GNT1 Contemporary Nursing Issues
Western Governors University
GNT1 Task One2
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 One3
and decreased homeostasis.
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
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...