RN

What’s Trending with Your Patient?

By Kim Maryniak, RNC, MSN

As nurses, we are consistently assessing and evaluating to make the best decisions in patient care. Assessment includes history, physical examination and incorporating results of diagnostic tests. A key point of assessing patients is to look at the whole picture, which includes not just the “snap shot” of the current situation, but any trends that indicate a change in patient condition.

Here are two patient scenarios that demonstrate the importance of this issue:

Patient:  Miss T. Rubble
Take, for example, a patient who was admitted a few hours previously with “weakness and rule-out stroke,” and has a history of type I diabetes. She complains of “not feeling right,” is pale and diaphoretic. The nurse’s first action is to take a blood glucose reading with the glucometer, and the results are 85 mg/dL. Vital signs are within normal limits. The nurse then calls the physician, who orders a CT scan to rule out active stroke. The CT scan is negative. An hour afterward, the patient becomes unconscious following the scan. A repeat glucometer shows a result of 27 mg/dL. The patient is treated with D50W, with good results. In reviewing the patient’s chart, her glucose was:

• 12 hours before:  325 mg/dL (treated with insulin).
• 8 hours before:  270 mg/dL  (given insulin).
• 4 hours before:  222 mg/dL (given insulin). 

Although the result of 85 mg/dL is within normal range, an abrupt drop in blood glucose can produce hypoglycemic reactions.  This also indicates a downward trend in blood glucose.

Patient:  Mr. I.M. Bad
Another patient was admitted yesterday for hematemesis, with a history of liver disease. Upon assessment, he complains of feeling weak and appears pale. His blood pressure is 103/59, heart rate is 112, respirations 18, and temperature is 97.8ºF.  His hemoglobin this morning was 13.6 g/dL and hematocrit was 41%. The nurse determines the patient is stable, but will require close follow-up. Twenty minutes later, the patient is unresponsive and the code team is called. The following was found upon review of the patient’s chart:

• Admission labs included hemoglobin which was 15.3 g/dL and hematocrit which was 47%.
• 8 hours before: blood pressure 122/78, heart rate 98, respirations 14, and temperature 98.2ºF. Hemoglobin was 14.2 g/dL, and hematocrit was 45%.
• 4 hours before:  blood pressure 114/66, heart rate 104, respirations 16, and temperature 98ºF. 
• 2 hours before: blood pressure 108/62, heart rate 108, respirations 16, and temperature 97.9 ºF. 

In viewing the trends with this patient, both the hemoglobin and hematocrit were dropping, although they remained within the normal range. The blood pressure was steadily decreasing, with the heart rate increasing. In putting all of the information together, it appeared that the patient was potentially bleeding, warranting further investigation.

Both scenarios are based on true situations in patient care. They demonstrate that it is necessary to take the time to review any trends emerging with patient assessment data, including vital signs and diagnostic results.  As nurses, we advocate for patients and can provide important insight into patient care situations.

 

References:
Convertino, V., Moulton, S.L., Grudic, G. & Ryan, K.  (2011). Use of advanced machine-learning techniques for noninvasive monitoring of hemorrhage. The Journal of TRAUMA® Injury, Infection, and Critical Care. 71(1), S25–S32.

Jarvis, C. (2008). Physical examination and health assessment (5th ed). St. Louis: W.B. Saunders.

Lee, M.  (2009). Basic skills in interpreting laboratory data (4th ed).  Bethesda, MD:  American Society of Health-System Pharmacists.

© 2012. AMN Healthcare, Inc. All Rights Reserved.

 

Biography:
Kim Maryniak, RNC, MSN is currently a Clinical Director with AMN Healthcare. She has more than 22 years of nursing experience, including med/surg, psychiatry, pediatrics, neonatal intensive care, education and management.