Importance of Nurses in Rural and Remote Healthcare

The document discusses the importance of nurses in rural and remote areas, where they often face challenges such as limited resources and technical knowledge. It emphasizes the need for nurses to be endorsed with technical knowledge and experience to provide high-quality care to patients. The summary also touches on the significance of nurses having a deep understanding of patient behavior and advanced nursing practices.

KETOACIDOSIS CLINICAL CASE
STUDY EMERGENCY CARE

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
Outline of particular case study..............................................................................................1
Steps for Triage scoring of patient.........................................................................................1
Stabilisation and management of patient ...............................................................................4
Comparison of roles performed by non-endorsed registered nurse at non-rural areas and
endorsed registered nurses at rural and remote areas.............................................................6
CONCLUSION ...............................................................................................................................8
REFERENCES ...............................................................................................................................9

INDEX OF TABLES
Table 1: Vital sign............................................................................................................................2

INTRODUCTION
The particular case is regarding a girl who is brought to the hospital due to being
collapsed. According to Health Management Protocol of Australia, as a patient arrives at the
hospital, it is necessary to perform primary survey first. As per the Primary Clinical Care Manual
(PCCM), initially general assessment is done to check the mental status of the patient by AVPU
scale i.e. A- Alertness of patient, V-Verbal talks with patient after receiving stimuli from nurse,
P stands for pain on gentle touch or pinch done to get response due to painful stimuli and the
final is U-Unresponsive. In this case, the patient is not responsive to both stimuli. After this, a
normal check up is performed regarding pulse rate, breath rate, and blood pressure. The
secondary survey is done on the basis of patients' medical history and cause of the emergency.
According to Nursing and Midwifery board of Australia, “Scheduled Medicines Rural and
Isolated Practice Registered Nurse” can perform the diagnosis and screening of the patients and
is responsible for results.
Outline of particular case study
This case revolves around the girl named Miss Hannah Smith from Aboriginal heritage.
She got collapsed and was brought to the emergency center by one of her friends. When she was
brought to the local hospital, her face was pale and paramedics performed some tests regarding
vital signs. According to the report, blood pressure was 108/60, heart rate was 130 bpm,
breathing rate 45 breaths/minute, while the temperature of body 35.6, BLG on glucometer was
HHH and GCS value is 13. According to her friend, last night, Hannah was on an alcohol binge
and suffers from type 1 diabetes mellitus from childhood.
Steps for Triage scoring of patient
The process of generating priority list is called giving the triage score to symptoms of a
particular condition. It is a very old method for treating patients when there was less availability
of technology and other required resources. This score can only be interpreted when the vital
signs are completely known. In hospitals, registered nurses can utilize this method to treat
patients who are brought during emergency cases.
According to available information about Hannah, following results can be interpreted:
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Table 1: Vital sign
Condition Normal reading Actual reading
Blood pressure 120/80-140/90 108/60
Heart rate 60-100 beats /minute 130 beats/minute
Breathing rate 12-20 breathe per/minute 45 breaths/minute
Body temperature 37 degrees Celsius 35.6
Blood ketone level 0.6-1.5 mmol/L 3.2 mmol/L
GCS level 9 to 12 13
Major concern according to available information is high blood ketone level, it can be life
threatening. As due to less insulin availability, the body starts burning fat to get energy. This, as
a result, produces ketones in the blood. High level of ketones makes blood more acidic and thus
in severe cases, it can be poisonous for the body (Nepean Guide DKA, 2007). As per the given
case, Hannah is suffering from high level of ketone in blood so it is necessary to be treated
immediately to normalize its level in the body. She needs to be provided with insulin to make
use of body glucose instead of fat for energy resource. If she is not provided with the insulin
immediately it may worsen her condition.
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The second priority is to provide treatment for high breathing rate. It is common in case
of patients with diabetes but in Hannah’s case, the rate is too high which may lead to many
respiratory disorders like lungs diseases, asthma and pneumonia. In severe cases, it may cause
heart failure. This is because due to high breathing rate the heart is not able to pump blood
properly which in turn supplies less oxygen to the body and finally leads to failure of the heart.
Next priority is related to the GCS level which means the level of consciousness of a
particular patient. In normal cases, the GCS level is between the 9-12 which is considered to be
moderate and have harsh effects on the proper functioning of the brain and results in brain
injuries. In case of GCS level between 3-8, a person is considered to be in the coma, in which
brain becomes completely unconscious and is unable to think or interpret anything (Liverpool
Diabetic Ketoacidosis, 2015). But in case of Hannah, reading of GCS is in between 13-15
(E3V4M6- E-Eye opening response, V-Response on verbal communication and M- stands for
the response from brain i.e. motor responses) and her GCS level is considered to be mild.
According to this, her motor response was normal and she opened her eyes on verbal
communication. But her conversation was disoriented which is not a major concern.
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Illustration 1: Type 1 Diabetes mellitus
Source: Diabetes mellitus type 1, 2017

The heart rate is quite high as a normal range is between 60-100 beats per minute.
However high pulse rate is common in case of diabetic patients. But heart rate more than 100
may lead to Multi Focal Atrial Tachycardia [MAT] which causes light-headedness and rapid
pulse rate which follows the chest pain.
In case of Hannah, the body temperature is 35.6 C which is much lower than 37 C which
is considered to be normal body temperature. Lowering of body temperature at this level may
lead to hypothermia, but there are lesser chances of that because it happens in cases where
temperature goes below 35 C (Nepean Guide DKA, 2007). So, this condition can be controlled
by providing some medicines and adequate amount of rest. Blood pressure is also considered to
be quite normal in case of Hannah. So, by studying the available data of vital sign of Hannah the
priority list can be generated and treated early as possible.
Stabilisation and management of patient
In the particular case, a girl named Hannah who had collapsed has been brought to the
emergency department of a local hospital. When she was brought to the hospital, her face was
pale and she looked confused. After being collapsed her level of consciousness had decreased
and needed urgent medical support. According to DKA Guideline (2015), Stabilization process
consists of ABCDE approach which is applied when the person gets collapsed. The main aim of
this technique is to provide patients with treatment that is life-saving. When the Hannah was
brought to the hospital her condition was very complex. Hence, to stabilize Hannah, the
following steps were taken. In this case, first A-Airways of Hannah are partially open on the
basis of the result of verbal response which was found disoriented. Secondly, breathing needs to
be checked which can be determined by inspecting thoracic wall and auxiliary respiratory
muscles. In the presence of stethoscope lungs, auscultation needs to be done and a pulse
oximeter is applied. This presented with a result which shows high breathing rate of 45
breathe/minute. In this condition, she relaxed by relieving the tension.
The second step in stabilization process of a patient was associated with the circulation of
blood. In the provided case of Hannah, her face was pale. Hence, heart auscultation should be
performed with the help of stethoscope along with the electrocardiography check. On arrival, her
heart rate was 130 bpm. In this condition, electrocardiography and the blood pressure should be
measured as soon as possible. Following this, the level of consciousness should be checked by
AVPU. Here A is for alertness, V for voice response, P is for the response to pain and U is for
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unconsciousness. This can be checked by using the Glasgow Coma Score. The score of Hannah
was found to be 13 which indicated the mild condition. During stabilization, the final check done
is for the exposure. But, in case of Hannah, there were no cuts or any sign of bleeding. Hence,
there is no need for checking for exposure.
Hannah was suffering from type 1 diabetes mellitus so other tests related to diabetes
should also be performed. These tests are also necessary as she had consumed alcohol last night.
Blood ketone level was found to be very high i.e. 3.2 mmol/L as compared to the normal
readings which are below 0.6 mmol/L. Thus, by using stabilization method, the actual condition
of Hannah could be recognized and thus further treatment can be done on the basis of the vital
reports obtained.
Along with stabilization, management of condition of the patient is also needed. In case
of Hannah, she was brought in an unconscious condition, the first step towards management is to
treat giddiness. In this regard, ABCDE approach is required to assess as well as treat the patient
(DKA Guideline, 2015). As per results of ABCDE test, Hannah’s breathing rate and heart rate
were too high while her blood pressure was quite low. In case of high breathing rate, it is
necessary to provide Hannah with oxygen directly by mask or through a bag and mask
ventilation side by side monitoring pulse rate, blood pressure, and respiratory rate. The main
reason for high pulse rate and low blood pressure is not getting the adequate perfusion. In
response to this, the body triggers the high heart pulse rate to pump more blood so that the blood
pressure comes to a normal level. Similarly, there is need to control an increased heart rate of
Hannah. This can be done by providing her with some relaxation massage that will reduce the
production of stress hormone in the body. It can also be done by regulating blood pressure. This
can also help in lowering down pulse rate to normal condition.
High ketone level in blood is an important aspect to be cured because it can poison the
body of the patient in the case. Due to a low level of insulin, the body is not able to utilize
glucose as source of the energy. Hannah is suffering from type 1 diabetes mellitus in which her
body gets short of insulin. In this case, her body starts breaking down fats and converting them
into ketones which release the ATP and supply body with energy.
In such cases, with the increase in the level of ketone, blood becomes more acidic that
sometimes poison the body. Insulin therapy is required to manage this condition of Hannah.
Intravenous act rapid infusions are prepared with a concentration of K+ > 3.3mmol/L. Fluid
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therapy should be provided for restoring the renal perfusion, in case of severe hypovolemia
administer 0.9% sodium chloride 15-20 ml/kg/hr (Liverpool Diabetic Ketoacidosis, 2015).
Comparison of roles performed by non-endorsed registered nurse at non-rural areas and
endorsed registered nurses at rural and remote areas
A comparison can be made in the role of a Registered Nurse (without endorsement) in a
non-rural health care facility and a rural Registered nurse. Registered nurses without
endorsement, at a non-rural healthcare facility, have higher dependency over other nurses due to
lack of experience in handling the patient. Hence, their role is assistive and usually aided by
other healthcare professionals. Hospitals and healthcare in urban areas and rural areas have
different ways of treating patients, it depends on the availability of resources in particular
organization. In this case, Hannah's condition was complex and demonstrated many abnormal
symptoms. She was also suffering from the type 1 diabetes mellitus. Therefore, a registered
nurse (without endorsement) in a non-rural healthcare facility would not have played the most
prominent role in the management of a critical patient like Hannah. She would have assisted the
healthcare professionals in carrying out the various steps for stabilization and management of
Hannah.
In contrast to this, in rural areas, the registered nurses play a significant role. They look
for all the vital signs like pulse rate level of consciousness and temperature on an hourly basis.
Therefore, in Hannah's case, the role of a registered nurse would have been different from that of
a nurse in a non-rural facility. She would have played a prominent role and taken the various
steps for management of medical condition of Hannah.
In non-rural areas, nurses are provided with equipment that keeps a regular check on the
vital signs and alerts them in any severe cases. Due to this reason, nurses are not able to give
more time to the patient for curing them in a better way but in a rural area, the nurses are
themselves responsible for each test. In this way, the patients get more attention personally and
are provided with good care. Referring to the case of Hannah, registered nurses in rural areas
would have been more successful in calming the patient by giving personal attention to her.
However, it can be analyzed that there are various similarities in the roles of registered
nurses (without endorsement) in a non-rural healthcare facility and rural areas. Registered nurses
at both rural as well as non-rural areas would have provided Hannah with proper treatment
regarding reducing the level of ketone in blood. Nurses in both the areas would have performed
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important tests on the patient such as a test for urine and interpreted results about the level of
ketones. Following this, they would have provided the patient with a required amount of insulin
to solve the problem. However, in case of non-endorsed registered nurses in urban areas, they
have to take the assistance of higher nurses for performing such tests. They can provide a patient
with a primary level of care but without practice, an advanced type of care is not possible.
In non-rural areas nurses without endorsement are not able to deal with patients with
higher breathing rate like as was in the case of Hannah. Such patients need immediate treatment
like the supply of oxygen through mask along with a check on blood pressure. Such conditions
may create more stress on these nurses and may prove riskier for patient's life. Rather, registered
nurses at rural area can easily provide relief to such patients by taking appropriate measure for
controlling the breathing rate along with decreasing blood pressure.
Endorsed registered nursed are provided with advanced nursing techniques which
involve the application of various types of therapies along with medical treatment. Rural nurses
can provide relief to diabetic patients by providing multidisciplinary care which includes the
proper medication along with proper diet. At non-rural areas, non-endorsed nurses are not
experienced and not having knowledge regarding primary care techniques. For advance care,
they have to depend upon the senior nurses and are not able to fulfill the requirement of care
needed by the patients.
In remote areas due to lack of advancement and availability of practitioners, nurses have
to play a role of professional working staff and provide the patients with primary health care
services. Sometimes in severe cases of hypoglycemia sufferer needs to be transferred to urban
hospitals but they need primary treatment which is important for them to survive till they reach
the urban hospitals. Here nurses come up with all there learning and on the evidence based
studies, they give primary treatment to make patient survive till they get advanced services.
In a remote area the development of nurse is difficult but in a rural area, there are chances
of getting advancement and improvement in nursing practice. The ratio of nurse to patient is very
low in remote areas and limited nurses are available to provide primary health care services. But
in case of rural areas workforce can be provided as it is reachable and along with technical
advancement high-quality primary care can be provided to the patients.
Education and knowledge are also important key point in a profession of nursing. Providing
rural and remote healthcare department and hospitals with high-quality equipment and
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technology is worthless without proper knowledge of their principle and application. Nurses at
rural areas need an interface with this technology to come up with a more better result with their
research based practices.
CONCLUSION
From the above report, it can be concluded that nurses practising in non-rural areas have
the technical knowledge and should be endorsed in order to provide patients with full-fledged
services. Non endorsed nurses need field experience and by providing them with knowledge and
technique of advanced nursing practices new working staff can be prepared to provide best
possible care to patients. It is recommended to the nurses at rural and remote areas to get
interfaced with technical advancement and nursing techniques. By getting knowledge of such
practices, they can improve their own nursing skills and helps in developing deep knowledge
regarding patient's behaviour and advance nursing practices. While treating the patient with type
1 diabetes mellitus it is necessary to provide with proper insulin therapy by confirming the
concentration of K+ and nurses from should keep a check on fluid volume status in a body and
provide patients with fluid therapy in case of mild dehydration. Proper management and
stabilization technique is the key factor to treat diabetic patients.
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REFERENCES
Online
Diabetes mellitus type 1. 2017. [Online]. Available through <http://qsota.com/diabetes-mellitus-
type-1/>. [Accessed on 1st September 2017]
DKA Guideline. 2015. [PDF]. Available through
<http://www.bsped.org.uk/clinical/docs/DKAguideline.pdf>. [Accessed on 4th
September 2017]
Liverpool Diabetic Ketoacidosis. 2015. [PDF]. Available through
<https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/306462/
liverpoolDiabetic_Ketoacidosis.pdf>. [Accessed on 4th September 2017]
Nepean Guide DKA. 2007. [PDF]. Available through
<https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/220679/
nepean_guide_DKA_2007.pdf>. [Accessed on 4th September 2017]
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