Western Governors University
Assessment and Management in Multisystem Failure
Assessment of Patient
Numerous patients present in an Emergency Department (ED) at a fast pace and nurses must be proficient triaging and prioritizing all patients based on their “medical condition and chance of survival” (Anderson, Omberg, & Svedlund, 2006). The primary assessment should identify the urgent issues and treat those that may become life threatening. Potential failure of any of the three main systems, circulatory, respiratory or central neurological systems, are the life threatening issues that must be recognized and treated immediately (Advanced Life Support Group, 2001). The well-known A-B-C-D-E process referring to airway, breathing, circulation, disability, and exposure are easy guidelines to use in this initial assessment. An experienced nurse can perform high level assessments of multiple issues simultaneously by simply being aware of key indicators. A visual assessment when the nurse initially greets the patient can identify the basic level of consciousness, the presence of wincing or guarding an extremity, open wounds or rashes, skin and lip color, symmetrical and effective chest expansion, rhythm, rate and depth of breathing, flared nostrils or pursed lips, and use of accessory muscles for breathing (Higginson, Jones, & Davies, 2010). These observations can be performed quickly during the initial greeting of the patient and guide the nurse toward potential life threatening conditions that need to be assessed. While visually examining the patient, a nurse should be aware of all of the sounds and responses from the patient. From the case study that was presented, Mrs. Baker was initially alert and responsive when admitted to the ED. As the nurse greeted Mrs. Baker and asked how she was feeling, Mrs. Baker was able to respond to some questions which indicated that her airway was patent at that time. Although Mrs. Baker was able to speak, if she was only able to answer with one or two word responses, it could have indicated that there was a partial airway obstruction and would have warranted further assessment. The nurse should listen for obvious wheezing, stridor or coughing and document if the patient appears to have difficulty breathing. With the use of a stethoscope, the nurse can listen to the lungs for less obvious breath sounds such as crackles, rhonchi, rales or complete absence of breath sounds. As the nurse begins to ask questions about the past medical history, allergies, onset or duration of symptoms, and pain level using the visual analog scale (VAS), she should also be able to assess the patient for appropriate responses and confusion using the AVPU scale. AVPU stands for Alert, Verbal, Painful and Unresponsive. Similar to the visual and auditory inspections above, the tactile inspection can also assess multiple issues. The nurse can obtain the basic vital signs such as blood pressure, heart rate, oxygen saturation and temperature with a spot vital signs monitor. She should be cognizant of the skin temperature and document if it is warm and dry as she places the blood pressure cuff on the patient. Evaluating the elasticity of the skin by gently pinching a small section of the skin on back of the hand will assess the skin turgor. Although the spot vital sign monitor detects the heart rate and oxygen saturation, the nurse can assess the rhythm and strength of the pulse by palpating the radial artery and the peripheral perfusion by measuring the capillary refill time. These baseline vitals are key factors in the measuring stability of the patient and will be referred to for comparison as the condition deteriorates or improves. Several of these high level assessments can be late effects of conditions that can be more definitively assessed with diagnostic testing. Peripheral IV access should be initiated using a large diameter...