Mrs O’Byrne appeared weak and she is exhibiting unrest behavior.
Weakness might have occurred in her because she is having nausea and vomiting since two days. Due to vomiting, there may be dehydration which might lead to weakness in her. However, usually she used to be fit and active.
19 months ago, she had transient ischemic attack.
She is not allergic to anything. She is repeatedly touching her abdominal area because she is having upper right quadrant abdominal pain.
Her body weight is 82 kg and height is 170 cm. Estimated Body mass index (BMI) of O’Byrne is 28.4. It reflects, she is overweight.
Her recorded vital signs are HR 120, BP 105/70, RR 23 and temperature 37.9?C.
Normal heart rate should be between 60- 100 beats per minute in an adult women, however O’Byrne exhibiting tachycardia because her heart rate is above 100. Increased heart rate may be due to stressful condition because of abdominal pain.
In case of O’Byrne, recorded blood pressure is towards lower side. Hence, she is having slight hypotension.
Normal respiratory rate in an adult should be between 12 – 20 breaths per minute. Since her respiratory rate is above normal value, it can be considered as tachypnea. Increased respiratory rate in O’Byrne may be due to anxiety.
Normal body temperature range is between 36.1 to 37.2?C, however in case of O’Byrne, body temperature is slightly higher than the normal.
Skin, nails and hair of O’Byrne seems to be normal. Her mouth, eyes and ears looks normal, however throat may be dry because she is feeling thirsty.
1) Following are the patient problems which need to be focused for the further assessment : nausea, tachycardia and hypotension.
2) To confirm the vomiting, she should be asked,
What is frequency of vomiting ?. Single episode of vomiting in the morning would not be considered as the vomiting problem.
How much amount of vomit ? Amount of vomit in the large quantity would be considered as vomiting problem .
Color of vomit ?. Color of vomit may be green due to presence of bile.
To confirm, tachycardia, she should be asked,
Do you have chest pain ? In tachycardia, there would be chest pain.
Are you experiencing breathlessness ? In tachycardia patient may experience breathlessness.
Is your lifestyle stressfull ? Stressfull life may lead to tachycardia.
To confirm hypotension, she should be asked,
Is there any blood loss for you ?. Hypotension may occur due to blood loss.
Are you drinking enough liquid ? Hypotension may occur due to dehydration.
Do you have vomiting and diarrhea ? Vomiting and diarrhea may lead to dehydration which causes hypotension.
There should be assessment for volume depletion in O’Byrne. Nutritional assessment and body weight monitoring should be there because in vomiting there would be nutritional depletion and loss of body weight. Oral cavity should be assessed for the loss of dental enamel. Regurgitation should be assessed during eating. In vomiting, there is forced expulsion of stomach and proximal intestine contents. Vomiting may lead to physiological changes like acid-base disturbance, electrolyte imbalance and malnutrition. Vomiting is generally preceded by other two events like nausea and retching. Nausea is associated with reduced gastric motility and increased tone in small intestine. Retching mainly occurs due to closed glottis. Retching is due to spasmodic respiratory movements. Vomiting occurs due to series of events. In vomiting there would be occurrence of deep breath hence glottis gets closed and larynx rose. As a result, there would be opening of upper esophageal sphincter. Diaphragm gets contracted towards downside and negative pressure built in the thorax. This leads to the opening of the esophagus and distal esophageal sphincter. As diaphragm moved downside, muscles of the abdominal wall gets forcefully contracted. It leads to stomach squeezing and elevation in the intragastric pressure. As pylorus gets closed, esophagus remains open and contents come out. Vomiting mainly occurs due to stimulation of chemoreceptor trigger zone which is also known as area postrema (Pleuvry, 2012; Pleuvry; 2015).
There may be appearance of reduced levels of diminished level of consciousness, pallor, and diaphoresis in patients with tachycardia. First heart sound should assessed because there may be variability in the first heart sound due to lost atrioventricular (AV) synchrony. There should be assessment of point of maximal impulse (PMI), and presence of murmurs associated with the valvular heart disease. There should be assessment and monitoring of mental conditions like anxiety, agitation, lethargy and coma in O’Byrne. Supraventricular tachycardias can occur in the atria or AV-node. Ventricular tachycardias have their origin in the ventricles. Ventricular tachycardias can occur in both myocardial and conduction system tissues. In tachycardia, there would be increase in the heart rate above the normal resting rate. Due to increase in the heart rate, heart pumps blood with less efficiency and supply less amount of blood to the other parts of the body. As a result of increased heart rate, there would be increased work and more oxygen demand. Sinus node which is a pace maker control rhythm of heart. Heartbeat starts with the electrical impulses. These electrical impulses start from the sinus node. Disturbances in these electrical impulses produces tachycardia (Caldwell et al., 2016).
Palpation should be performed in O’Byrne. It is generally done by palpating the radial pulse. It is useful in estimating systolic blood pressure and not useful in diastolic blood pressure. Auscultation should be done by using stethoscope and sphygmomanometer. It includes listening and measuring blood pressure. There should be assessment of mental state like confused state in O’Byrne for hypotension. Urine output also should be measured in patients with hypotension. Breath sound should be assessed in O’Byrne. O’Byrne should be assessed for hyperemic skin, cold, and clammy skin. Hypotension mainly occurs due to fall in blood pressure below normal level. Origin of hypotension is mainly of two types like cardiac and vascular origin. Hypotension may occur due to slow sinus rate and atriventricular block. This results in the reduced ventricular rate and decreased cardiac output. Tachycardia produces decreased ventricular filling time, reduced stroke volume and reduced cardiac output. Cardiomyopathies like systolic and diastolic dysfunction can lead to reduced cardiac output and hypotension. Hypovolemia mainly due to blood loss lead to hypotension. Excessive vasodilatation also leads to hypotension (Iaizzo, 2015).
Accurate measurement of blood pressure is necessary for medical diagnostics, prevention and treatment of disease. Increase in the blood pressure is one of the most significant causes of death worldwide. Hence, accurate measurement of blood pressure is very important to prevent cardiovascular disease and related co-morbidities. Specifically, in the elder patients, accurate measurement of the blood pressure is useful for monitoring cardiovascular homeostasis. Hypertension is one of the risk factors for cardiovascular diseases and blood pressure data is useful as epidemiological and clinical data. Most of the epidemiological studies established that hypertension can lead to heart attack, stroke and kidney diseases. Measurement of blood pressure following standardized protocol in epidemiological studies would be useful at different sites and it would also be comparable for longer period. There are multiple manual and environmental factors responsible for the inaccurate measurement of the blood pressure. Operator error, poor use of the equipment, and inadequate maintenance are the most important factors responsible for alteration in blood pressure. There may be white coat effect on the patients while recording blood pressure. Hence, nurse should take precautions while measuring blood pressure in elderly, children and preganant women (Handler, 2009).
However, small erroneousness in the measurement of the blood pressure can lead to substantial consequences for the patient. Even small increase in blood pressure by 2 mmHg, can increase chances of stroke by 10 % and coronary heart disease by 7 %. Error in the blood pressure measurement by value as small as 5 mm Hg can lead to label that particular patient as prehypertensive, when that patient is true hypertensive. This could delay in the initiation of the accurate treatment and exaggeration of the patient condition. Increase in systolic blood pressure without treatment can lead to 25 % increase in chances of fatal stroke and fatal myocardial infarction (Ogedegbe and Pickering, 2010). Accurate measurement of blood pressure is important in pregnant women because hypertension is a good indicator of pre-eclampsia in pregnant women. On the other hand, overestimation of 5 mm Hg can lead to unnecessary treatment which would lead to the adverse conditions in that patient and further detoriation of the patient. Nurse should maintain calm environment in the room because active talking of the patient can lead to increase in blood pressure of patient by 10 mmHg. Measurement of the blood pressure form the unsupported arm, lack of support form the back and crossed legs can increase blood pressure by 10 mmHg. If patient wish to urinate, there may be increase in the blood pressure. Hence, nurse should take proper precautions during measurement of the blood pressure for eliminating these factors. Forearm blood pressure measurement generally gives slightly higher blood pressure measurement as compared to the upper arm. Use of standard blood pressure arm cuff in obese patients would increase measurement of blood pressure by 10 mmHg. Nurse should keep in mind that follow up blood pressure measurement in the same patient within as short duration of time can lead to lesser blood pressure recording as compared to the initial measurement. This may happen due to subsiding of alertness effect (Roubsanthisuk et al., 2007). In conclusion, there are multiple factors responsible for the inaccuracy of blood pressure measurement and it is associated with different cardiovascular and metabolic disease. Hence, nurse should take special provision for accurate measurement of blood pressure.
Caldwell, M. A., Calkins, H., Conti, J. B., and Deal, B. et al. (2016). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm, 13, e136–e221.
Handler, J. (2009). The Importance of Accurate Blood Pressure Measurement. Permanente Journal, 13(3), 51–54.
Iaizzo, P. A. (2015). Handbook of Cardiac Anatomy, Physiology, and Devices. Springer
Ogedegbe, G. and Pickering, T. (2010). Principles and techniques of blood pressure measurement. Cardiology Clinics, 28(4), 571–586.
Pleuvry, B. (2012). Physiology and pharmacology of nausea and vomiting. Anaesthesia & Intensive Care Medicine. 13(12), 598–602.
Pleuvry, B. (2015). Physiology and pharmacology of nausea and vomiting. Anaesthesia & Intensive Care Medicine. 16(9), 462–466.
Roubsanthisuk, W., Wongsurin, U., Saravich, S., and Buranakitjaroen, P. (2007). Blood pressure determination by traditionally trained personnel is less reliable and tends to underestimate the severity of moderate to severe hypertension. Blood Pressure Monitoring, 12(2), 61–8.