Multi-system Failure Assessment

A. A patient in multi-system failure needs to be assessed and treated as fast as possible. Many factors can lead up to multi-system failure such as bleeding out and sepsis. So the assessment has to be precise and quick. First, is to assess the patient’s alertness and orientation. If the patient can talk they will be able to explain the events that led up to the incident, any weird things happening, and if there is any pain. Since Mrs. Baker is unresponsive, we need to check and see if her pupils are dilated, equal, and reactive. The next key quick assessment is to look at the patient’s circulation, airway, and breathing. Obtain a quick set of vital signs (heart rate, respiratory rate, blood pressure, temperature, and O2 saturation) to help guide your assessment. Do a quick look over the patient to see if she is pale or sweating. A quick assessment for circulation is to assess the patient’s heart rate and blood pressure. Mrs. Baker does take lisinopril for hypertension. A low blood pressure will be questionable for this patient. Assessing the patient’s capillary refill, pulses, and the skin’s temperature will be quick indicator if the patient is getting proper perfusion to the extremities. Next assessment will be to check the patient’s airway to make sure there is nothing obstructing her airway. Mrs. Baker was having difficult time breathing and we need to know if her body is getting enough oxygen. Checking the respiratory rate will let us know how bad the patient is getting. The O2 saturation will let us know how much oxygen the blood is carrying. You also may want to assess her lung sound to see if she is having good air movement, any wheezing, or any coarseness due to fluid overload. Mrs. Baker is taking hydrochlorothiazide that is to suppose help get rid of extra fluid in her body. Also, checking patient’s skin color will also let us know if her oxygenation is good or not. Mrs. Baker cannot give an effective pain rating because she is unresponsive. A good indicator is she is in pain if she is having any facially grimaces or if her blood pressure has increased. Also, checking Mrs. Baker’s skin turgor, mucous membranes, sunken in eyes for dehydration. It will also be wise to check for any edema to help rule out fluid overload. Checking for any bumps or bruises on her head will be a good idea since she passed out in the backyard. Sending some vials of blood to the lab for a CBC, CMP, BS, ABS, cardiac markers, and acid-base balance will also give you good indicators of what is going on. Urine analysis will also be a good idea to send down.

B. Some technical tools that a nurse may use to assess Mrs. Baker are a cardiac monitor for vital signs. You need a blood pressure cuff to assess her blood pressure at least every 15 minutes in her condition. A pulse oximeter to determine her O2 saturation. You will need a stethoscope to listen for lung sounds, apical heart rate, and bowel sounds. If Mrs. Baker O2 saturation is below 90%, it may be wise to place a nasal cannula for oxygen. An importance tool will be a glucose meter to check her blood sugar since she does have diabetes. Since she is unresponsive it will be good to get an EKG also just to help rule out neurological disturbances because we do not know if she hit her head when she passed out in the backyard. If the patient is dehydration or if blood sugar is super low, you may need an I.V. and I.V. pump to run fluids like NS or D10. Also, will need to get a chest x-ray to access if the patient has fluid in the lungs. It will be wise to have a crash cart with a defibrillator on it nearby just in case patient starts to crash. If patient breathing keeps getting worse, intubation and a ventilator may be an option.
C. I would prioritize the data collected from the most critical to less critical findings. I would start with the data collected on her vital signs, especially her blood pressure. If anything