Homeostasis and Pain Management in patient with Multisystem Failure
Assessment of the Patient
There are lot of key assessment that nurse can use in assessing homeostasis, oxygenation and pain in the patient. First we have to remember the fundamental of nursing assessment before starting to assess the patient. ABC of assessment include airway,breathing and circulation.Nurses should assess the airway first that is to look at the nose and mouth to assess for patent airway and if any obstruction seen make every effort to remove obstruction. Nurses should check for chest movement,resp rate and lung sound.Mrs Baker vital sign should be taken while we are doing lung assessment.Vital sign include blood pressure, temperature,pulse and oxygen saturation.Inform the MD if any bitalsign are out of normal range.
Nurse should check EKG 12 lead and connect patient to heart monitor so continuous EKG monitoring done because it is important to keep an eye on heart rhythm.Patient blood sugar should be checked because patient have a history of diabetes. Patient need head to toe assessment.use penlight to use PERRL .nonbehavioural pain scale assessment like assess for grimacing,moaning,restless to assess pain level.Draw some blood work like complete blood count,complete metabolic count,ABG for acid base imbalance.Urine sample can send for ketones,blood,protein.chest xray for fracture,any fluid or abnormality in lungs.CT scan for any bleed in brain or swelling. The circulation of extremity can be check by palpating pulses,checking capillary refills .look for the colour or temp change on all four extremity . Afoley cath can be inserted to check if patient retaining any urine in the bladder.
Technological Tools Uses and Benefits
There technology tool can be use to assess patient. The dynamp machine can be used for blood pressure check,oxygen saturation and check heart rate. –Nurse will know the blood pressure is within normal limits (90/60-120/80) or not. Thermometer is used to check the temperature orally, auxiliary or rectal.
The glucometer is used to check blood glucose level.This will give patient random glucose level of patient is within normal range (70-110).
Stethoscope can be used to ascultate,heart,lung and bowel sound.It will help nurse to assess any abnormal sounds for assessment.
The pen light is used to check the pupil for any sign of irritation, swelling, and reaction. Nurse can do the neuro assessment by shinning the light in eye and see it they pupil react to light by constricting.
Bladder scanner can be used to scan the bladder and find how much urine is in bladder.If bladder is foley can be used to drain urine out of bladder.
EKG machine can be used to assess for heart rhythm.
The X-ray machine ,CT scanner or MRI machine to get radiographic picture of the patient.
The lab tubing can be used to draw blood and send it to the lab for results. CBC is obtained to check electrolyte and blood cell counts. This will show if the potassium, sodium, bun /creatinine is out of range since the patient is taking a diuretic. It will also show the blood cell count, in particular the hemoglobin, which is responsible for transporting oxygen in the blood to the brain.. Syringes and needles are used to obtain blood samples for ABG’s.
Data Collection Prioritization The nurse prioritize the data following ABC ‘s (Airway, Breathing and Circulation). The blood pressure, blood glucose,heart rate,respiratory rate,temperature ,pain level and neurological status before the rest of test.It will give nurse and physician results of the patient condition.The nurse choose to do blood pressure because patient is on blood pressure medication and there is possibility that patient have low blood pressure. She then obtain oxygen saturation to assess the patient oxygenation level due to dyspnea or her unresponsiveness.heart rate is assess while checking B.P and pulse oximeter to see if patient have low heart rate due to antihypertensive meds.The