not best practice, identify best practice and justify with literature. At least one intervention must be pharmacological and one nursing.

Priority

Name of Intervention

Type of Intervention

(i.e., pharmacological or nursing)

Justification (with reference to scholarly literature)

1. Administration of GTN (Glyceryl Trinitrate)

Pharmacological

Michelle clinical manifestations include chest pain, and Acute Coronary Syndrome (ACS). GTN is a vasodilator, which is administered during managing ACS because it relieves chest pain through dilation of coronary arteries and enhances the blood supply to the myocardium (Gottlieb et al., 2022). However the following must be looked at considering Michelle’s hypotension as GTN results in a low blood pressure. The gradual administration of GTN and regular BP check is advisable and concordant with the NICE standard, as stated in the guidelines: GA.(2021:Chapter 1).

In the care of patient with ACS, the use of GTN as a therapy is important to enhance the supply of oxygen to the myocardial cells and relieve the patient of Ischemic chest pain. However, Michelle has hypotension as a risk factor and GTN triggers further hypotension. According to several guidelines, GTN should be administered over time while observing the patient frequently, increasing the doses of GTN while measuring patient’s blood pressure frequently (NICE, 2021). This conservative manner allows optimal pain management with fewer hypotensive crises.

2. Morphine administration

Pharmacological

Michelle complained of chest pain and tachycardia which are cardinal signs which might herald respiratory or cardiac disorders including pneumonia, pulmonary embolism or cardiac failure. The best practice response in this situation includes performing bilateral lung uses at the moment as quietly as possible to investigate for crackles, wheezing or diminished breath sounds that indicate fluid overload, respiratory infections as well as other respiratory complications including failure. As Michelle is now complaining of severe chest pain morphine can be given for pain management. Morphine is an opioid analgesic that can be effective in decreasing pain along with anxiety level and sympathetic tone in myocardial infarction and thus Oxygen demand will be decreased (Sodha et al., 2021). But it has to be used with care because it is a vasodilator agent that may lead to production of hypotension. The guidelines from the European Society of Cardiology ESC recommend the use of Morphine, where pain remains uncontrolled after nitrate administration and with close observation of vital signs (ESC, 2020).

The other important drug that is useful in treating severe chest pain includes morphine when other agents have not worked. It does so by decreasing pain and anxiety, which subsequently decreases a sympathetic response and myocardial oxygen demand (Sodha et al., 2021). However, morphine is known to have a practically proven action of dilating the blood vessels thus likely to worsen hypotension. The recommendations also contain strict observation of blood pressure and respiratory status, and maintaining stability (ESC, 2020). Holding and or reducing the dose of GTN when intraoperative pain develops is required before administering morphine as coined by the cardiology guidelines.

3. Auscultation of heart and lungs

Nursing

Michelle’s blood pressure 100/60 mmHg and tachycardia, 115 bpm suggest hypovolemia or dehydration, a situation that will worsen her condition. That low blood pressure and tachycardia are giving Michelle means that she may not be supplying her organs adequately, so she is in shock. Michelle’s chest pain and tachycardia are symptoms that could suggest the presence of the respiratory or the heart complications like heart failure, pulmonary embolism or pneumonia. Lung or heart sounds, crackles, wheezes, and murmurs are essential for diagnosing these conditions, and auscultation should be performed right after the patient is physically examined (Rozanski, 2022). Knowing early when the child starts making unusual noise can prevent developments of conditions such as heart failure through administering diuretics or pneumonia through administration of antibiotics. Bates’ Guide to Physical Examination still introduces auscultation as one of the main methods of clinical assessments to diagnose abnormalities.

Auscultation is one of the essential and basic nursing care in evaluation of clients with chest pain and respiratory complaint. Michelle’s tachycardia, and hypotension along with respiratory distress require auscultation, to exclude heart failure, pulmonary embolism or pneumonia (Rozanski, 2022). Lung or heart sounds are usually checked as part of routine assessments to identifying any abnormalities early enough to institute early management. For example, the noises like crackles or wheezing may call for diuretics or antibiotics, and enhance patient’s longevity by responding effectively.

* Please choose a specific intervention not a section of the A-E framework. For instance, do not choose the whole airway section.

Part C: Interprofessional Communication

Critically reflect on how the interprofessional communication may impacted Michelle’s health outcomes.

*Please make reference to one NMBA Registered nurse standards for Practice (Choose from Standard 1: Thinks critically and analyses nursing practice, Standard 2: Engages in therapeutic and professional relationships or Standard 3: Maintains the capability for practice)

On this basis, working relationships involving interprofessional communication are essential for providing the best patient care within situations which involve Michelle’s kind of a case. The flow of information enhances the crucial information interchange amongst carers thereby ensuring that interventions occur in an efficient and timely basis. Presumably, poor communication between the members of the healthcare team was a major reason for delays when assessing and treating Michelle, which may have worsened her condition.

Impact on Health Outcomes: These parameters were expounded by Michelle’s clinical deterioration such as tachycardia, low oxygen saturation, and chest pain called for an interdisciplinary response to the problem (Aljahan, Abdullah M, 2023). Lack of interprofessional collaboration has probably contributed to the prospects of time delays for other interventions, for instance oxygen therapy, prescription of medication, or other tests that may be deemed necessary (Parrish et al., 2022). Such failure of communication may lead to a compromise in the optimal care that a patient may require, augmented levels of patient stress, and potentially detrimental outcomes as well.

 Registered Nurse Standards for Practice: SC 1 – Able to Think Critically and Analyse Nursing Practice The first of the five standards establish communication can be applied when defining interprofessional communication in relation to skill demonstrated by a nurse. This particular standard entails the ability of the nurse to evaluate, analyse, and integrate information to make rational clinical decisions (Pegueroles et al., 2020). If Michelle were more involved in self-reflected critique of her symptoms and more actively provided her data to the healthcare team, the treatment plans could have been introduced in this case sooner. As to NMBA (2016), nurses should promote interventions and engage in conversations that will benefit the outcomes of a certain patient by identifying what the patient requires.

 National Safety and Quality Health Service Standard: The Communicating for Safety Standard is aimed at effective and proper transfer of information that is essential in the healthcare facility so as to promote safety to the patients (SDavey & Wyatt 2009). Handover and update could have significantly reduced the possibility of unfavourable outcomes as all the care team members would be informed of Michelle’s status and the actions required (NSQHS, 2021).

Person-centred Care

Critically reflect on how the delivery of person-centred care may impacted Michelle’s outcomes

*Please make reference to one National Safety and Quality Health Service Standard (Choose from Partnering with Consumers Standard, Communicating for Safety Standard or Recognise and respond to Acute Deterioration Standard) 

Patient self-determination stands for caring for the individual needs, solicitude, and values in acknowledging healthcare decisions (Gomes, 2024). In Michelle’s case, the major priority was to deliver person-centred care since she was physically uncomfortable with chest pain tachycardia and low pulse oximetry. However, some drawbacks are likely to have been experienced by the healthcare team, including delayed response on miscellaneous aspects of her worries and or symptoms (Aiyegbusi et al., 2021). While initial gross assessments were done, there is an evident failure to fully respond to some of the emerging priorities such as lung sounds examination and subsequent updates on the patient’s status in that regard.

Impact on Health Outcomes: Hence, the patient’s voice is put in the centre through person-centred care (Öhlén & Friberg, 2023). In Michelle’s case, her symptoms were not denied, but there was an inadequate attentive reaction to her severe complaints in the course of the manipulations, for instance, to the chest pain. The conscience of the censure might include a more active interaction with Michelle; listening to her Narrative, making sure she was taken seriously, and effectively following the right actions immediately when her condition had been deteriorating. For instance, Michelle may not have been apprehensive as a result of regular information sharing regarding her treatment plan and repudiation of her deteriorating symptoms.

National Safety and Quality Health Service Standard: This standard relates to Partnering with Consumers Standard which highlights engagement with patients, meaningful consideration of their values, preferences and Involvement in making choices (Jerofke‐Owen et al., 2020). Therefore, if healthcare had included Michelle as a significant decision-maker in her treatment, her concern about chest pain would have been listened to and addressed. This may have resulted in early interventions in case her experience worsened and thus constantly improved her condition. By joining me in this way Michelle would have also received coaching around feeling reassured, as well as general improvement in the care and how it is delivered aligning it with her needs more effectively.

ERROR Partnering with Consumers Standard when implemented will enhance Person-Centred care and patients’ involvement in their care plan (Pateman et al., 2023). Its absence can therefore result in the lack of early identification of major alert signs as was evident in Michelle where patients need to be fully embarked on decision-making processes.

References

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