Multisystem Failure in Geriatrics

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Mrs. Baker’s immediate assessment would include ensuring a patent airway, adequate breathing and circulation, and a brief neurological status. Once the immediate assessment is complete then a secondary assessment is conducted that includes a full set of vital signs with focused adjuncts, pain control, a full head-to-toe assessment with a patient history. Knowing that Mrs. Baker was recently started on lisinopril while already taking metformin and hydrochlorothiazide, the immediate assessment would include possible adverse reactions to the medications. Therefore, edema could be a possible factor when examining a patent airway. If Mrs. Baker’s airway is compromised in any way due to edema or an obstruction, it will be necessary to intubate prior to proceeding to breathing issues. However, assuming that Mrs. Baker is able to maintain her own airway with minimal assistance or maybe just an oropharyngeal or nasopharygeal insertion, a breathing assessment will follow immediately. Key assessment regarding breathing status consists of spontaneous breathing, equal rise and fall of the chest, rate and pattern of breathing, use of accessory muscles, and bilateral breath sounds. Prior to Mrs. Baker becoming unconscious she was complaining of dyspnea and was tachypnea. Therefore, it would be necessary to place a nonrebreather mask with 15 liters/minute to assist in oxygenation. The last part of the immediate assessment is adequate circulation that can be assessed by pulse rate, blood pressure, capillary refill, and examination of skin for color, temperature and moisture. It is observed that the patient is tachycardia and will require a large bore IV to administer an isotonic fluid for re-expansion such as normal saline. The neurological assessment is brief by examining the patient’s level of consciousness. It is said that the patient became unconscious indicating that further investigation is required during the secondary assessment to identify possible causes. Although the immediate assessment appears lengthy and detailed, the assessment is actually done within minutes by a nurse, while the rest of the team is assisting in IV placement, monitors, and other adjuncts. Also during this initial assessment the nurse is critically thinking of the possible causes and attempting to rule out possible causes using technological tools. For instance, while placing the IV, blood will be drawn prior to administration of fluids to evaluate possible causes. Additionally, an ACCU-CHEK is also performed. This is very important in this case due to the fact that the patient is a diabetic and also was recently placed on lisinopril while taking metformin, which could cause hypoglycemia leading to the patient becoming unconscious. An I-Stat is utilized to evaluate the patient’s blood levels, electrolytes, and troponin. The patient is placed on dynamic monitoring, which includes continuous blood pressures every 5 minutes, continuous pulse oximeter, and cardiac monitors. A rectal temperature is required as well as a pain assessment. Adjunct measures would include placement of a Foley catheter to assess fluid volume, labs, VBG or ABG, EKG, chest x-ray, and any other emergent measures deemed necessary such as gastric tube, chest tubes, etc. A full head-to-toe assessment is done to ensure nothing was missed during the initial assessment as well as a more thorough history that includes allergies and medications. Now that the initial and secondary assessments are done, which again happens rather quickly, we are able to utilize some of the data collected to evaluate possible causes and interventions. The obvious causes of the patient’s condition based on history of diabetes and hypertension as well as medications, would be hypoglycemia, stroke based on blood pressure with altered mental status prior to transport, or adverse reactions to medication, more specifically lisinopril. An ACCU-CHEK is a critical test done within the first few minutes of arrival that can...
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