Management of Patient with Altered Mental Status
GNT1 - Task One
The case review presents a 73-year-old female patient who is brought to the emergency department after collapsing at her residence. Just prior to the incident, the patient is reported to have been acting “confused.” Upon arrival to the emergency department, the patient is having difficulty breathing with an increased respiratory rate and pulse. The nurse is unable to complete the initial examination before the patient becomes unresponsive and has increased work of breathing. At this point, it is necessary to active an emergency response team and begin advanced cardiac life support (ACLS) interventions. These interventions involve the initiation of an algorithmic approach to assessment and the initiation of emergency interventions necessary to stabilize the patient.
A primary assessment of airway, breathing, circulation, neurological status and inspection of body must be initiated immediately. This assessment is rapid and requires little to no use of specialized technological tools. The case study indicates that patient “collapsed” in her backyard; therefore, cervical spine immobilization must be maintained at all times until the possibility of spinal injury has been ruled out.
This rapid assessment begins with an inspection of the patient’s airway to ensure no obstructions exist. Possible airway obstructions include the patient’s tongue, loose teeth, foreign objects, vomit or blood. The airway must be cleared of any obstructions before proceeding with the assessment. The case study does not indicate the presence of any airway obstructions. Once the airway is deemed clear, an assessment of breathing occurs. This includes observing the patient for signs of spontaneous breathing, including rise and fall of the chest, rate of breathing, work of breathing and breath sounds. The case study reports the patient as both unresponsive and as having difficulty breathing. In an unresponsive patient, it is important to begin ventilation with a
The case review presents a 73-year-old female patient who is brought to the emergency department after collapsing at her residence. Just prior to the incident, the patient is reported to have been acting “confused.” Upon arrival to the emergency department, the patient is having difficulty breathing with an increased respiratory rate and pulse. The nurse is unable to complete the initial examination before the patient becomes unresponsive and has increased work of breathing. At this point, it is necessary to active an emergency response team and begin advanced cardiac life support (ACLS) interventions. These interventions involve the initiation of an algorithmic approach to assessment and the initiation of emergency interventions necessary to stabilize the patient.
A primary assessment of airway, breathing, circulation, neurological status and inspection of body must be initiated immediately. This assessment is rapid and requires little to no use of specialized technological tools. The case study indicates that patient “collapsed” in her backyard; therefore, cervical spine immobilization must be maintained at all times until the possibility of spinal injury has been ruled out.
This rapid assessment begins with an inspection of the patient’s airway to ensure no obstructions exist. Possible airway obstructions include the patient’s tongue, loose teeth, foreign objects, vomit or blood. The airway must be cleared of any obstructions before proceeding with the assessment. The case study does not indicate the presence of any airway obstructions. Once the airway is deemed clear, an assessment of breathing occurs. This includes observing the patient for signs of spontaneous breathing, including rise and fall of the chest, rate of breathing, work of breathing and breath sounds. The case study reports the patient as both unresponsive and as having difficulty breathing. In an unresponsive patient, it is important to begin ventilation with a
References: American Nurses Association. (ANA). (2001). Code of ethics for nurses with interpretative statements [PDF file]. Retrieved from http://nursingworld.org