Introduction

This reflection report will highlight the pathophysiology of hypovolemic shock exacerbation, the risks of worsening health conditions, and a related care plan for Zahara’s Juma, who is 80-year-old women. Patients whose health is in a deterioration state are at risk of requiring unscheduled critical care admission, as well as increased mortality and morbidity (Reilev et al., 2019). This article describes the ABCDE (airway, breathing, circulation, disability, and exposure) nursing assessment tool method for Zahara health record evaluation, which helps healthcare practitioners to detect and respond to life-threatening problems in the order of priority. According to Taherkhani's 2019 research, ABCDE evaluation plays a significant role in maintaining patient deterioration surviving as well as achieving the first step toward promoting health. It also aids in obtaining time for a diagnostic, which serves as the foundation for appropriate treatment for Zahara. As part of the ABCDE evaluation, the patient's vital signs should be taken and documented utilizing a track and trigger tool to improve the identification of physiological irregularities that signify the worsening of an individual's health (Moraes et al., 2019). According to the case study, Zahara was wearing her pendant alarm and quickly pressed it for assistance when she fell into the kitchen when turning around, tripped over her cat, and smashed the glass pane of the back door. She had a 2-inch cut to the inside of her wrist as a result of shattered glass. Zahara attempted to apply pressure to the cut, but there was obvious blood loss. Since Zahara is experiencing discomfort in her left wrist as a result of significant blood loss, the pathophysiology of hypovolemic shock is being explored in this case study. I will next go through how a person-centred care strategy was applied, as well as certain ethical and legal considerations, including the study of Gibbs's Reflection Cycle (1998).

Main Body

When assessming and providing the valuable tretaments to the ill patients within the healthcare facility, the Resuscitation Council UK (2021) states that the healthcare professionals needs to adopt the use of the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach to evaluate the patient health conditions early as possible. This systematic ABCDE approach helps the doctors and nurses, to identify the potential life-thretaning problems which the patients are facing as soon as possible (Smith & Bowden, 2017). According to Moruzzi & McLeod (2017), using the ABCDE evaluation model to identify physiological decline in individuals with heavy blood loss due to some injuries, is a rapid and helpful strategy assessment tool. The only notable exception is the armed services, which use (C in ABC), where C stands for catastrophic haemorrhage. Strezhak (2022) indicated that the best treatment option for penetrating injuries is to focus on stopping the bleeding early, and study the Pathophysiology & Management of Hypovolaemic Shock, in case of Zahara Juma.

My co-worker and I meet the patient and began the A-E assessment. This is a deliberate approach that ensures that every element of the Zahara’s health needs is addressed before moving on to the next (Thim, 2012). But due to time constraint, me and my team failed to complete the A-E assessment on Zahara. According to the Zahara case study, some of her physiological indications are normal while others are abnormal. On nursing evaluation, a nurse questioned Zahara when she last passed urine, and she replied positively, "at home." According to Witsberger (2020), normal size range of human pupils is within 2 to 6 mm, and Zahara pupil size for PEARL (equal and reacting to light) seems to be 4 mm, which shows her pupil size is normal, and her body temperature also seems to be normal which is around 36.2°C. Her consent is always requested during her clinical check-ups, and nurses have also respected Zahara's privacy and dignity at all times while assisting her with her medication and treatments (Papastavrou et al., 2014). According to Penzel et al., (2016), in his study shows that normal range of indivivudlas respirate rate is 12-20 bpm, normal heart range is 60-100 bpm in older individuals, staturated oxygen level normal is 94-99%, and CRT (Capillary refill time) normal range is around 1 to 2 sec, but when I and my co-workers done ABCDE assessment on Zahara her some reports comes to be abornmal which includes a high respiratory rate of 27bpm, an increase in heart rate of 120 bpm, less in saturated oxygen levels in the blood (SpO2) which is around 87%, her CRT (Capillary refill time) is also high around 4 seconds.

I was able to address both the situation and the background clearly, but progress was lost while completing the assessment as a nurse. I didn't have the NEWS2 score with me, which caused a glitch in the discussion. To communicate effectively, all necessary information must be available in order to establish a clinical image of the patient and identify the patient's deterioration in her health. On reflecting, I realized that I was unable to check Zahara's blood sugar level, and her demands and preferences were also not fully understood by me. To combat this, I have adopted the use of effective, clear, and succinct communication, which is required when discussing care with a multidisciplinary team. Due to a lack of information, I lost faith in my performance, which hampered the required reaction. Looking ahead, I realize that while elevating an issue, it is critical to have all information available because it might jeopardize the patient's treatment in the following phases. Despite the mistake made at the third stage of SBAR, I was able to transmit my recommendations, which I believed were critical in the patient's care in the following phases. This included IV fluids and blood transfusion to assist in restoring Zahara's blood levels to normal and avoiding hypovolemic shock in future.

I recommended using the simple and widely used AVPU scale to record whether a patient was alert, responded with Voice, Pain, or was Unresponsive while promoting the first National Early Warning Score (NEWS), for sober mindset while measuring a patient's level of consciousness. Since it is possible for those taking the score at the hospital bed to describe a patient as prepared (which would be scored at 0 points) while at the same time failing to recognize that the patient is severely confused (which ought to always have scored 3 focuses, even in the NEWS), we considered feedback from users of the NEWS who had noticed that the current AVPU scale could overrate illness seriousness in some patients. This "chaos" regarding how to apply the AVPU scale to a generally notify and severely confused patient caused concern because newly developing or destroying confusion, delirium, or any other altered mental function should always raise a concern about potentially serious underlying causes and call for urgent clinical evaluation. Thus, effective communication skills are highly recommended to be used by healthcare professionals when delivering the best possible care to patients who need immediate care.

Figure 1: Gibbs reflective cycle (1988) (Sicora, 2010).

Respiratory rate– 27bpm (Abornmal- 12-20)

ACVPU – C

GCS Glasgow Coma Scale (GCS): E4 (open eye spontaneously) V4 (confused distoriented-verbal) M6 (Motor- obeys command)

Last passed urine at home

Pain – complaining of pain to left wris

References

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Papastavrou, E., Efstathiou, G., & Andreou, C. (2014). Nursing students’ perceptions of patient dignity. Nursing Ethics, 23(1), 92–103. https://doi.org/10.1177/0969733014557136

Sicora, A. (2010). Gibbs' reflective cycle. | download scientific diagram - researchgate. Self-evaluation of social work practice through reflection on professional mistakes. Practice makes “perfect”? Retrieved January 3, 2023, from https://www.researchgate.net/figure/Gibbs-reflective-cycle_fig1_341090108

Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard, 32(14), 51–63. https://doi.org/10.7748/ns.2017.e11030