Ssment and Management in Multisystem Failure
Assessment and Management in Multisystem Failure
Western Governors University
Assessment and Management in Multisystem Failure
Assessment of Patient
Numerous patients present in an Emergency Department (ED) at a fast pace and nurses must be proficient triaging and prioritizing all patients based on their “medical condition and chance of survival” (Anderson, Omberg, & Svedlund, 2006). The primary assessment should identify the urgent issues and treat those that may become life threatening. Potential failure of any of the three main systems, circulatory, respiratory or central neurological systems, are the life threatening issues that must be recognized and treated immediately (Advanced Life Support Group, 2001). The well-known A-B-C-D-E process referring to airway, breathing, circulation, disability, and exposure are easy guidelines to use in this initial assessment.
An experienced nurse can perform high level assessments of multiple issues simultaneously by simply being aware of key indicators. A visual assessment when the nurse initially greets the patient can identify the basic level of consciousness, the presence of wincing or guarding an extremity, open wounds or rashes, skin and lip color, symmetrical and effective chest expansion, rhythm, rate and depth of breathing, flared nostrils or pursed lips, and use of accessory muscles for breathing (Higginson, Jones, & Davies, 2010). These observations can be performed quickly during the initial greeting of the patient and guide the nurse toward potential life threatening conditions that need to be assessed.
While visually examining the patient, a nurse should be aware of all of the sounds and responses from the patient. From the case study that was presented, Mrs. Baker was initially alert and responsive when admitted to the ED. As the nurse greeted Mrs. Baker and asked how she was feeling, Mrs. Baker was able to respond to some questions which indicated that her airway was patent at
Western Governors University
Assessment and Management in Multisystem Failure
Assessment of Patient
Numerous patients present in an Emergency Department (ED) at a fast pace and nurses must be proficient triaging and prioritizing all patients based on their “medical condition and chance of survival” (Anderson, Omberg, & Svedlund, 2006). The primary assessment should identify the urgent issues and treat those that may become life threatening. Potential failure of any of the three main systems, circulatory, respiratory or central neurological systems, are the life threatening issues that must be recognized and treated immediately (Advanced Life Support Group, 2001). The well-known A-B-C-D-E process referring to airway, breathing, circulation, disability, and exposure are easy guidelines to use in this initial assessment.
An experienced nurse can perform high level assessments of multiple issues simultaneously by simply being aware of key indicators. A visual assessment when the nurse initially greets the patient can identify the basic level of consciousness, the presence of wincing or guarding an extremity, open wounds or rashes, skin and lip color, symmetrical and effective chest expansion, rhythm, rate and depth of breathing, flared nostrils or pursed lips, and use of accessory muscles for breathing (Higginson, Jones, & Davies, 2010). These observations can be performed quickly during the initial greeting of the patient and guide the nurse toward potential life threatening conditions that need to be assessed.
While visually examining the patient, a nurse should be aware of all of the sounds and responses from the patient. From the case study that was presented, Mrs. Baker was initially alert and responsive when admitted to the ED. As the nurse greeted Mrs. Baker and asked how she was feeling, Mrs. Baker was able to respond to some questions which indicated that her airway was patent at
References: Abraham, S., Madhu, R., & Provan, D. (2010). Hands-on guide to data interpretation [Adobe Digital Editions version]. Retrieved from http://site.ebrary.com/lib/westerngovernors/Doc?id=10419296&ppg=117 Adam, S. (2010). Rapid assessment of the acutely ill patient [Adobe Digital Editions]. Retrieved from http://site.ebrary.com/lib/westerngovernors Advanced Life Support Group. (2001). Acute medical emergencies: the practical approach (1 ed.) [Adobe Digital Editions]. Retrieved from http://site.ebrary.com/lib/westerngovernors/home.action Anderson, A. K., Omberg, M., & Svedlund, M. (2006). Triage in the emergency department: a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 11, 136-144. Higginson, R., Jones, B., & Davies, K. (2010, September 9). Airway management for nurses: emergency assessment and care. British Journal of Nursing, 19, 1006, 1008, 1010. Retrieved from http://ehis.ebscohost.com.wguproxy.egloballibrary.com Lewis, T. V., Zanotti, J., Dammeyer, J. A., & Merkel, S. (2012, January). Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. American Journal of Critical Care, 19(1), 55-61. Mauk, K. (2010). Gerontological nursing: Competencies for care (2 ed.) [Adobe Digital Editions ]. Retrieved from http://wgu.coursesmart.com/9780763772819#extendedisbn Tveita, T., Thoner, J., Klepstad, P., Dale, O., Jystad, A., & Borchgrevink, P. (2008, August). A controlled comparison between single doses of intravenous and intramuscular morphine with respect to analgesic effects and patient safety. Acta Anaesthesiologica Scandinavica, 52, 920-925. doi:10.1111/j.1399-6576.2008.01608.x