Anna Bunting
Contemporary Nursing Issues
GNT1 – 724.2.1-01-08
October 25, 2011
Rubric A: Assessment of Patient
The geriatric patient in multisystem failure presents many challenges to successful treatment. Differentiation between organ dysfunction and deterioration is often difficult to achieve. Also many typical signs of infection or sepsis that precipitate organ failure are masked or delayed in the elderly patient. It is important to recognize the physical and physiological differences in the geriatric population and take these into account when performing an assessment. Because all people age differently a thorough medical history is important in determining the patient’s baseline physical status and physiologic reserve. Immediate assessment of a patient’s homeostasis, oxygenation and pain level are critical for early diagnosis and treatment.
A preliminary physical assessment would include: vital signs, oxygen saturation, finger stick blood sugar, lung and bowel sounds, skin turgor and mucous membrane assessment and capillary refill to all extremities. Respiratory rate should be determined, keeping in mind that tachycardia and labored breathing are results of pulmonary dysfunction. Likewise lung sounds should be assessed for crackles/wheezes that indicate the presence of fluid in the lungs. Tachypnea is recognized as a sign/symptom of sepsis and Systemic Inflammatory Response Syndrome (SIRS).
Multisystem failure usually develops as a result of SIRS, most commonly caused by infection, trauma, or major surgery. The pulmonary system is usually the first to show signs of failure from SIRS. Respiratory rate is a good indicator of the severity of dysfunction (Burdette, 2010).
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Unit 1: Understanding the principles and practices of assessment – Indicative Content This unit is for those who wish to gain an understanding of the principles and practices of assessment before they begin to practically assess where their job role does not require them to assess. Title Understanding the principles and practices of assessment – This is a knowledge based unit which gives anyone ...
Pulse oximetry should also be monitored to measure the patient’s oxygenation. Temperature and pulse should be checked keeping in mind that both increase in the presence of infection and dehydration. Decreases in temperature and pulse may indicate cardiac impairment or decreased metabolism. A weak pulse pressure is also an earlier indicator of shock than a low blood pressure. The patient’s blood pressure should be monitored with the knowledge that hypotension equals decreased tissue perfusion and oxygenation. Hypotension often results from sepsis, SIRS, dehydration, blood loss or cardiac impairment. The blood glucose level should be checked to rule out hypoglycemia, hyperglycemia and diabetic ketoacidosis. These states could either precipitate or result from SIRS related processes. Skin turgor and mucous membranes should also be checked for signs of dehydration. Dry mucous membranes are more reliable indicators as skin turgor in the elderly patient’s extremities usually lessens with age.
While the patient remains alert and oriented it is imperative to attain as much medical information as possible. This includes any recent onset of symptoms such as fever, chills, nausea/vomiting, diarrhea etc. The presence of preexisting conditions and medications are needed to determine the patient’s baseline physical condition. The names of the Primary Care Provider and a family member/significant other would allow verification of history and access to recent lab work or changes in the patient’s condition. The presence and level of pain the patient is experiencing should also be determined. Pain’s location, onset and character can help determine possible sites of infection or injury, as well as the type of medication that will be effective in treating the pain.
Rubrics B, B1 and B2: Technological Tools
Tools utilized in the patient’s initial assessment would include: blood pressure cuff, stethoscope, thermometer, pulse oximeter, glucometer and the observational skills of the nurse. The initial assessment being made, the patient’s blood pressure, pulse, heart rhythm and oxygen saturation should be continually monitored by a medical or physiological monitor. These monitors found in acute care settings allow the nurse immediate notification of changes in the patient’s status.
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Using the physical assessment and information gained from the patient as a guide, a set of diagnostic tests should then be performed. A complete blood count with differential (CBC with Diff) should be drawn to acquire a picture of the patient’s general physiological condition. An increase in white blood cells (Webs) indicating infection and Europhiles greater than ten percent indicating SIRS and leuckocytosis. The values for hemoglobin (Hgb), hematocrit (Hct) and red blood cells (RBCs) should be evaluated to determine if the patient’s blood has enough oxygen carrying capacity and to rule out blood loss.
A complete metabolic panel (CMP) allows for a more detailed analysis of the function of the lungs and kidneys. The electrolytes should be monitored for imbalances that need to be corrected. Abnormalities of the major electrolytes, sodium (Na+), potassium (K+) and chloride (Cl-) are indicative of kidney dysfunction and should be corrected to maintain cellular function and promote homeostasis. Elevations in creatinine and blood urea nitrogen (BUN) also indicate kidney failure. Bicarbonate levels affect the pH of blood and body fluids and increases result from poor lung and kidney function.
Liver function studies should also be analyzed. While alkaline phosphatase may normally increase slightly with age, serum alanine aminotransferase (ALT) and serum glutamine aminotransferase (AST) should remain with in normal limits barring chronic liver damage (Mauk, 2010. p268).
Highly elevated values for ALT and AST are also indicators of shock. As with all diagnostic studies it is helpful to compare present values with the patient’s established norm when possible.
Lactic acid levels should also be monitored. The presence of lactic acid is a sign that the cells have resorted to anaerobic metabolism due to hypoxia. When levels rise to the point of lactic acidosis, the blood pH will be altered and oxygen carrying capacity will be decreased even further. Increased lactic acid values are often present as a result of sepsis or SIRS.
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Arterial blood gases (ABGs) measure the amount of oxygen and carbon dioxide in the blood as well as its pH. They give an accurate picture of how well the pulmonary system is delivering oxygen to and removing carbon dioxide from the bloodstream. Increased carbon dioxide can cause a decreased blood pH. Sepsis, kidney failure and anaerobic metabolism can also cause acidic blood pH. ABGs will also be used to monitor the effectiveness of oxygen administration.
Blood cultures should be drawn to determine if the patient is septic and identify the causative microbe. It is imperative that infection be treated with the most specific drug even if the patient is at risk for organ toxicity (Ruan and Stamatos, 1997).
A return to homeostasis can only be achieved in the septic patient by removing the source of infection.
The patient in multisystem failure should be catheterized for a urine sample and to monitor intake and output. Urinalysis provides an analysis of kidney function as well as metabolic processes. The specific gravity/concentration of urine will increase with dehydration or with decreased filtration by the kidneys. High amounts of glucose or ketones are signs of diabetic ketoacidosis and RBCs may indicate injury to the kidney. The presence of WBCs and bacteria in the urine are indicative of infection. If these are found the urine should be cultured for causative microbes to determine the appropriate treatment. Geriatric patients are especially prone to develop sepsis as a result of urinary tract infection due to their chronic immunosuppressed state.
A prompt portable chest xray should be done in the acute setting. Time should not be wasted in transporting the patient to the radiology department. The presence and severity of pulmonary edema or pneumonia can quickly be realized by xray. Pericarditis, chronic heart and lung disease and acute injury can also be determined.
In most cases, multiple organ dysfunction syndrome (MODS) is a result of SIRS brought on by sepsis. If another cause is at work it should be determined as soon as possible. Amylase and lipase levels should be drawn to rule out pancreatitis. Serial cardiac enzymes and EKG need to be evaluated to assess for myocardial infarct and CT scans performed to rule out stroke. Determining the insult that set SIRS in motion is key to restoring homeostasis.
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Rubric C: Data Collection Prioritization
An initial physical assessment is critical in determining the patient’s immediate needs and acuity of condition. Vital signs, lung and bowel sounds, and oxygen saturation should be done first to assess the status of the cardiac, digestive and respiratory system. A cursory glance at mucous membranes will give an indication of the patient’s hydration. A fingerstick blood glucose should then be taken to rule out hypoglycemia and diabetic ketoacidosis as causes of distress. Communication with the patient while she is alert is key to gaining knowledge of medical history and the presence, location and level of pain. Questions should be asked during the initial assessment and for as long as the patient is coherent.
It is imperative that blood samples be drawn as soon as the assessment is complete. Knowledge of the patient’s physiologic status, causes of dysfunction and severity of condition cannot be determined without these studies. Peripheral intravenous access can be obtained at the time blood is drawn for the administration of medications or volume resuscitation. An indwelling foley catheter should then be placed to obtain an initial urine specimen and begin monitoring intake and output.
Once blood and urine samples are taken to be processed an EKG and chest xray should be performed. These should be done in the acute care setting so the patient can be continually monitored. When initial studies have been done, if the patient is stable, she can be transported to radiology for a CT scan.
Rubric D: pain assessment Comparison
During the initial assessment of the patient, while she is alert, her pain should be completely evaluated. A comprehensive pain assessment may give clues to the location of infection or insult that that caused SIRS to develop. It may also provide information on the extent of chronic disease. Determining the severity, character, location and onset of pain is essential to provide proper treatment.
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The severity of pain should be determined first, so if the patient’s level of consciousness deteriorates she can be treated accordingly. Pain scales and rating tools give a quick indication of intensity, are easy to use, and usually correlate with treatment protocols. The Numeric Rating Scale (NRS) and the Pain Thermometer Scale are easily understood and recognized by geriatric patients. The Pain Thermometer Scale has been recommended as the most preferred by older adults who are literate (STTI, 2011).
The visual image of the thermometer is also readily recognized and understood by those with mild to moderate cognitive impairment. When a comprehensive pain history cannot be obtained and level of pain and treatment need to be determined quickly these tools are very useful.
When the patient’s condition and time permit a more in depth evaluation should be made. Keep in mind that many geriatric patients expect to live with some amount of pain and view it as a natural consequence of aging. Thus chronic pain and pain that is sporadic often go unreported. It is helpful to use descriptors for pain such as: aching, soreness, tenderness, burning or nagging. Also, questions about chronic pain and new or recent onset pain should be asked separately. Have the patient localize pain if possible. Musculoskeletal pain is easy to localize while visceral pain is more diffuse and may be hard to pinpoint. Neuropathic pain may be described as burning, shooting, stabbing or shock like (Mauk, 2010. p766).
If the types of pain can be determined proper treatment will be easier to administer. Learning what pain meds have been effective in the past will also be helpful. As always, the patient should be observed for nonverbal signs of discomfort such as: wincing, fidgeting, guarding or flinching during assessment.
The skills of observation are even more valuable when the patient is not alert. Moaning, grimacing and restlessness are all signs of a moderate to severe pain level. Increased confusion and resisting care are signs of pain as well and should not be construed as a decreasing level of consciousness alone. Observing the patient during care and with movement for signs of increased pain will give clues to pain’s location and severity.
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The results from the study show that most of the patients are served within five minutes upon their arrival at the hospital. Taking an overview look on the results, it emerges that medical personnel in Netherlands serve their patients faster than their counterparts in Saudi Arabia. However, it is discouraging to find out that the percentage that is served beyond five minutes after the arrival is ...
While the alert patient can verbalize pain, the pain level of nonalert patients often becomes the subjective opinion of the nurse or caregiver. There are several pain assessment tools available for confused, nonalert or cognitively impaired adults. The Checklist for Nonverbal Pain Indicators (CNPI) is a short, simple instrument that can aide in obtaining an accurate assessment. The CNPI prompts caregivers to assess for six behaviors commonly associated with pain: vocalization, facial grimaces, bracing, restlessness, rubbing and verbal complaint (Nygaard and Jarland, 2006).
A study performed by Nygaard and Jarland (2006) supports the reliability of the CNPI for proper pain assessment of the mentally impaired. Keep in mind that the presence of one or two indicators is enough to warrant treatment. No matter which assessment tool is used, it should be used consistently to assess and reassess pain to assure adequate treatment.
Rubric E and E1: Pain Management
In the patient with MODS uncontrolled pain may hasten death by increasing physiologic stress (Mauk, 2010.p762).
The presence of pain increases the demand for oxygen on an already hypoperfused patient and increases the workload of the cardiac and pulmonary systems. While pain control is important for all patients, it is imperative in the geriatric who already have a decreased functional reserve.
The patient exhibiting behaviors of moaning, restlessness and grimacing should be considered in moderate to severe pain. The World Health Organization’s (WHO) Ladder for pain management is widely accepted and used by clinicians worldwide to treat pain(STTI,2011).
Using the WHO ladder as a guide, the patient in moderate to severe pain should be treated with an opioid (morphine) and nonopioid (acetaminophen).
Acetaminophen is well tolerated and effective for musculoskeletal pain which is common in the elderly. Morphine is commonly used to treat visceral pain and is also very effective. Most geriatric patients experience two or even three kinds of pain on a regular basis. Regardless of the cause or pertinence to present situation, pain should be treated to reduce physiologic stress. Short acting or intravenous (IV) morphine should be administered in a trial to assess for adverse effects. The patient should be monitored for itching and nausea/vomiting in the short term and constipation and sedation after 24-48 hours of use. Morphine may have a longer action in the elderly due to prolonged elimination of the drug from the blood plasma. The decreased muscle mass and perfusion in the elderly cause distortion in normal absorption and distribution. Altered liver and kidney function will also affect the breakdown and excretion of morphine’s metabolites. A buildup of these may result in sedation or confusion. Care should be taken to differentiate between a patient who is sedated and one who is simply able to rest due to pain relief.
Reassessment for effectiveness of IV morphine should be done 15-30 minutes after administration. If the drug has been effective the patient will no longer exhibit behaviors indicative of pain. The breathing should be less labored and the pulse and respiratory rate may both decrease. The patient should appear to be comfortable and able to rest. Intravenous morphine will allow for a quicker titration of dose if the initial dosage is not sufficient. Intramuscular morphine may be less effective due to the decreased muscle mass and absorption of the older adult. It also has a longer action and should not be used until a trial of short acting opioids is performed.
Rubric E2: Learning
The care of the geriatric patient with multisystem failure is made more complex by the degenerative changes associated with aging. Many physiologic and structural changes to organs that are seen with aging closely resemble criteria for MODS (Rauen and Stamatos, 1997).
A thorough assessment and history are necessary to differentiate acute dysfunction from chronic disease. The geriatric patient typically has decreased physiologic reserve, compromised immunity and an inability to compensate when stressed.
The normal aging process may also mask or inhibit the body’s response to insult. Signs or symptoms common for sepsis or infection may be delayed or absent altogether in the older adult. Commonly used meds; beta blockers, steroids, and ace inhibitors, may also mask symptoms or inhibit successful treatment.
A patient’s medical, psychological and social history should also be taken into account when interpreting lab results. Certain values may increase with age while others decrease. Keep in mind that commonly used drugs and supplements may also alter lab results. A patient’s individual norm should be established to distinguish chronic from acute processes.
It is common for older adults to underreport pain. Many view chronic pain as a normal consequence of aging. Caregivers and patients alike often fear that patients will become addicted to opioids or narcotics. Elderly patients also may not want to undergo testing or treatment that is prescribed for pain. Research shows that 25-50 percent of older adults in the community suffer from significant chronic pain (Mauk, 2010. p762).
A comprehensive pain assessment should be performed when possible to determine the most appropriate treatment.
Rubric F: Team Members
Assessing, diagnosing and treating the patient with MODS will require a collaborative effort. The primary nurse will be responsible for coordinating the departments and services needed to treat the patient and relaying information to all caregivers including the doctor. The nurse will perform the initial assessment and history to determine the acuity of the patient’s condition. She will be responsible for constant monitoring of the patient‘s status. Any changes in the vital signs, level of consciousness or deterioration of condition will be reported to the doctor. Peripheral IV access and blood samples are obtained by the nurse as well as insertion of an indwelling catheter and acquiring a urine specimen to be sent to lab. The laboratory department may be called on to assist in obtaining blood specimens. Specimens should be processed in a timely manner and critical values reported directly to the nurse who in turn will notify the doctor. The cardiopulmonary department will be contacted immediately to further assess the patient’s oxygenation, obtain ABGs and treat increasing respiratory distress as appropriate. They should also perform an EKG. Radiology technicians will be contacted to perform a portable chest xray and inform the nurse when results of same can be viewed. Radiologists will also schedule and perform a CT scan when the patient’s status allows. The emergency department technician will assist in the constant monitoring of the patient’s vital signs, level of consciousness and pain. She will also perform patient care as necessary and assist other departments as needed in performing their duties. Changes in the patient’s condition will be reported directly to the nurse for further assessment. The emergency department doctor will also assess the patient and determine specific diagnostic studies to be performed. Using the patient’s medical history and information gained through these studies the doctor will prescribe treatment. The patient’s significant other/family member should also be contacted to obtain additional social, psychological and medical history. Their presence and communication should help alleviate any anxiety the patient is experiencing. The primary care provider should be consulted as well to obtain information on the patient’s baseline status, normal lab values and insight into their condition. Communication between departments and team members is essential to provide continuity of care and successful treatment.
References
Burdette, S. (2010 July 20).
Systemic Inflammatory Response Syndrome Clinical Presentation.
Retrieved from: http://emedicine.medscape.com/article/168943-clinical
Mauk, K. (2010).
Gerontological Nursing: Competencies for Care. Jones and Bartlett Publishers, LLC
Nygaard, H.A., & Jarland, M. (2006).
The Checklist of Nonverbal Pain Indicators (CNPI): Testing of reliability and validity in Norwegian nursing homes. Age and Ageing, 35(1).
Retrieved from: http://ageing.oxfordjournals.org/content/35/1/79
Rauen, C.A., & Stamatos, C.A.(1997).
Caring for Geriatric Patients with MODS. The American Journal of Nursing, 97(5).
Retrieved from:
Sigma Theta Tau International. (2011).
Recommendations for Pain Assessment in Cognitively Intact Older Adults. Retrieved from: http://www.geriatricpain.org
