Nursing Care in Multi-Organ Disfunction Syndrome
When a patient enters the Emergency Department (ED), immediate and accurate assessment is mandatory to ensure prompt medical diagnosis and appropriate care. In the case of Mrs. Baker, a 73-year-old female who collapsed in her backyard, this assessment will assist in determining the reason for her collapse as well as identifying underlying medical problems that may have led to this incident. Upon her arrival at the ED, Mrs. Baker gives her previous medical history, states her primary symptoms, and lists her current medications. Luckily, the nurse is able to get this information before Mrs. Baker becomes unresponsive with more labored breathing. Once the patient becomes unresponsive, prompt action is necessary. Several interventions and assessment steps will happen simultaneously by the nurse, paramedics and patient care techs. ASSESSMENT
First, the nurse will ensure a patent airway through auscultation of breath sounds and observing chest rise while also applying oxygen via nasal cannula or mask using pulse ox readings to titrate the oxygen, maintaining adequate saturation. The nurse will then attach telemetry leads to the patient’s chest and abdomen so that the electrical conductivity of the heart can be visualized. These tasks can be accomplished while a sphygmomanometer, wrist watch and thermometer are used by other staff to obtain the blood pressure, respirations per minute and temperature of the patient for comparison to those taken en route. The nurse will also instruct trained staff to check the patient’s blood sugar with a glucometer, since the patient listed diabetic medications. The nurse assessment will begin with the lungs, since oxygen is mandatory for homeostasis. The nurse must ensure that there is air movement in the lungs to support life. To do so, using a stethoscope, the nurse auscultates breath sounds, listening for abnormalities during inspiration and expiration in all lung fields. If abnormalities exist, they may indicate an excessive fluid volume (crackles), tightness in the airways (wheezes) or a diminished capacity for air exchange (diminished air movement in the lung fields). As she listens, she is also watching for equal chest expansion; for, unequal expansion could indicate injury to the underlying tissues or atelectasis. After the respiratory assessment is complete, the nurse focuses on the heart, as its function circulates oxygen throughout the body. To assess the heart, the nurse auscultates in four areas of the anterior chest to verify the pulse regularity and pace shown on the monitor, while listening for possible heart valve function abnormalities (murmur or extra heart sounds), or inflammation (friction rub), all indicators of cardiac output. Once it is established that there are no immediate cardiac issues to address, the nurse will inspect the abdomen, noting its shape, abnormalities in the skin, masses and movement with respiration, then auscultate for bowel sounds in all four abdominal quadrants (Ferguson, 1990). Bowel sounds indicate a bowel peristalsis, while those sounding distant indicate a buildup of gas or fluid in the abdomen. After the auscultation, the nurse palpates the abdomen for tenderness or masses. Since the patient is unresponsive, the nurse will pay special attention to the patient’s body language during palpation—facial grimacing, physical guarding or flinching—to identify pain or discomfort. The nurse will then move on to explore the rest of the patient’s body, palpating for broken bones, enlarged lymph nodes, possible masses or other abnormalities. Because the patient is a diabetic, the nurse will also inspect the patient’s skin for signs of injury, as well as noting the temperature and color of the extremities and nail beds, which are indicators of circulation and perfusion. DATA COLLECTION WITH ADDITIONAL TECHNICAL TOOLS
While the nurse is finishing her assessment, other...
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