Assessment of Geriatric Patient with Multisystem Failure
The initial immediate assessment of the patient would be to assess Mrs. Baker’s airway and breathing since she is having dyspnea. Next, obtain vital signs: respiration rate, blood pressure, temperature and pulse rate. The nurse should also listen to lung sounds. It would be extremely important to determine the oxygenation of the patient by placing a pulse oximeter on an available index finger while observing Mrs. Baker’s skin color, skin around lips and beds of her fingernails. Capillary refill time should also be noted while assessing the fingernail beds. The nurse will need to determine Mrs. Baker’s current level of consciousness. She would do this by assessing pupil reactivity, orientation to person, place and time and asking her questions to gauge her mental status. The nurse should also assess Mrs. Baker for symptoms of dehydration including skin turgor, lethargy, decreased blood pressure, confusion, sunken eyes, dizziness and dry mucous membranes. If Mrs. Baker is conscious on her arrival to the hospital, the nurse should try to assess her pain level while she is still able to speak by asking her to rate her pain on a scale of 1 to 10. 1 meaning that she feels zero pain and 10 being the worst pain she has ever felt. If Mrs. Baker is unresponsive on at the time of arrival, the nurse needs to be vigil in looking for clues to how she is experiencing pain by looking for signs such as moaning, agitation, restlessness and facial grimacing. Since Mrs. Baker has a history of diabetes, it will be extremely important to check her blood sugar levels using a glucose meter. The nurse will also need to start an IV since there is a standing order for intravenous medication and labs will most likely be ordered and they can be drawn off of the IV. Tools that will be utilized in the assessment of Mrs. Baker may include: A stethoscope and blood pressure cuff to obtain Mrs. Baker’s lung sounds, pulse rate and blood pressure. A pulse oximeter will be used to measure Mrs. Baker’s oxygenation. The pulse oximeter can also be used to obtain Mrs. Baker’s heart rate and can be compared to what you obtained when doing the heart rate by stethoscope. An oral thermometer will be used to obtain body temperature. Supplies to start intravenous access: tourniquet, chloraprep swabs, tegaderm, gauze, IV catheter, j-loop, 5cc flush and a towel to put under Mrs. Baker’s arm in case blood runs. The nurse should also bring an emesis basin in case Mrs. Baker feels nauseated and needs to vomit, since she is in and out of consciousness the nurse does not want her having to get up to vomit in the toilet as this presents a fall risk in her condition. A nasal cannula and oxygen mask (whichever is more convenient for the patient under the circumstance) and oxygen should be at bedside since Mrs. Baker is experiencing shortness of breath which in turn can be causing her to panic and experience hypercapnia. A pen light will be used to check Mrs. Baker’s pupil reactivity, more specifically PERRLA (pupils equal, round, reactive to light and accommodation). To assess Mrs. Baker’s pain level, the nurse will use a pain scale. She can use a mini mental status scale to see if the patient is experiencing cognitive ailments. If the patient is unconscious, physical and objective signs must be under watchful eye to determine the amount of pain Mrs. Baker is experiencing at that time. Mrs. Baker’s cardiac status should be evaluated and using an EKG machine can determine this. A CT scan can be performed of the patient’s head to rule out or confirm if Mrs. Baker has had an ischemic incidence or cerebral vascular accident. If Mrs. Baker is unconscious and the likelihood of getting her up out of bed is not an option, a foley catheter can be used to obtain specimens of urine to check for kidney function and possible bladder/urinary tract infections. The benefit of having all these up to date tools on hand makes it easier for...
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