Task 1: Homeostasis and Pain Management in Patient with Multisystem Failure.
Western Governor’s University
IMMEDIATE ASSESSMENTS: HOMEOSTASIS, OXYGENATION, & LEVEL OF PAIN.
Upon receiving patient, Mrs. Elli Baker the nurse would complete the following key assessments to determine her level of homeostasis, oxygenation and level of pain.
While using technological tools to obtain the patient’s vital signs including: oxygen saturation, respiratory rate, heart rate, blood pressure, heart rhythm and pain level on a 1-10 scale. The nurse could complete a blood sugar check with a glucose monitor. At the same time nurse should do a thorough assessment of what the patients normal values are for vital signs, and blood glucose ranges are while at home prior to the injury. This will be helpful in having a baseline to refer to while interventions and treatments are implemented (Rauen & Stamatos, 1997).
The nurse would assess any recent symptoms the patient was feeling prior to collapsing in her backyard. This may include any changes in appetite, mental status, general malaise, and feelings of anxiety or distress (Mauk, 2009).
After obtaining the medications the patient is taking at home, it is important to ask if there are any over the counter medications, she is taking such as aspirin. Along with herbal remedies that could affect the other medications, she is taking, and homeostasis (Mauk, 2009).
During the initial assessment, it is very important that the nurse ask if possible the patient’s primary care providers full name, phone number and address. In calling the primary care provider, the nurse can obtain vital information regarding the patient’s status prior to the injury to determine which organs were functioning properly prior to the injury. Blood work, laboratory results, mediations prescribed, and Physician history and physical can be useful in determining an effective care plan to return the patient back to her homeostasis prior to the injury (Mauk, 2009).
Many elderly patients have had a significant amount of changes in their autonomy and independence regarding their health status and health care. These changes can affect the patient’s self-esteem, security and wellness. With many losses the elderly experience with loved ones and function, it is important to take into consideration their loss of autonomy, independence, and control of their body and ability to do things they once did before with no problems. With any one of these changes, it can create feelings of anguish, despair, restlessness, and anxiety. Any one of these can affect the patient’s vital signs and are similar in the signs of pain or hypoxia (Mauk, 2009).
The nurse would ask the patient for the name and phone number of any family members, friends, caregivers, or surrogates that she has had consistent contact with, if not living together in the same household. This person can be a key reference in determining the patient’s prior status to the injury, what their normal behavior is in response to pain and any recent changes they have noticed in the patient that she may not have been aware of (Herr et al., 2006).
In the assessment of the patient’s oxygenation, the nurse can immediately apply an external device such as a handheld pulse oximeter to the patient’s finger. The percentage of oxygen saturation will display on the pulse oximeter along with the patient’s heart rate. Anything below 95%-100% would be considered abnormal. This assessment can begin as soon as the nurse encounters the patient, while interviewing the patient. The nurse can assess the patient’s mental status. If the patient is displaying restlessness, agitation, or confusion, these can all be signs of poor oxygenation (Rauen & Stamatos, 1997). The nurse can view the lab tests results in the patient’s blood work to see if the hemoglobin, hematocrit, or blood counts are not within the normal limits, which can also...
References: Mauk, K. L. (2009) Gerontological Nursing: Competencies for Care. 2nd Edition. Jones & Bartlett Learning. VitalBook file. Bookshelf. Retrieved on 4/29/14 from https://online.vitalsource.com/#/books/9781449679361/pages/49345133
Herr, K., Coyne, P., Key, T., Manworren, R., McCaffery, M., Merkel, S., & Wild, L. (2006). Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing, 7 (2), 44-52.
Rauen, C., Stamatos, C. (1997). Caring for Geriatric Patients with MODS. The American Journal of Nursing, 97, (5). Retrieved on 4/28/14 from http://wgu.libguides.com.wguproxy.egloballibrary.com/loader.php?type=e&id=109991
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