Question

The nurse is caring for the client admitted with severe chest pain. After checking the vital signs, the nurse's next action should be to: A. Prepare to administer oxygen by mask B. Administer morphine C. Prepare the defibrillator D. Take a complete history

Short answer

#Short Answer# The best next action for the nurse in this scenario is to prepare to administer oxygen by mask. This is based on the ABCDE approach to healthcare emergencies, which prioritizes treating and maintaining a patient's Airway, Breathing, Circulation, Disability, and Exposure, in that order. Providing oxygen helps maintain proper oxygen saturation levels, which should be addressed right after checking the patient's vital signs. The other options might be crucial later in the process but are not the most immediate actions needed in this situation.

Step-by-step solution

Review the given scenario

The problem at hand is about a nurse caring for a patient with severe chest pain. The nurse has already checked the patient's vital signs. Now, it is time to decide what should be the next appropriate action among the given options.

Analyze the given options

We have four possible next actions to evaluate: A. Prepare to administer oxygen by mask B. Administer morphine C. Prepare the defibrillator D. Take a complete history Inorder to do this, let's recall the common steps when dealing with a health emergency situations called ABCDE approach. Which stands for Airway, Breathing, Circulation, Disability, and Exposure.

Apply the ABCDE approach to the options

Based on the ABCDE approach, let's compare the given options: A. Prepare to administer oxygen by mask - Breathing: Oxygen administration may be crucial for patients with severe chest pain, as it can help to relieve discomfort and maintain adequate oxygen saturation levels. B. Administer morphine - Circulation: Administering morphine helps in relieving pain but not of priority when you are focusing on steps you can do at once before relieving pain. C. Prepare the defibrillator - Circulation: A defibrillator is used when a patient is in cardiac arrest or having abnormal heart rhythms. There is no information in the question stating that the patient's heart has stopped beating. D. Take a complete history - This option could be considered later in the process, when the patient's condition has been stabilized and prioritised according to the ABCDE approach.

Choose the best answer and explain why

From the ABCDE approach and comparison, the best next action for this scenario is: A. Prepare to administer oxygen by mask This is because, after checking the vital signs, the nurse needs to address the patient's immediate needs, which include maintaining proper oxygen levels in the blood. The other options might be crucial later in the process but not as the next immediate action after checking the vital signs.

Key concepts

Nursing Assessment

Nursing assessment is the first and most critical step when a nurse encounters a patient, especially in an emergency. This process involves gathering vital information about the patient's condition to identify any immediate care needs. For a patient admitted with severe chest pain, as in the scenario you read, assessment would include:

• Checking vital signs: temperature, pulse rate, respiration rate, and blood pressure.
• Understanding the history of the chest pain, including onset, duration, and intensity.
• Evaluating the patient's appearance: any signs of pale skin or sweat could indicate distress.

Gathering this information helps in evaluating the patient’s stability and planning further interventions. The focus should be on identifying symptoms that need urgent care, helping the nurse to quickly determine the next steps in addressing the patient's needs.

Health Emergency Management

Managing a health emergency requires decisiveness and efficiency. In the context of severe chest pain, the nurse must prioritize actions that address life-threatening symptoms. The goal is to stabilize the patient while ensuring they receive appropriate care.

• Immediate assessment and intervention are crucial.
• Quick decision-making based on the assessment helps prevent complications.
• The nurse must use clinical judgment to prioritize actions that support patient stabilization and symptom management.

In this situation, managing the emergency involves recognizing the symptoms that require urgent attention, applying protocols like the ABCDE approach, and coordinating care with other healthcare professionals as needed.

ABCDE Approach

The ABCDE approach (Airway, Breathing, Circulation, Disability, and Exposure) is a systematic and quick method used by healthcare providers to assess and address critical health issues. In applying this model to severe chest pain:

• Airway: Ensure the airway is clear. For a conscious patient, ask them to speak to confirm clarity.
• Breathing: Check for adequate breathing. Administering oxygen helps improve oxygen saturation and relieve discomfort, making it a priority.
• Circulation: Assess circulation, including pulse and skin color. Look for any signs of shock or poor perfusion.
• Disability: Evaluate consciousness using AVPU scale (Alert, Voice, Pain, Unresponsive).
• Exposure: Examine the patient for other injuries or conditions, maintaining their dignity and warmth.

The ABCDE approach is designed to uncover life-threatening conditions quickly, allowing the nurse to take immediate action in caring for the patient.

Patient Care Priorities

Determining patient care priorities is essential in delivering effective nursing practice, particularly in emergencies. The primary goal is to address life-threatening issues first and then focus on less urgent needs. In this scenario with chest pain:

• Administering oxygen is prioritized because it addresses potential breathing difficulties, which can exacerbate chest pain.
• Pain management and further diagnostic steps can follow once the patient's immediate breathing needs have been addressed.
• Documenting a thorough history and examination helps solidify the care plan once the patient's condition stabilizes.

Care priorities guide nurses in making informed decisions about interventions, ensuring that resources are focused on interventions that provide the most significant benefit to the patient's health at any given time.