Homeostasis and Pain Management in Patient with Multisystem Failure Essay

A. Assessment of Patient The assessment of Mrs. Baker should include vital signs including pulse oximetry. Given her difficulty in breathing, lung sounds should be auscultated. Because she is on two different medications that could affect blood pressure, lisinopril and hydrochlorothiazide (HCTZ), hypotension could be one cause of her collapsing. In addition to vital signs, decreased peripheral pulses and capillary refill can also be indicators of hypotension. Also, because HCTZ is a diuretic, dehydration should be considered. Since she was in her backyard when she collapsed, it could be that she was doing yard work. Thus, it is important to know what she was doing before she collapsed. The outside temperature and whether Mrs. Baker became overheated or drank enough fluids could be useful factors in assessing her fluid-electrolyte balance. Serum electrolyte levels and vital signs should be taken, and color and skin turgor should be assessed. Dehydration could also contribute to hypotension. Mrs. Baker should be placed on a cardiac monitor and an EKG obtained to rule out any dysrhythmias. Given Mrs. Baker’s respiratory symptoms and her history of hypertension and diabetes (which are the two biggest risk factors for congestive heart failure), a chest x-ray should be done. Arterial blood gases could assist in further assessing her oxygenation, as well as acid-base balance. Also, since Mrs. Baker is a diabetic, a blood glucose level should be done, since hypoglycemia could be a cause of her mental status changes. When Mrs. Baker is alert, pain can be assessed through a verbal â€Å"numbers† scale, or a â€Å"faces† scale if she is mildly confused. When she becomes unresponsive, non-verbal indicators of discomfort should be observed, such as muscle tension, grimace, and grunting. B. Technological Tools A stethoscope is an essential assessment tool. It is needed to assess breath sounds, heart sounds, and perhaps assist in taking the blood pressure. A stethoscope works by amplifying internal sounds through a diaphragm and transmitting them through a hollow tube to the earpieces. (Schunk, p. 1) The sounds can be interpreted by a skilled assessor and used to make a diagnosis and prescribe treatment. In Mrs. Baker’s case, it would be extremely important to listen to her lung sounds to determine if there are changes associated with atelectasis, or more likely, to assess for fluid sounds in the lungs, which would be an indicator of congestive heart failure. If a manual blood pressure measurement is being taken, the stethoscope would also be essential to listening for restored peripheral blood flow as the pressure in the cuff is being released. The benefit of a stethoscope is that it is a simple tool that can be used to easily obtain an initial assessment of a patient’s breath sounds while waiting on more complicated assessments, such as blood gases and chest x-rays. If a manual blood pressure cuff is not available, blood pressure will probably be obtained using an electronic blood pressure device such as a Dinamap. A blood pressure measurement, as well as other vital signs, would be key in determining whether Mrs. Baker was suffering from hypotension related to her new medication, lisinopril. A manual blood pressure cuff has the benefit of being more accurate at extremely high or extremely low pressures, while an electronic device, such as a Dinamap, can be set to automatically check blood pressure at regular intervals. Many cardiac monitors also have blood pressure capabilities built in, so that may be an option for obtaining blood pressure. A cardiac monitor would be used for Mrs. Baker to watch for arrhythmias, which could be caused by lisinopril, or be another sign of congestive heart failure or an acute myocardial infarction. Mrs. Baker has a history of hypertension and diabetes, which are the two greatest risk factors for heart disease. An electrocardiogram (EKG) would be useful for diagnosing heart disease or damage as well. A cardiac monitor is essential in continuous monitoring of the patient, but a 12 lead EKG has the benefit of being able to better pinpoint the specific areas of the heart that are affected or damaged. Blood sugar can be obtained from a drop of blood with a glucometer such as One Touch, or it may be obtained along with the serum chemistry and electrolyte analyses from the lab. A glucometer is a quick and easy way of determining the blood glucose level. Mrs. Baker is a diabetic, and is on an antidiabetic drug, Metformin. Her change in mental status could be due to low blood sugar. This would be easily diagnosed with a glucometer, and easily treated with IV glucose, so it should be one of the first assessments made. A glucometer has the benefit of being a quicker and easier way to obtain a blood sugar level, while a serum glucose may be more accurate at extremely high or low levels. Pulse oximetry can be done with a dedicated pulse oximeter, or it may also be built in to the capabilities of the cardiac monitor. Since Mrs. Baker is suffering from respiratory difficulty, it is essential to find out her blood oxygen saturation level. An arterial blood gas would not only be helpful in giving a more precise measurement of arterial oxygen and carbon dioxide, it would also give useful information about the pH of her blood and the bicarbonate level. Pulse oximetry has the benefit of alerting caregivers to acute changes in blood oxygenation level, while arterial blood gases gives a more detailed picture of the of the state of gas exchange in the lungs Serum electrolytes would be measured by the laboratory. These would be helpful in diagnosing dehydration and/or kidney function. Electrolytes are also essential in cardiac function. In fact, serum electrolytes are a good overall way to assess homeostasis in a patient. A radiographer will use an X-ray machine to obtain the chest x-ray, either in the radiology department, or will use a portable model. A chest x-ray is another way to assess respiratory function. A chest x-ray could show fluid in the lungs, as well as atelectasis or infiltrate. It would also show cardiomegaly, which is another indicator of congestive heart failure. A portable chest x-ray would be beneficial, as it would not require Mrs. Baker to be taken from the emergency department. Finally, if Mrs. Baker has been a patient at this facility before, the Electronic Medical Record can make it easy to find information on her past medical history. This is an improvement over medical records of years past, which usually had to be located in extensive file cabinets or even on microfiche. Sometimes these records were lost or misfiled. Electronic Medical Records are usually easy to locate. C. Data Collection Prioritization Vital signs, pulse oximetry, and a visual assessment should always be the first assessments performed on a patient. The severity of the vital signs will determine whether emergency life-support interventions need to be initiated at once, and will give the caregivers clues to what needs to be looked at next. Since hypoglycemia is an emergency situation, a finger-stick blood sugar should be the next assessment formed. And since Mrs. Baker is having respiratory difficulty, breath sounds should be assessed as soon as possible to determine what measures need to be taken to insure adequate ventilation. Lab work, x-rays, and other tests should be done after the initial assessments, since the results will take longer to obtain. D. Pain Assessment Comparison In alert and oriented patients with no cognitive impairments, the best way to measure pain is to use the â€Å"numbers† scale. Using this scale, you have the patient rate their pain on a scale from 0 to 10, with 0 being no pain, and 10 being the worst pain they can imagine. Pain is subjective, meaning that it can only be judged by the person in pain, and not by an observing party. The numbers scale gives an easy way for a person to tell her nurse the level of her pain, and to judge how much it is relieved by interventions. A geriatric patient who is alert but has mild cognitive impairments may be confused by numbers, but can be given the Wong Baker faces pain scale to help to measure their pain in the same way as the numbers scale. A patient who is not alert or who is unconscious is obviously not going to be able to describe her pain to her caregiver. In this case, the caregiver will have to observe the patient for non-verbal signs of discomfort. These include grimace, muscle tension, increase heart rate, respirations, or blood pressure, and moaning or grunting. E. Pain Management If Mrs. Baker was not alert enough to respond to questions but was showing signs of pain, and given the standing orders of acetaminophen or morphine, I would elect to give the patient morphine. The patient is not alert enough to take any medication by mouth, and an oral medication will take longer to work. Intravenous Morphine works very quickly, and may decrease the work of breathing in patients with congestive heart failure. The caregiver should reassess the patient’s pain after giving any pain medications. In the case of a non-alert patient, the caregiver would look for signs such as stabilization of vital signs and muscle relaxation. I have learned that the geriatric patient has a decrease in physiologic reserve, and therefore there is a shorter time between changes in homeostasis and a state of shock. Because of this, when an elderly patient is showing signs of distress, assessment and interventions should be done quickly to improve outcome. I also learned that an elderly patient may live their everyday life with a certain level of chronic pain, so when they complain of acute pain, it should be taken seriously and treated promptly. F. Team Members Mrs. Elli Baker may have been assessed initially by an EMT or paramedic, if emergency medical services had been called to transport her to the emergency room. Upon arrival, she would have been assessed by a nurse, and at the same time or shortly thereafter, the emergency room physician. The nurse would have obtained vital signs, applied the cardiac monitor, and obtained the finger stick blood sugar, while the physician would have given an initial set of orders. A respiratory therapist would have probably been called, given her respiratory difficulties, and an EKG technician would have been called to do an electrocardiogram. Labs may have been drawn by a phlebotomist or a nurse, and the arterial blood gases would have been obtained by the respiratory therapist or a phlebotomist, depending on the facility’s policy. Finally, a radiology technician would have performed the chest x-ray. When the nurse noticed that Mrs. Baker became unresponsive and started having more difficulty breathing, she would have notified the physician of the changes and called any necessary support staff to assist with Mrs. Baker’s immediate care.