Detect Model Of Patient Assessment.

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DETECT MODEL OF PATIENT ASSESSMENT.

DETECT Model of Patient Assessment

Abstract

This paper is based on a case study of post-operative appendectomy patient. The paper describes the assessment of patient through ABCDE protocol. It shows how nursing intervention can help in preventing the post operative complications in these patients. It also shows the pharmacological treatment of post-operative patents.

DETECT Model of Patient Assessment

Introduction

In post-operative surgical patients, nursing assessment and care is very important. When a nurse assesses a post-operative patient, ABCDE protocol should be followed.

Airway (A)

Breathing (B)

Circulation (C)

Disability (D)

Exposure (E)

Discussion

Airway (A)

When a nurse approaches a patient, she must look for the signs of airway obstruction. It can cause 'paradoxical' chest movements, due to use of the accessory muscles of the chest e.g., neck muscles. A nurse must look at the signs of central cyanosis, which also tells about airway obstruction. If there is complete airway obstruction, there would be no breath sounds. If there is partial airway obstruction, an inspiratory 'stridor' can be heard, which tells that the obstruction is at laryngeal level or above. If there is expiratory 'wheeze', it means that the obstruction is at lower airways. This is seen in asthmatic patients or with chronic obstructive pulmonary disease. If gurgling sound appears that means, there is liquid material in the upper airway. Partial occlusion of pharynx by the tongue causes snoring (Mulder, 2003).

Breathing (B)

During the assessment of breathing, it is important to diagnose and manage the breathing problems, for example, acute severe asthma. When a nurse assesses the patient, she must look, observe and feel for the signs of respiratory distress, central cyanosis, sweating, and use of the accessory muscles. Respiratory rate should be counted, the normal rate is 14 to 20 breaths per minute. An increased rate is a sign of abnormality and warns that the patient's condition may deteriorate and medical intervention should be done. Depth of each breath, and the pattern of respiration should be assessed and it must be checked that the chest expansion is equal on both sides. A nurse must listen to the breath sounds. Gurgling usually indicates airway secretions. Wheeze and stridor suggest partial airway obstruction. If the patient's breathing is inadequate, the nurse should use bag and mask with supplemental oxygen (Mulder, 2003). Circulation (C)

Vasovagal faints episodes are the important cause of circulation problems. These will usually be corrected by laying the patient flat and raising the legs. The nurse should look at the colour of the fingers and hands, if they pale blue, pink, or mottled. Limb temperature should be assessed by touching the patient's limbs. Capillary refill time can be measured by apply cutaneous pressure for up to five to six seconds on skin to cause blanching. Refill time should be measured, which should be less than two seconds. A time more than two seconds is a sign of poor peripheral perfusion. If checking pulse, carotid pulse is easier to feel than the radial pulse. It should be checked first. Slow capillary refill time and weak pulses show ...
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