Multisystem Failure Homeostasis And Pain Management Case Study

Multisystem Failure Homeostasis and Pain Management
Western Governors University

When patient’s present to an emergency department in multisystem failure many factors contribute to the way the nurse will perform. In an emergency situation when a patient presents it involves quick assessment, complex observation, and decision making to assess the patient homeostasis level, pain management, and oxygenation. It is the nurse’s duty to prioritize what needs to be done for the patient in a limited amount of time.

Upon reading this scenario, Mrs. Baker presents to the emergency department with shortness of breath and an increased respiratory rate and pulse. As a nurse prioritization is imperative.
A quick was help prioritize would be for the nurse to revert back to basics of assessment the classic A-B-C-D-E way of assessment. By assessing the airway, breathing, circulation, disability, and exposure the nurse can perform a quick assessment and prioritize the needs of the patient. The nurse’s first priority on initial assessment should be a focused assessment of addressing the patient’s airway and breathing due to the complaints of shortness of breath and increased respiratory rate, a focused assessment of mental status and orientation, and a quick pain assessment.
Once a focused assessment is completed then a secondary assessment including a head to toe assessment, full vital signs, a brief history, and secondary adjunct assessment functions can be performed.
The first priority is to perform a focused assessment to include the patient’s respiratory function, pain, mental status, and any medication the patient has taken. The patient’s airway and ability to breathe and maintain a patent airway becomes the first priority. By asking the patient the four questions of orientation the nurse can assess the patient’s mental status. The patient’s pain can also be assessed quickly by using a numerical value or the Wong-Baker Scale prior to the patient becoming unresponsive, as well as asking the patient for a brief history of her medical condition and any co-morbidities. For the patient’s airway and breathing, the patient should be placed on 15 liters of oxygen with a non-rebreather mask to allow for increased oxygenation and a pulse
oximeter should be placed on the patient’s fingers to assess oxygen saturation to ensure proper oxygenation. In the event that the patient would be unable to maintain a patent airway the possibility of intubation may be considered to assist the patient in obtaining oxygenation properly. Once it has been established that the patient can maintain her airway respiratory status can be assessed by watching the patient breathe and looking for flaring of nostrils, the use of accessory muscles for breathing, lung sounds, and the rise and fall of the chest to ensure adequate breathing. While the patient is conscious the nurse can proceed in the focused assessment and ask the patient if she is having any pain and at what level the pain is at current by using a 0-10 numerical scale to detect the severity of pain the patient is feeling if any. The next area to be assessed would be the patient’s orientation the nurse can ask the patient who they are, where they are, what time are we in, and what brought them to the emergency department if the patient is able to answer all four questions appropriately the patient is considered to be orientated. If in the event the patient is unable to answer one or more correctly further assessment of the patient’s orientation and mental status is warranted. Assuming the patient is oriented; the nurse can proceed to acquire a brief history of the patient including any co-morbid conditions and any medication the patient is currently taking at home and what the patient has already taken for the day.
In the scenario the patient becomes unresponsive; however, this should not be a hindrance of the nurse continuing to perform a head to toe assessment and begin looking for more objective data that can be gathered with including a physician to obtain orders and including other members of the interdisciplinary team to care for the patient.
Since the patient has become unresponsive the nurse should begin with a neurological assessment by checking pupils for reaction and using a blunt needle on the extremities to insure a response from both the autonomic and peripheral nervous system. The respiratory and cardiovascular system can be assessed with the use of a stethoscope by listening to lung and heart sounds, as well as, checking peripheral pulses, capillary refill time, and checking for any discoloration of the skin especially around the mouth and extremities. To conclude the assessment of the integumentary system the nurse should check for any abrasions, bruising, or wounds sustained by the patient during the fall the patient reported. The nurse can continue to assess the patient’s pain level by looking for key expressions that would indicate the patient is in pain such as furrowing brow, flared nostrils, grimacing, or restlessness at the point of at which external pain factors are used to determine responsiveness of the patient such as a sterna rub or pinching of the knuckles. The scenario indicates that the patient has begun to have increased difficulty with breathing at
this time a physician and respiratory therapist should be included in the immediate care of the patient. The physician can begin to write orders for an intravenous catheter to be placed considering the patient is unresponsive and intravenous morphine for pain control and possible fluid resuscitation can also be considered due to the patient having hydrochlorothiazide ordered and a new prescription for lisinopril that could have had a synergistic affect on the patient causing more fluid to be eliminated from the patient’s body. The physician can also order labs that would be needed to obtain more objective data needed to determine the condition of the patient such as arterial blood gases that can be drawn by the respiratory therapist, a complete blood count, electrolyte levels, creatinine and BUN levels can also be collected. The respiratory therapist can assess the patient PO2, ph, and CO2 levels to determine if the patient is experiencing respiratory acidosis or alkalosis due to the patient’s increase in difficulty breathing. With an intravenous catheter ordered the nurse could administer morphine for the patient’s pain management due to the patient being unresponsive oral medication would not be considered, based on the patient’s external responses to pain will determine the amount of morphine to be administered. In this case because the patient is an elderly patient the nurse would begin with 0.05 mg of morphine for pain and reassess the patient’s response to the morphine in one hour. The nurse can determine the effectiveness of the pain medication by reassessing the patient and where the patient continues to show signs of external discomfort and another set of vitals can be obtained due to the fact that morphine not only acts on the pain but can affect the respiratory rate, heart rate, and blood pressure. If no discomfort is noted, the nurse can determine that the morphine administered for pain control was effective. The physician and respiratory therapist can then determine if it would be necessary to intubate the patient and place the patient on a ventilator. Once all lab reports have been seen and assessments completed by the nurse, respiratory therapist, and physician the physician is then able to determine what has caused the patient to become unresponsive. The physician can then determine whether or not the patient would need to be admitted to the hospital and what level of care would be deemed necessary for the patient to recover.
In conclusion, although Mrs. Baker entered the emergency department responsive and became unresponsive the triage nurse, whose assessment abilities are honed to look for certain indicators, can react quickly and appropriately to significant changes in the patient’s condition. The nurse can also determine when and who is necessary to become part of the interdisciplinary team that would be utilized for the care of the patient. In this day and age it is quite rare for nurse to complete the entire care for a patient, although nurses have some autonomy without a physician and other members specialized in certain area such as a respiratory therapist the total care and stabilization of the patient could not have been effective.

Work Cited
Baird, M.S., Keen, J. H., & Swearingen, P.L. (2005) Manual of Critical Care Nursing Nursing Interventions and Collaborative Management 5th ed. St. Louis, MO: Elsevier Mosby

Ignatavicious & Workman (2013) Medical Surgical Nursing Patient Centered Collaborative Care 7th ed. St. Louis, MO: Elsevier Saunders