Due to reduced circulatory blood volume patients can experience symptoms of hypoxia which presents as confusion and agitation.
The nurse should check the level of consciousness using the Glasgow Coma Scale (see table below). This is a scale where the nurse assesses the degree of reaction to sensory stimuli. The scale is mostly used for head injuries, but can also be used for cerebral alteration of other causes.
Oxygen saturations should be assessed using pulse oximetry.
|Glasgow Coma Scale|
|Best eye response ( E )||4. Spontaneous- open with blinking at baseline|
|3. Opens to verbal command, speech, or shout|
|2. Opens to pain, not applied to face|
|Best verbal response ( V )||5. Oriented|
|4. Confused conversation, but able to answer questions|
|3. Inappropriate responses, words discernible|
|2. Incomprehensible speech|
|Best motor response ( M )||6. Obeys commands for movement|
|5. Purposeful movement to painful stimulus|
|4. Withdraws from pain|
|3. Abnormal (spastic) flexion, decorticate posture|
|2. Extensor (rigid) response, decerebrate posture|
Exposure & examination (E)
In order that patients are examined properly, and detail is not missed, full exposure of the body may be necessary. Do this in a way that respects the dignity of the patient and prevents heat loss.
The nurse should assess fluid status of the patient. Urine production is a measure of the patient’s renal function, but also an indication of cardiac function. In the event of pump failure in the heart’s function, circulation is prioritised to vital organs such as heart, brain and lungs. This results in less blood flow to the kidney and decreased urine output. Normal urine output is approximately 0.5 ml / kg body weight per hour. When urine output is less than 400 ml per day, this is called oliguria. Anuria is the term for urine output less than 50-100 ml per day. In such cases a urinary catheter maybe necessary in order to measure hourly urinary output and the effectiveness of diuretic medications. The nurse must:
- observe urine colour and odour
- record a strict fluid balance and assess for positive/negative fluid balance
- measure hourly urine output
Chest pain in heart disease is caused by lack of oxygen (ischaemia) in myocardial cells and occurs when the coronary vessels become narrowed due to atherosclerosis. The pain occurs when there is an imbalance between oxygen supply and oxygen demand of the heart muscle. Angina pectoris is characterized by severe retrosternal pain with radiation to the left arm, neck region and lower jaw with duration of 1-5 minutes. The pain commonly occurs during exertion and can be relieved following use of glyceryl trinitrate spray or tablets administered sublingually and the person ceasing exertion.
The nurse must:
- observe the intensity of the pain, distribution, localization, duration and depth
- map the patient’s experience of pain, what relieves or aggravates the pain and the degree of anxiety
- observe the effectiveness of medication
Complete the sentence: Elimination
One of the things you should do to monitor fluid loss is to: