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.
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
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