Gnt1 Task 1

GNT1 TASK ONE 1

Advanced Pathophysiology
Molly Williams
GNT1 Contemporary Nursing Issues
11-7-12
Western Governors University

GNT1 Task One 2
Assessment of Patient The key immediate assessments that a nurse should make to assess a patient for homeostasis are: oxygenation (airway, breathing, and circulation), vital signs: blood pressure, pulse, respirations and temperature, mental status, blood sugar levels, fluid intake and output and level of pain.
Oxygenation is important because oxygen needs to reach all the organs of the body in order for them to maintain homeostasis. When oxygen levels are low (under 90%) it indicates oxygen is not reaching all body cells. Shortness of breath indicates poor oxygenation, fluid overload, or possible pulmonary emboli. Vital signs need to be taken frequently to monitor for any changes in the body. Dehydration can cause low blood pressure. Increased pulse can indicate poor blood supply to the heart or high anxiety. Temperature is important to help rule out any signs of infection. Mental status is monitored by asking the patient if they know who they are, where they are and past health history. When this is compromised it makes it difficult to do any further assessment. Most diabetics need their blood sugar levels monitored daily. Blood sugar levels indicate if a person has a low or high blood sugar. When sugar levels in the body are low, this can cause confusion, disorientation and ultimately coma. When sugar levels are high this can cause increased thirst, hunger and irritability. Fluid intake and output measurements are important as they allow the nurse to assess how well the kidneys are functioning. Listening to the lungs for crackles or wheezes would indicate if there was fluid volume overload or congestive heart failure (CHF). CHF can cause shortness of breath. Assessing the level of pain and where it is, will help the nurse determine what part of the body is experiencing de-compensation
GNT1 Task One 3 and decreased homeostasis.
Technological Tools Oxygen saturation can immediately be assessed by placing a pulse oximeter on the patient’s finger. A pulse oximeter measures the amount of oxygen in the blood by using a laser. The laser is able to measure the saturation of oxygen in the blood. When oxygen levels are low, this can cause confusion, disorientation, increased heart rate, increased respirations along with difficulty breathing. Vital signs, such as blood pressure, are measured using a manual blood pressure cuff. The cuff is compressed full of air and when released allows the nurse to hear the systolic and diastolic heart-beat. A manual cuff should be placed on the patients left arm as this is closest to the heart and will give a more accurate reading of the patient’s blood pressure. Increased blood pressure puts an individual at risk of stroke, heart attack and damage to the heart. Low blood pressure puts an individual at risk of fainting, dizziness or shock. The pulse is measured by using two fingers at the patient’s wrist or neck and counting for a full minute. Respirations are counted by watching the patient breath and counting the breaths. At this time it is also important to note if there is difficulty in obtaining air. Temperature is best measured by using a tympanic thermometer; this is less invasive and only takes about 5 seconds to obtain results.
Blood sugar levels are measured by a glucometer. This is quicker than lab results. This entails poking the patient’s finger with a lancet and gathering the blood on a strip that is inserted into the glucose monitoring machine. A glucometer is able to give immediate results so that the

GNT1Task One 4 nurse will know what treatment to implement. Results are ready within 30 seconds. A sample of the blood will measure sugar levels in the body. Fluid output is measured by placing a foley catheter to monitor urine output and intake is monitored by counting how much the patient takes in of all fluids. Counting can be done by an IV machine or the nurse writing down how much a patient has drank. (Usually counted in milliliters). Pain is assessed by asking a patient on a scale of 0-10 with 10 being the worst pain, what is their pain level? Where is it? What kind? (sharp, dull, throbbing, aching, etc.) Pain is known as the fifth vital sign. Pain can also be measured by non-verbal cues, such as anxiety, irritability, grimacing, and fidgeting.
Use of Tools The important use of these tools is to monitor and maintain homeostasis. Each tool has a specific purpose and provides results for which the treatment team will act on. The oximeter was used to get immediate oxygen level results. This will help the nurse determine if oxygen is needed via nasal cannula, or re-breather mask. A manual blood pressure cuff gives more accurate results because the nurse listens to the heart beat via a stethoscope. A glucometer machine is much quicker in giving blood sugar results than drawing blood via a vein or capillary and sending it to the lab. Placing a foley catheter, if needed, will allow precise measurement of fluid output. IV fluids replenish fluids if the patient is dehydrated and also measures fluid intake. Assessing pain is always useful, to keep all patients comfortable.
Benefits of Tools The benefits of these tools are that they give quick and definitive results. This will ensure that the patient’s treatment will not be delayed. When a patient becomes unresponsive, time is
GNT1 Task One 5 critical. Immediate results are necessary to implement life-saving treatment. Without these tools it would be difficult to treat the patient.
Data Collection Prioritization Breathing is the first thing to assess when presented with a compromised patient. Mrs. Baker was having dyspnea with an increased respiratory rate and later became unresponsive with a difficult time breathing. At this point it’s important to maintain an airway and oxygenation. Mental status would be affected if oxygen was low, so mental status is assessed when you first come in to contact with a patient. Vital signs would be next for assessment and paint a picture of what may be going on with Mrs. Baker, as she recently started a new BP med. Blood sugar levels would be the next important and fast result to obtain. If Mrs. Baker’s blood sugar was low then replacement glucose via IV would be needed. If her blood sugar was too high, then insulin would be given. Fluid input and output would indicate if fluid is being retained, possibly in the lungs, around the heart, and also indicate how the kidneys are functioning. Mrs. Baker was also taking hydrochlorothiazide which is a diuretic and can deplete fluids and mess up electrolytes, such as potassium, which in turn affects the heart. Last but not least, pain is assessed by asking questions, observing the patient, and if needed, showing a face chart for the pt. to point to how they are feeling.
Pain Assessment Comparison
Assessing pain in a geriatric patient who is alert would consist of asking: If there is any pain? Where is the pain? How long does the pain last? Describe the pain? What brings the pain on? Blood pressure and pulse would need to be monitored. Asking the patient: What has helped
GNT1 Task One 6 the pain in the past? Assessing pain in a geriatric patient who is not alert is much more difficult. High blood pressure and pulse may indicate pain, along with increased breathing. If the patient is not alert then they most likely will not be fidgety. Assessing for any other causes of pain, such as infection, constipation, wounds, and recent surgery will let the nurse know if the non-alert patient is having pain. (Smith, 2010)
Pain Management The management of pain in the geriatric patient who is experiencing multisystem failure would entail many things. It is important to assess facial expression, vocalizations, body movements, muscle tension, alertness, calmness, respiratory response, heart rate and blood pressure. Assessing for preexisting painful conditions would be pertinent if there is access to past medical history or access to family. In Mrs. Baker’s situation there is not. It is important for the patient to be in a comfortable position with adequate oxygenation. After compiling all of the above assessments the nurse would then determine if pain medicine is needed. It is highly likely given Mrs. Baker’s age and having collapsed in her backyard that she is experiencing discomfort. She may have hit her head or she may have neuropathy from her diabetes. Assessing input and output of fluids, heart function via EKG, obtaining a CT of the head to rule out subdural hematoma would also determine if the patient may be experiencing pain.
Success of Pain Management
In the geriatric patient it is best to start out with the smallest dose and lease potent of drugs, due to their fragile system. As a person ages their body starts to absorb, and distribute medicines differently. It also depends on any comorbidity they may have. In this scenario the
GNT1 Task One 7 patient is not alert enough to respond to questions, so swallowing Tylenol may be difficult. If there is already an IV access, I feel it would be best to administer the morphine via IV. If there is not an IV access then it could be given IM. This would work quicker and calm the patient down. It would be very important to monitor the patient’s breathing and for any other side effects, such as hallucinations or rash. If the morphine was successful, a patient’s blood pressure, pulse and heart rate may decrease. The patient may become less anxious and more cooperative. Also repositioning the patient may help alleviate some discomfort, giving reassurance and explaining everything as you go, will help make a patient feel at ease.
Learning
Assessing the geriatric patient involves many more factors. As a person ages, it is likely, that they will have more than one medical diagnoses. There is much more to be considered by the medical team when assessing the geriatric patient for pain. Behavior changes, physical changes, health history, and ability to report pain are all factors. It is best to approach pain assessment, system by system. Pain is the fifth vital sign and should always be assessed, even if the nurse has no reason to believe there is pain.
Team Members The team members involved in this scenario consists of the ER nurse, respiratory therapist, the doctor, and possibly a code team, because of Mrs. Baker’s respiratory distress. The response of the charge nurse after Mrs. Baker became unresponsive would be to make sure she is still breathing and to make sure she still has a pulse. This is done by looking to see if her chest rises, listening for breathing close up to her mouth and nose, and feeling for a pulse on her
GNT1 Task One 8 jugular vein. If there were no pulse or breathing had stopped, the nurse would then call a code blue (in most hospitals). The nurse would then immediately start CPR and would be relieved from her chest compressions once someone else arrived. It would be imperative to start an IV line, with a standing order or immediate doctor’s order. An IV would allow fluids or any needed medicine to be administered and start working immediately. In any ER, there will be a team of medical professionals to assess the presenting individual. Other team members if accessible should be a family member of Mrs. Baker. It is uncertain who called the ambulance, if her neighbor did, then a social worker would be able to ask them if there is any family that they can call to get more information about Mrs. Baker. A family member may be able to provide code status or documentation of Mrs. Baker’s wishes in an emergency. If Mrs. Baker was more responsive she would be part of the team, in that, she would provide information that the medical team could then make critical decisions.

GNT1 Task One 9
References
Smith, Nathalie, RN, MSN, CNP. Grose, Sara, MSN, RN, PHN, CNL, CLE. August 2010. Pain Assessment in Older Adults. Retrieved from http://www.ebscohost.com/uploads/poc/pdf/NRC_skillPaper.pdf

References: Smith, Nathalie, RN, MSN, CNP. Grose, Sara, MSN, RN, PHN, CNL, CLE. August 2010. Pain Assessment in Older Adults. Retrieved from http://www.ebscohost.com/uploads/poc/pdf/NRC_skillPaper.pdf