ABCDE Structure Assessment of Patient with Cystic Fibrosis
Info: 3616 words (14 pages) Nursing Essay
Published: 11th May 2020
Tagged: assessmentcystic fibrosis
The ABCDE structured assessment will be discussed throughout this essay. The ABCDE approach is a tool which Healthcare Professionals use to assess a deteriorating patient quickly and effectively. The structured assessment allows Healthcare Professionals to identify and respond to life threatening situations in a priority order of what is most at risk (Thim et al., 2014). The main body of this essay will have a section for each of ABCDE in depth. This will be explained by assessing and treating a patient, while providing explanations for these findings if they are deemed as normal readings or abnormal. This essay is scenario based and the chosen scenario to undertake the assessment on is a 10-month-old child called David who presents to hospital with possible undiagnosed Cystic Fibrosis (CF).
Cystic Fibrosis is a condition which affects the exocrine glands which secrete their products they produce such as enzymes, ions and water directly into ducts (Jones and Lopez, 2014).
Cystic Fibrosis is an autosomal recessive disease affecting more than ten thousand people in the United Kingdom (Farrell et al., 2017). Waugh and Grant (2018) state around 20% of people are carriers of the abnormal recessive gene, but the gene must be present in both sets of parents to cause the child to have the condition. Cystic Fibrosis affects the patient’s life as it is a life shortening genetic condition that results from abnormalities in the Cystic Fibrosis Transmembrane Conductance (CFTR) (Goldfarb and Josephson, 2019). The CFTR gene provides the instructions for the make-up of the protein called CFTR (Genetics Home Reference, 2019a). This protein causes chloride channel, these channels transport negative particles called chloride ions into and out of cells (Pettit and Fellner, 2014). Pettit and Fellner (2014) state that the proteins that are located on the surface of the epithelial membrane act as the chloride channels that will in turn lead to regulation of the epithelial sodium channel and other anion channels which are at the surface of the cell. Due to the function of the glands, it causes an increased production of abnormally thick mucus which leads to a blockage in the pancreatic ducts, intestines and bronchi, which in turn leads to respiratory infection (Waugh and Grant, 2018). The gene that has the abnormalities from cystic fibrosis controls the movement of salt and water in and out of the cells which leads to the necessary production of thin and free flowing mucus (Farrell et al., 2017).
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Airway is assessed first within the structured assessment. A patent airway is the first part of the assessment to examine, as having a patent and clear airway is essential for life (Smith and Bowden, 2017). When assessing a child, it is important to look for signs of an airway obstruction (Resuscitation Council UK, 2019). An obstruction can quickly become life threatening so this would be classed as a medical emergency (Smith and Bowden, 2017). Smith and Bowden (2017) states that an airway obstruction can often be recognised by the patient having noisy breathing or where there are no breathing sounds (Smith and Bowden, 2017). Due to this, oxygen would be given at a high concentration level (Resuscitation Council UK, 2019).
Within the scenario we are told that David’s airway is patent and he is not at risk of having a c-spine injury. A child without CF uses the mucus as a lubricating substance that protects the lining of the airways (Genetics Home Reference, 2019a). However, a child with CF, due to the abnormal mucus, could possibly have an obstruction of the airway and intervention may be needed (Genetics Home Reference, 2019a). As no intervention is currently required the assessment can be continued by moving on to breathing.
Breathing is assessed by looking, listening and feeling for signs of respiratory distress (Resuscitation Council UK, 2019). Within this part of the assessment the patient’s respiratory rate should be taken lasting one full minute and should include the depth and rate of breathing (Smith and Bowden, 2017). Oxygen saturations should also be taken at this point (Resuscitation Council UK, 2019). When listening to the patient’s breathing, if they are presenting rattling noises, this indicates the patient has a build-up of airway secretions (Resuscitation Council UK, 2019).
Within the scenario, David is showing some mild distress and is breathing through his mouth. He is also displaying signs of possible recession due to being so thin. David has a respiratory rate of 40, normal parameters for breaths per minute are between 20-40 (Royal College of Nursing, 2017). Although David’s respiratory rate is still within normal parameters, it is at the high end of what is deemed normal and this should be closely monitored. As children with CF are prone to bacterial infections, this can lead to severe problems with their breathing as infections can cause chronic coughing, wheezing and possible inflammation (Genetics Home Reference, 2019b). Due to the bronchioles being impacted with thick mucus, the cilia cannot affectively unblock the obstruction out of the smaller passages resulting in mucus plugs, the trapped bacteria then leads to chronic infection (Hurley and Gossman, 2019). In response to the chronic infections, the body realises white blood cells into the lungs to destroy the infection (King, Toler and Woodell-May, 2018). Once the infection has been destroyed, the white blood cells die and add further thickness to the mucus and also cause inflammation (King, Toler and Woodell-May, 2018). Oxygen and carbon dioxide levels within the blood fall, leading to the potential falling of saturations. This is because of the ratio of oxygen and carbon dioxide in the alveoli not being significant enough to allow the blood to become more acid due to the increased amount of carbon dioxide (Hurley and Gossman, 2019). Additionally, this increases the work of breathing leading to a high respiratory rate (Hill et al., 2017). Genetics Home Reference (2019b) furthermore state due to an increased amount of infections, over a period of time, can result in permanent lung damage including the formation of scar tissue. Progressive lung disease can result in bronchiectasis and respiratory failure (Sly et al., 2013). The Healthcare Professional did not call for help at this stage of the assessment, so continued on to circulation.
Circulation assessment begins by checking the patient’s pulse for rate, rhythm and volume (Smith and Bowden, 2017). Next is an accurate blood pressure measurement. This is an essential component of the circulatory system (Smith and Bowden, 2017). It is important to look at the colour and feel the temperature of the patient’s peripheries, by assessing are they pink, blue or mottled and do they feel warm or cool (Resuscitation Council UK, 2019). A capillary refill time should be measured, with the normal reading being less than two seconds. An accurate reading of blood pressure, capillary refill time and checking peripheries shows whether the circulatory system is in intact (Resuscitation Council UK, 2019). An assessment should be carried out of the patient’s fluid balance including measurement of urine output (Smith and Bowden, 2017).
Within the scenario, David’s heart rate is 146 beats per minute. This is within the baseline of normal parameters for his age being 110-160 beats per minute (Royal College of Nursing, 2017). Although David’s heart rate is within normal parameters it is high for him being rested, this is due to the heart having to work harder to pump the blood through the damaged lungs causing David’s heart rate to increase to compensate (Richter et al., 2013). The next area to assess is blood pressure, temperature check of peripheries and a capillary refill time. By doing these together can quickly assess if the patient has an intact circulation or displaying signs of shock (Mayo, 2017). David has normal feeling peripheries and blood pressure is currently not available. David has a capillary refill time of two seconds, this shows he is suffering from dehydration as his body is excreting too much fluid and resting energy expenditure (Mayo, 2017). Although the assessment would continue, a possible intervention at this stage would be to commence intravenous fluids and encourage oral rehydration (Fuchs, Adams and Byerley, 2017). An accurate fluid balance and output should commence to calculate and measure a positive fluid gain with stool analysis, to check for diarrhoea and steatorrhea (Davies et al., 2017).
Disability is evaluating the function of the central nervous system (Smith and Bowden, 2017). Further-more an initial assessment of the patient’s conscious level is undertaken by using the AVPU tool (Smith and Bowden, 2017). AVPU tool stands for; Alert is the patient aware and can respond to the environment around them. Verbally responsive is when the patient’s eyes only open in a response to verbal stimulus that is directed to them (Romanelli and Farrell, 2019). Painfully responsive is when the patient’s eyes do not open spontaneously and the patient only responds to the act of painful stimuli. Unresponsive is when the patient does not respond spontaneously or to verbal or painful stimuli (Romanelli and Farrell, 2019). A blood glucose measurement should be carried out to exclude hypoglycaemia (Resuscitation Council UK, 2019).
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Within the scenario, David’s AVPU score is A for alert. AVPU and Glasgow coma scale are used to assess the neurological status and trends displayed by patients which determine clinical decisions (Palmer and Knight, 2013). The conscious level for a child with cystic fibrosis should not alter due to the condition not being a neurological condition (Palmer and Knight, 2013). Palmer and Knight (2013) state that although cystic fibrosis is not a neurological condition, practitioners must be able to recognise the signs of when to escalate from AVPU to Glasgow coma scale. The scenario also states that blood glucose is not available. Furthermore, this is due to David being under one year old and the shortage of insulin would not affect David at this stage of his condition (Kwong et al., 2019). Cystic Fibrosis Related Diabetes Mellitus (CFRDM) is a gradual loss of beta cells in the pancreas which can lead to an insulin deficiency. CFRDM is a well-known comorbidity for adolescents and adults with cystic fibrosis as it affects between 40-50% of the population (Kwong et al., 2019). No intervention was required, continue to exposure.
Exposure requires the body to be fully exposed to perform a visual top to toe inspection of the patient’s body (Resuscitation Council UK, 2019). Resuscitation Council UK (2019) states that while this is being carried out, it is important to maintain the patient’s dignity and to minimise heat loss. The healthcare professional should be examining the body for evidence of any trauma and should note the presence and location of any rashes or bruises (Smith and Bowden, 2017).
Within the scenario, David has no rashes or bruises or trauma, although he is very thin with little fat on his arms and legs. Failure to thrive is a common problem for children with CF. This is due to calorie intake being insufficient to maintain growth as they have excessive losses due to steatorrhea, infection and resting energy expenditure (Larson-Nath and Biank, 2016). The issue can be reversed with increased calorie provisions (Larson-Nath and Biank, 2016). Close attention is required for nutrition and growth and this is essential when caring for a child with CF (Lusman and Sullivan, 2016). Lusman and Sullivan (2016) state that growth and nutrition should be regularly monitored as part of the routine care of a child with CF. Improving nutrition for children is critical as there are higher growth parameters associated with improving pulmonary function and outcomes, but for patients with CF they are prone to malnutrition, vitamin failure and growth failure (Ratchford, Teckman and Patel, 2018). Furthermore, the importance of starting nutrition in the early stages of life to optimise the patient’s outcome (Ratchford, Teckman and Patel, 2018). There are varied ways to optimise nutritional status, some include taking oral supplements, behaviour treatment, pharmaceutical drugs and enteral nutrition (Lusman and Sullivan, 2016). Nutritional management includes a high calorie and high fat diet (Schindler, Michel and Wilson, 2015).
Pancreatic enzyme release starts before food is entered into the mouth through gastric secretion (Alkaade and Vareedayah, 2017). For someone with CF, thick sticky mucus leads to blocked ducts within the pancreas, this prevents enzymes required for digestion from reaching the small intestine to absorb food as the gut cannot process the enzymes (Alkaade and Vareedayah, 2017). Alkaade and Vareedayah (2017) state this further leads to the incomplete digestion of food, particularly fats, proteins and nutrients not being fully absorbed into the blood stream. This is due to the dysfunction of the CFTR gene which results in reduced chloride and bicarbonate transport and malfunction across the epithelial cells (Singh and Schwarzenberg, 2017). Exocrine Pancreatic Insufficiency (EPI) is present at birth in babies with CF and majority of patients are diagnosed within the first year of life (Kashirskaya et al., 2015). EPI is related to the reduced chloride and bicarbonate transport in the pancreas which then leads to reduced water content in secretions, the highly concentrated secretions obstruct the pancreatic ducts which prevents the pancreatic enzymes from being secreted and then emptied into the small intestine (Singh and Schwarzenberg, 2017). EPI is the outcome of the maldigestion of food and the malabsorption of nutritions, these include malnutrition and symptoms of poor weight gain and steatorrhea (Kashirskaya et al., 2015). Due to the pancreatic ducts being blocked, creon is used as a pancreatic enzyme replacement therapy as it helps support normal digestion and maintaining suitable nutritional status, creon should be taken before each meal to support the breakdown of food correctly and allowing the body to absorb the nutritions required (Kashirskaya et al., 2015). Vitamin and mineral replacement supplements may also be necessary.
From the above scenario it is evident the nurse did not need to call for any assistance at any given point through-out the structured assessment. From the above findings, David does not appear to be acutely unwell at present but has potential to deteriorate and appropriate action would be to contact medical staff with current findings. Medical staff would then carry out formal testing to confirm the diagnosis of Cystic Fibrosis. The testing would include genetic testing of David and both parents and undergoing a sweat chloride test (Pettit and Fellner, 2014). Once diagnosed, David would begin attending a paediatric respiratory clinic where he will be seen by a specialist nurse and other members of the multidisciplinary team.
To conclude, this essay is a breakdown of the structured ABCDE assessment with an in-depth analysis of each section based on a scenario. By performing this assessment, it is giving the Healthcare Professional experience and exposure of undertaking a structured assessment. This research on Cystic Fibrosis is also giving the Healthcare Professional an insight into the condition and how to be confident in providing the patient with evidence-based practice and care for the condition. It is clear that ABCDE covers all aspects of a patient’s vital signs and is critical for preventing further deterioration and will lead to early diagnosis of acute conditions.
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