History, Physical Examinations and Investigations
In simulation 1, the history and physical examination suggests that the patient could be having diabetic coma as a result of hypoglycemia. Features that would favor hypoglycemia include syringe found next to patient, cold skin, rapid pulse, blood sugar of 21mg/dl and unresponsiveness. The findings of normal pupil reaction to light would imply that the coma is not due to brain parenchymal lesions, while normal temperature would rule out an infection of the brain. The technological tools used include the pulse oxymetry, capnometer, glucose machine and BP machine. The pulse oxymetry is important for continuous monitoring of pulse rate, capnometer estimates the carbon dioxide levels and thus oxygenation, glucose machine measures blood sugar levels and BP machine is used for blood pressure measurements.
In simulation 2, the history of a middle aged male collapsing during a marathon is quite significant. Long distance racing can lead to hyperthermia which increases evaporation of fluid from the body leading to dehydration and electrolyte imbalance; usually hyperkalemia because of damage to the cells and movement of potassium into the extracellular compartment. Hyperkalemia affects the neuromuscular activity and the function of skeletal muscle and this explains why the person collapsed during the marathon (Burke & Lemone, 2007). Assessment of pain with sterna rub, facial expressions and any verbal sounds; as was done in this case would give an estimate of the person’s level of consciousness although not very accurate. From the vital signs recording, the patient had very high body temperature of 1050f, tachycardia of 175beats/min and tachypnea of 38/min. The treatment given to lower his temperature and potassium is acceptable and technological tools used in this patient are quite useful. For example, since hyperkalemia was suspected use of ECG was important to monitor its effect on cardiac function. Hyperkalemia also causes muscle weakness and therefore auscultation of the chest becomes very essential, and in addition, medications given to correct this situation may also lead to fluid overload that may result in pulmonary edema and this then justifies the use of supplemental oxygen in this simulation. In simulation 3, a man found to be unresponsive and hypothermic with temp of 88.50f, normal respiratory function and normal blood sugar is justified to have cardiac monitoring. Since examination of head to toe did not reveal evidence of head injury then a myocardial infarction could be seriously considered and patient moved to ICU as was done in this case. In simulation 4 Carl Potts, a kidney patient collapses. This could be as a result of muscle weakness due to hyperkalemia. The use of supplemental oxygen was justified as the weakness could also affect respiratory muscles and heart muscles and this justifies use of oxygen mask and ECG machine. Patient remained alert because the central nervous system was not affected.
In the last simulation, the history was too short and may not have been sufficient to justify diagnosis of diabetic keto-acidosis. For a diagnosis of keto-acidosis to be made, other facts like signs of severe dehydration due to hyperglycemia (thirst, warm dry skin with poor turgor, soft eyeballs, dry mucous membranes, rapid pulse and hypotension), signs of metabolic acidosis (nausea and vomiting, ketone like breath, lethargy and coma), and other manifestations like abdominal pain and kussmals respiration are needed. In addition, use of other technological tools like glucometer, kidney function tests and CBC before initiation of treatment (Burke and Lemone, 2007) will be required.
Prioritization of Data Collection
In serious medical cases like the ones simulated, history and physical examination are very useful in data collection for one to arrive at a correct diagnosis. This should be followed by use of technological tools for patient diagnosis, management and follow-up as was the case in the five simulations. For simulation 1, physical examination of the patients’ eye, skin turgor, lung sound, bowl sound, CO2, pulse rate, blood pressure, blood glucose and temperature was made using the relevant clinical diagnostic skills and investigative tools such as the pulse oxymetry, capnometer, glucose machine and the BP machine, and the results revealed that the patient was diabetic. For instance, in simulation one, the findings of normal pupil reaction to light implied that the coma was not due to brain parenchymal lesions, while normal temperature ruled out an infection of the brain.
Assessment and Management of Pain
The assessment of pain is critical to patient management and follow-up. The assessment of pain is usually based on patient’s perceptions, physiological responses and behavioral responses. For patients who were alert and conversant, their response was relied upon to gauge the severity of pain as they were asked to locate the site of the pain and gauge its severity using the numeric pain intensity scale of 1-10. Other measures of pain include the visual analog scale and simple descriptive pain intensity scales. However, all these scales cannot be used in comatose patients (Burke and Lemone, 2007). Assessment of pain in a patient who is not alert for instance in multisystem failure can be very difficult and many physicians continue to manage pain inadequately (Ferrell, 1996). Nurses can help manage patients pain through regular assessment, intervention planning and through administration of pharmacologic and non-pharmacologic treatments. Such patients may respond to pain through exhibiting increased agitation and restlessness through behavioral cues such as moaning and grimacing (Ferrell et al., 1999). When increased pain is suspected, an increase of pain medication is employed with frequent patient assessment and reassessment. If patients’ response is good and symptoms of restlessness and agitation ceases then the most likely cause for the patient’s reaction was pain. Patient with major organ dysfunction and who are in pain should be treated with an opiod of a short half-life such as hydromorphine, oxycodone or fentanyl (Coyle & Layman-Goldstein, 2001).
Relationships between the simulations, patients’ management and chain of command
The simulations are very useful as they help in formulation of ideas from managing one patient to the next and knowledge learnt may be useful in actual cases when faced with them. For instance, in simulations 1 and 2, the standard procedures for assessing pain in the unresponsive patients was similar (using sterna rub, facial expressions and verbal sounds) hence suggesting that lessons learnt in simulation one could actually be applied in some of the subsequent simulations and similar treatments and patient management given.
The chain of command in management of these very sick patients is ICU ward primary care nurse, senior nurse, House officer, senior doctor.
Burke, K. and Lemone, P. (2007). Textbook of medical surgical nursing; Third edition. Prentice Hall Publishers. ISBN 9780131713086.
Coyle N. and Layman-Goldstein M. (2001). Pain assessment and management in palliative care. In: Matzo ML, Sherman DW, editors. Palliative care nursing: quality care to the end of life. New York: Springer, 362-486.
Ferrell, B. R. (1996). Humanizing the experience of pain and illness. In: Ferrell, B. R. editor. Suffering. Sudbury (MA): Jones and Bartlett Publishers, p. 211-21.
Ferrell, B. Virani, R. Grant, M. (1999). Analysis of end-of-life content in nursing textbooks. Oncol Nurs Forum, 26(5): 869-76.