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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 bag-valve mask using high-flow oxygen. It is possible that a more definitive method of airway management, such as endotracheal intubation, may be required.
The patient is now assessed for circulation. This involves the palpation of central pulses, either carotid or femoral, assessing for strength and rate. Palpation of a radial pulse is consistent with a systolic blood pressure of at least 80 mmHg, which is adequate for short-term profusion to the brain and other vital organs. Other observations include skin color, temperature, moisture and capillary refill. The case study indicates the presence of a rapid pulse prior to the patient becoming unresponsive. In the absence of a pulse, chest compressions would begin immediately.
Once airway, breathing and circulation have been assessed, a quick neurological assessment occurs. This includes determining the patient’s level of consciousness and assessing pupils for size, shape and reactivity to light. There are two quick methods for assessing the level of consciousness. The first is the AVPU scale, which is an acronym for alert, verbal, pain and unresponsive. The case study indicates the patient is unresponsive. The second is the Glasgow Coma Scale, which measures eye opening, verbal response and motor response. This scale is most commonly used when a traumatic brain injury is suspected, including stroke.
Pupillary assessment is performed with the use of a penlight. In addition to noting size, shape and reactivity to light, it is also important to note if asymmetry of the pupils exists. Finally, the last observation assessment made is that of inspecting the patient’s body for any signs of obvious injury, including any head and/or pelvic injuries that may have been sustained in the fall. For an accurate assessment, the patient’s clothing must be removed. Once the primary assessment is complete, and all lifesaving interventions have been initiated, a more detailed technological assessment occurs.
A 12-lead electrocardiogram is obtained to assess for life-threatening cardiac arrhythmias and potential damage to the heart muscle, such at that sustained during myocardial infarction. A full set of vital signs must be obtained, including blood pressure, pulse rate, respiratory rate, temperature, and oxygen saturation using an automated cardiac monitoring device. These levels should be continuously monitored throughout the patient’s care to assess for acute changes in hemodynamic stability. A capillary blood glucose level should be obtained on all patients with an altered mental status to rule-out the possibility of hypoglycemia.
In addition to changes in mental status, the case study also indicates that the patient is a diabetic on oral glycemic medication further indicating the need for blood glucose monitoring. If not already present, two intravenous vascular access sites using large caliber catheters should be obtained. This is needed to provide fluid hydration, aid in treating hemodynamic instabilities and administer medication. An indwelling urinary catheter may also be placed to provide an accurate measure of urine output and secondarily to monitor core body temperature and help prevent skin breakdown.
The patient also requires radiographic examination and further diagnostic testing. Radiographic testing should include anterior/posterior and lateral chest radiographs to assess for irregularities in the lungs and/or chest, such as infection, heart failure, pneumothorax or cardiac tamponade. If spinal injury is suspected, cervical spine x-rays are required to assess for the presence of fractures or misalignment. The patient’s altered mental status warrants a computerized tomography (CT) scan of the head to assess for bleeding or other abnormalities of the brain.
In addition, if pulmonary embolus (PE) is suspected, the patient should undergo either a CT or ventilation-perfusion (V-Q) scan of the chest. Further diagnostic sampling includes: Complete blood count (CBC) to assess for signs of infection, anemia and/or dehydration. Abnormal results may indicate the need for antibiotics, fluid resuscitation and/or the need for blood products; Comprehensive Metabolic Panel (CMP) testing to evaluate serum glucose and protein levels, electrolyte and fluid balance and kidney and liver function.
Abnormal results may indicate the need for medications to treat hyper/hypoglycemia, hyper/hypokalemia, hypomagnesaemia, hyper/hyponatremia, and/or interventions needed for renal insufficiency; Coagulation studies (PT/PTT) to assess for potential bleeding problems and to establish base-line levels if anti-coagulant medications are administered; Arterial Blood Gas (ABG) to measure blood pH, oxygen and carbon dioxide levels to determine the effectiveness of breathing and ventilation.
This test is collected separately from venous blood sampling; D-Dimer is helpful in rule-out the suspicion of a PE. This blood test is only partially diagnostic in that an elevated level does not confirm the presence of a PE. This test is used to help determine if further testing is warranted, such at CT or V-Q scanning, to rule-out PE. Urinalysis (UA) to assess for urinary tract infection, the presence of sugar and/or protein in the urine, and abnormal specific gravity levels, which may indicate dehydration.
Urine Drug Screen (UDS) to assess for the presence of illegal drugs and some prescription medications; Pain Management Pain is an individualized experience making it difficult to assess. One patient may find pain associated with an experience tolerable, whereas another patient may find it excruciating and intolerable. Pain should be accepted as what the individual experiencing it says it is. It is inappropriate for a healthcare provider to minimize or dismiss a patient’s complaint of pain.
The American Nurses Association’s Code of Ethics states, “the nurse respects the worth, dignity and rights of all human beings irrespective of the nature of the health problem” (ANA, 2001, Provision 1. 3). This includes advocating on behalf of the patient for pain management when needed. A patient’s verbal report of pain is the most reliable measurement of pain. When assessing the geriatric responsive patient, the patient should be asked to assign an intensity level to their pain. There are several different standardized pain scales.
Two commonly used scales with an alert patient include the 0-10 numeric rating scale and the faces scale. Family members should understand that the assignment of an intensity level for pain is individualized and can only be determined by the individual experiencing the pain. The patient and family should also understand that reassessment of the intensity level will be performed after pain relieving therapies are delivered to evaluate the effectiveness. Other important factors in assessing pain include asking the patient: Where is the pain located?
What is the character of the pain, i. e. burning, stabbing, cramping, pressure, etc.? Does the pain travel to another part of the body? What causes the pain to occur? When did the pain start? What were you doing when the pain started? Have you experienced this pain before? Is the pain intermittent of constant? What relieves the pain or makes it worse? Do you have any concerns about taking pain medications? Assessing pain in a patient with an altered mental status or who is unresponsive can be difficult. This is true regardless of the patient’s age.
When a patient is unable to verbalize pain, the nurse must rely on nonverbal and behavioral signs to indicate the presence of pain. Some of these signs include changes in facial expressions, grimacing, crying, clenching of the jaw or fists, restlessness, agitation, moaning, and changes in behaviors. Information should be gathered from family members, if possible, as to the patient’s previous history of nonverbal and behavioral expressions of pain. Other less reliable indications of pain may include changes in blood pressure, heart rate, respiratory rate, pupillary dilatation and diaphoresis.
Although considered, these indications are not completely reliable because other factors, such as other medical conditions and medications, can affect their measurement. Also, patients who are chemically sedated and paralyzed are unable to provide nonverbal and behavioral signs of pain. When treating these patients, the nurse must rely on nursing judgment as to the existence of pain, such as pain due to mechanism of injury, pre-existing conditions and painful procedures.
In managing pain in a geriatric patient experiencing multisystem failure, it is important to obtain a complete medical history, including medical conditions and the use of medications. This will help in preventing adverse drug reactions. It will also give an understanding as to the patient’s past history with pain medications. Patients taking narcotic pain medications on a regular basis may require more pain medications than the opiate naive patient. The case study indicates the nurse has a standing order to administer Tylenol 500 mg by mouth, morphine 0. 5 mg/kg IV or morphine 0. 1 mg/kg IM to treat the patient’s pain. In the case study, the patient is moaning, grimacing and is restless, which indicates the patient is experiencing severe pain, as well as, possibly some anxiety. Morphine 0. 05 mg/kg IV would be the most appropriate analgesic to administer at this time due to both its effectiveness in relieving pain and its ability to decrease anxiety by creating a euphoric effect. Intravenous morphine acts quickly and can be titrated easily to control pain while also maintaining adequate hemodynamics, i. e. lood pressure, and respiratory effort. It should be administered in small controlled doses until the patient’s pain behaviors (moaning, restlessness, grimacing, etc. ) are no longer present. Intramuscular morphine has a delayed peak onset of 30-60 minutes after administration. It should not be considered in the acute phase of pain unless vascular access is not present. Intramuscular injections also subject the patient to unnecessary pain at the injection site. Due to the altered mental status of this patient and the risk for aspiration, Tylenol by mouth should not be considered.
Also, Tylenol is also generally used to treat mild pain. This patient needs more aggressive pain management at this point. Geriatric patients require close monitoring and frequent reassessment to ensure medical therapies are both effective and appropriate. Absorption and distribution of medications may be altered from that of a younger adult patient due to the physiological effects of aging. That is to say, changes in renal function, liver function and fat/water distribution in the body can change the rate of absorption and/or metabolism of medications.
Some medications may have no or little effect on the patient, while others may have an exaggerating effect. The half-life of medications could also be prolonged resulting in a compounding effect after several doses are given. Team Members Inter-professional collaboration and teamwork plays an important role in the management of patients. If the patient in the case study arrived to the emergency department via ambulance, the emergency medical technician (EMT) and/or paramedic would have provided first responder care.
That is to say, they would have gathered as much information about the patient while they were at her house as possible. This would include obtaining medication information, medical history, living conditions and family presence. This information is reported to the emergency room staff upon arrival. They also may have already obtained vital signs, vascular access, a blood glucose level and an electrocardiogram. Upon arrival to the hospital, the emergency room nurse is generally the second medical person to contact the patient.
When the patient became unresponsive, the emergency nurse would immediately activate an emergency response team consisting of an emergency room physician, additional nurses, patient care technicians, respiratory therapist, phlebotomist, radiology technician and clerical support staff. A social worker and clergy, if requested, should also be available to assist with family needs. Everyone plays an important role during resuscitation of an unresponsive patient. References American Nurses Association. (ANA). (2001). Code of ethics for nurses with interpretative statements [PDF file]. Retrieved from http://nursingworld. org