Geriatric Patient With Multisystem Failure

¶ … Geriatric Patient With Multisystem Failure

Key immediate assessment you should make that would help assess the patient's homeostatis, oxygenation, and level of pain (inc. physical observations and observations made though technology and in the laboratory)

The patient appearing dyspenic or mentally confused may show signs of deficiency in oxygenation. The skin color may also be checked (pallor) as well as signs of pulse oximetry (a medical device that indirectly measures the oxygen levels). Cyanosis, drowsiness, and lethargy are also signs. Usually, it is extremely difficult to assess without technological assistance, and the blood would have to be measured for a more accurate assessment.

Homeostasis is assessed by checking the patient's vital signs, pulse oximetry, and heart response as well as neuromuscular function. A nurse can also determine if a patient has homeostasis by checking fluid volume.

Signs of fluid volume excess include dyspnea, sudden weight gain, edema, hypertension, bounding pulse, and crackles.

Signs of fluid volume deficit include dizziness, confusion, sudden weight loss, weak pulse, and shortness of breath, confusion, and orthostatic hypertension. Urine of less than 30ml / her for two hours should be taken into consideration as well as excessive urine that is greater than 2500ml in 24 hours.

Signs of acute pain include the patient being restless, legs drawn up to chest, pupils are dilated, heart rate is around 90, blood pressure = 158/82, respiration is 24, her skin is pale and moist, the CXA and UR is negative, and the WBC is 12,000.

No protective body positioning, no pupil dilation, and ability to verbalize pain and discomfort as well as lower readings indicates mild to moderate pain.

2. The technological tools you would utilize to assess and treat the patient

a. Why you would utilize these tools

b. The benefit of these tools in determining the patient's status

Tools for assessing pain

The McGill Pain Questionnaire is widely used for comprehensively evaluating sensory, evaluative, and affective aspects of pain intensity (Melzack, 1975). This tool is important since health care providers tend to underestimate the pain of the patient, and it is important to be as objective as possible. By eliciting the patient's feedback via a comprehensive grasp of all possible components of pain, this instrument is more effective than the visual analog scale that relies on the nurse's subjective assessment (Marvin, 1995).

I might also use the Thermometer Pain Scale, in this case, particularly if the patient retains inability to communicate or demonstrates diminished cognitive abilities.

The Pain Intensity Scales used by the National Institute of Health are another option. Commonly used on the elderly, these 5 pain intensity scales also have a checklist of nonverbal indicators for patients who have challenges communicating.

Also helpful, in this instance, is the Multilanguage numerical pain rating scale (British Pain Society) where a 6 question instrument using a 0-10 scale provides one signal question in 18 languages: "Please point to the number that best describes your pain.'

There is also the authoritative tool: "The Assessment of Pain in Older People" (Royal College of Physicians of London. October 2007), and I like the idea of the 'Pain drawing' instrument where the patient is provided with a 1-page anatomical diagram and she marks each painful location with a symbol according to symptom type. This may be particularly helpful here since patient has difficult responding and may be fatigued. (Pain & Disability Assessment Tools. http://pain-topics.org/clinical_concepts/assess.php )

I would reduce or eliminate the factors that induce the pain in the following ways:.

I would check willingness to use relaxation techniques then demonstrate and practice relaxation techniques. I would determine the type of analgesic to be given based on the patient's pain assessment. I would evaluate the effectiveness of the analgesic, and instruct the patient to request analgesic at the onset of pain. I would treat patient's pain with morphine by IV or acetaminophen by mouth as per the doctor's instructions.

Tools for assessing and treating fluid and electrolyte balance

I would employ a physical examination measuring her respiration and seeing her urine output in order to see whether she retain her urine. I would also assess her blood pressure. A dry oral mucosa, cracked lips, and a furrowed tongue would also be indicators of fluid depletion. She would also receive a chest x-ray.

The decreased urine output, increased pulse rate, and decreased blood pressure as well as weakness, fever, and dry mucous membranes indicates deficit fluid volume.

I would obtain specimens for analysis of altered potassium levels; administer prescribed supplemental potassium per policy; monitor for neurological and neuromuscular manifestations of hypokalemia (indicating lethargy, altered levels of consciousness, and muscle weakness); provide frequent oral hygiene and fluid ((as appropriate); monitor of lethargy, irritability, and hyperreflexia; as well as for cardiac manifestations of hypernatremia. I would also maintain an accurate I&O record, as well as monitoring vital signs and administering IV therapy as prescribed.

Tools for assessing and treating poor oxygenation

The patient appearing dyspenic or mentally confused may show signs of deficiency in oxygenation. The skin color may also be checked (pallor) as well as signs of pulse oximetry (a medical device that indirectly measures the oxygen levels). Cyanosis, drowsiness, and lethargy are also signs. Usually, it is extremely difficult to assess with the raw eye, and the blood would have to be measured for a more accurate assessment and chest x-ray taken

I would monitor respiratory status; monitor the results of blood gases, chest x-ray studies, and incentive spirometer volume. I would also monitor level of consciousness as well as constantly check vital signs (i.e. blood pressure, pulse oximetry, and TPR).

I would direct patient in breathing and coughing techniques (in order to free respiratory passageway). Remind him to perform them. I would administer the prescribed expectorant, and help her maintain the Fowler or semi-Fowler position. I would also administer the prescribed analgesic and tell the physician if the pain is not being reduced.

Discuss how you prioritized data selection in the scenario

The patient in this scenario is experiencing an issue with fluid and electrolyte imbalance, acid/base imbalance, oxygenation imbalance, and blood glucose imbalance. Upon arrival at ER, patient shows increase in respiratory rate and pulse. Patient's history includes diabetes and hypertension. Her current blood pressure medication is lisinopril, whilst her other medications include metformin and hydrochlorothiazide. Patient has been able to answer initial question but then becomes unresponsive and has difficulty breathing.

I would deal with her oxygenation concerns first since this is the most important linking her up to an IV for air. Her fluid intake would be see to next, before morphine or acatemophien would be administered to alleviate her pain. I would consistently and constantly monitor each of these interventions and assess the outcome

4. Compare how you would assess pain in a geriatric patient who is alert to one who is not alert

I would perform a comprehensive assessment of the pain to include the onset, frequency, location, duration, intensity, and precipitating factors.

I would consider cultural influences on the patient, and, in both alert and non-alert patients would reduce factors that precipitate or increase pain.

I would also elicit her history. The history should include the description of the pain characteristics with specific inquires about psychological disorders, infectious disease, rheumatologic disease, neurological disease, thyroid disease, hepatic and renal disease, gastrointestinal disorders, and diabetes. Patient should also be questioned regarding incidence to trauma or falls (Portenoy, 1997).

Verbal descriptive scales, visual analog scales, and numerical scales are the most popular measures used to assess pain in geriatric patients.

On an alert patient, a functional evaluation would also be performed which includes questions about daily living, current of former occupations, questions about home environment, recreational occupation, and about assistive devices used for patient's ambulation.

On a patient who is not alert, I would simply monitor for signs of acute pain i.e. The patient being restless, legs drawn up to chest, pupils are dilated, heart rate is around 90, blood pressure = 158/82, respiration is 24, her skin is pale and moist, the CXA and UR is negative, and the WBC is 12,000.

5. How you would manage pain in a geriatric patient experiencing multisystem failure and showing signs of pain who is not alert enough to respond to questions

a. How you would know whether your choice of pain management was successful.

b. What you learned regarding assessment of the geriatric patient.

(Assume you have standing orders to administer acetaminophen or morphine)

I would determine the type of analgesic to be given based on the patient's pain assessment. I would evaluate the effectiveness of the analgesic, and instruct the patient to request analgesic at the onset of pain. I would also reduce or eliminate the factors that induce the pain.