Nursing Care in Multi-Organ Dysfunction Syndrome
Nursing Care in Multi-Organ Disfunction Syndrome When a patient enters the Emergency Department (ED), immediate and accurate assessment is mandatory to ensure prompt medical diagnosis and appropriate care. In the case of Mrs. Baker, a 73-year-old female who collapsed in her backyard, this assessment will assist in determining the reason for her collapse as well as identifying underlying medical problems that may have led to this incident. Upon her arrival at the ED, Mrs. Baker gives her previous medical history, states her primary symptoms, and lists her current medications. Luckily, the nurse is able to get this information before Mrs. Baker becomes unresponsive with more labored breathing. Once the patient becomes unresponsive, prompt action is necessary. Several interventions and assessment steps will happen simultaneously by the nurse, paramedics and patient care techs.
ASSESSMENT
First, the nurse will ensure a patent airway through auscultation of breath sounds and observing chest rise while also applying oxygen via nasal cannula or mask using pulse ox readings to titrate the oxygen, maintaining adequate saturation. The nurse will then attach telemetry leads to the patient’s chest and abdomen so that the electrical conductivity of the heart can be visualized. These tasks can be accomplished while a sphygmomanometer, wrist watch and thermometer are used by other staff to obtain the blood pressure, respirations per minute and temperature of the patient for comparison to those taken en route. The nurse will also instruct trained staff to check the patient’s blood sugar with a glucometer, since the patient listed diabetic medications. The nurse assessment will begin with the lungs, since oxygen is mandatory for homeostasis. The nurse must ensure that there is air movement in the lungs to support life. To do so, using a stethoscope, the nurse auscultates breath sounds, listening for abnormalities during inspiration and expiration in all
ASSESSMENT
First, the nurse will ensure a patent airway through auscultation of breath sounds and observing chest rise while also applying oxygen via nasal cannula or mask using pulse ox readings to titrate the oxygen, maintaining adequate saturation. The nurse will then attach telemetry leads to the patient’s chest and abdomen so that the electrical conductivity of the heart can be visualized. These tasks can be accomplished while a sphygmomanometer, wrist watch and thermometer are used by other staff to obtain the blood pressure, respirations per minute and temperature of the patient for comparison to those taken en route. The nurse will also instruct trained staff to check the patient’s blood sugar with a glucometer, since the patient listed diabetic medications. The nurse assessment will begin with the lungs, since oxygen is mandatory for homeostasis. The nurse must ensure that there is air movement in the lungs to support life. To do so, using a stethoscope, the nurse auscultates breath sounds, listening for abnormalities during inspiration and expiration in all
References: American Association for Clinical Chemistry. (2001-2011). Complete Blood Count. Retrieved October 15, 2011, from http://labtestsonline.org/understanding/analytes/cbc/tab/test American Society for Pain Management Nursing. (2006). Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations, 49. doi:10.1016/j.pmn.2006.02.003 Ferguson, C. M. (1990). Inspection, auscultation, palpation, and percussion of the abdomen. In H. K. Walker, W. D. Hall, & J. W. Hurst (Eds.), Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed., Ch. 93). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK420/ Mauk, K. L. (2010). Gerontological Nursing: Competencies for Care. Retrieved from http://wgu.coursesmart.com/9780763772819/