Assessment and Management in Multisystem Failure Western Governors University Assessment and Management in Multisystem Failure Assessment of Patient Numerous patients present in an Emergency Department (ED) at a fast pace and nurses must be proficient triaging and prioritizing all patients based on their “medical condition and chance of survival” (Anderson, Omberg, & Svedlund, 2006).
The primary assessment should identify the urgent issues and treat those that may become life threatening.
Potential failure of any of the three main systems, circulatory, respiratory or central neurological systems, are the life threatening issues that must be recognized and treated immediately (Advanced Life Support Group, 2001).
The well-known A-B-C-D-E process referring to airway, breathing, circulation, disability, and exposure are easy guidelines to use in this initial assessment. An experienced nurse can perform high level assessments of multiple issues simultaneously by simply being aware of key indicators.
A visual assessment when the nurse initially greets the patient can identify the basic level of consciousness, the presence of wincing or guarding an extremity, open wounds or rashes, skin and lip color, symmetrical and effective chest expansion, rhythm, rate and depth of breathing, flared nostrils or pursed lips, and use of accessory muscles for breathing (Higginson, Jones, & Davies, 2010).
These observations can be performed quickly during the initial greeting of the patient and guide the nurse toward potential life threatening conditions that need to be assessed.
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While visually examining the patient, a nurse should be aware of all of the sounds and responses from the patient. From the case study that was presented, Mrs. Baker was initially alert and responsive when admitted to the ED. As the nurse greeted Mrs. Baker and asked how she was feeling, Mrs. Baker was able to respond to some questions which indicated that her airway was patent at that time. Although Mrs. Baker was able to speak, if she was only able to answer with one or two word responses, it could have indicated that there was a partial airway obstruction and would have warranted further assessment.
The nurse should listen for obvious wheezing, stridor or coughing and document if the patient appears to have difficulty breathing. With the use of a stethoscope, the nurse can listen to the lungs for less obvious breath sounds such as crackles, rhonchi, rales or complete absence of breath sounds. As the nurse begins to ask questions about the past medical history, allergies, onset or duration of symptoms, and pain level using the visual analog scale (VAS), she should also be able to assess the patient for appropriate responses and confusion using the AVPU scale.
AVPU stands for Alert, Verbal, Painful and Unresponsive. Similar to the visual and auditory inspections above, the tactile inspection can also assess multiple issues. The nurse can obtain the basic vital signs such as blood pressure, heart rate, oxygen saturation and temperature with a spot vital signs monitor. She should be cognizant of the skin temperature and document if it is warm and dry as she places the blood pressure cuff on the patient. Evaluating the elasticity of the skin by gently pinching a small section of the skin on back of the hand will assess the skin turgor.
Although the spot vital sign monitor detects the heart rate and oxygen saturation, the nurse can assess the rhythm and strength of the pulse by palpating the radial artery and the peripheral perfusion by measuring the capillary refill time. These baseline vitals are key factors in the measuring stability of the patient and will be referred to for comparison as the condition deteriorates or improves. Several of these high level assessments can be late effects of conditions that can be more definitively assessed with diagnostic testing.
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Peripheral IV access should be initiated using a large diameter cannula prior to the start of this diagnostic testing. Drugs and intravenous fluids are usually needed in acutely ill patients and some blood samples could be taken from this access. Blood work, consisting of a glucose finger stick, troponin level, arterial blood gas, complete metabolic panel, complete blood count with differential, urinalysis, prothrombin, and partial thromboplastin times, and blood culture should be ordered.
In combination with this, a 12 lead EKG should be placed and a chest x-ray, CT of the brain, Ventilation/perfusion scan (VQ Scan), doppler ultrasound of the lower extremities, and an echocardiogram should also be ordered. The case study indicates that Mrs. Baker became unresponsive and supplemental oxygen should be administered via nasal cannula to keep Mrs. Baker well oxygenated if this had not previously been started. A foley catheter should also be inserted to monitor the urine output and eliminate problems associated with unexpected voiding. Because of Mrs.
Baker’s state of unresponsiveness, a MRI would probably not be ordered. The MRI is a more sensitive study, but is lengthy and more difficult to continue resuscitation because of the metal restrictions in the area of the magnet (Advanced Life Support Group, 2001).
After Mrs. Baker became unresponsive, the nurse would have to access her pain using an alternate scale like the FLACC scale. This scale is also important to evaluate for potential neurological failure by using a pen light to assess PERLA. Technological Tools There are several basic nursing tools that are routinely used when assessing a patient.
The stethoscope is used to listen to the sounds within the body. It is most commonly used to listen to the lungs, heart and abdomen. The stethoscope consists of two earpieces connected by tubing on one end and a swivelable diaphragm and bell on the other. The diaphragm side is used to detect high frequency heart and lung sounds and the bell side detects lower frequency sounds and murmurs. A pen light is used to make a pupillary assessment for neurological problems. The nurse uses a quick, sweeping motion from the side of the eye to assess that the pupils are equal, reactive to light and accommodation.
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A large bore cannula, preferably a 16 or 18 gauge needle, is used when initiating a peripheral IV. It is usually placed in the antecubital fossa and can be used for administration of medications and fluids as needed. It can also be used to initially draw blood samples. If blood is not obtained at this time, it is usually taken from the medial cubital vein with an evacuated tube system. The foley catheter that is inserted for monitoring urinary output is flexible tubing that is passed through the urethra into the bladder. This allows the urine to drain into a collection bag.
Some diagnostic tools provide continuous monitoring and provide immediate feedback. Spot vital sign monitors continuously monitor blood pressure, heart rate and oxygen saturation once the blood pressure cuff is placed on the arm and the pulse oximeter probe on the finger. A 12 lead EKG machine provides continuous monitoring of electrical activity of the heart by placing electrodes to the skin on all four extremities (RA, LA, RL, LL), in the fourth intercostals space to the right and left of the sternum (V1 and V2), in the fifth intercostals space n the mid-clavicular line (V4), between the fourth and fifth intercostals space, (V3), horizontally even with V4 in the anterior axillary line and horizontally even with V4 and V5 in the mid-axillary line. The patient’s temperature will be taken periodically with a thermometer. Imaging studies such as chest x-rays, doppler ultrasounds, VQ Scans, MRIs and CT scans require specialized equipment. Chest x-rays can be performed using a portal machine or a standalone x-ray machine in the radiology department. Echocardiograms, doppler ultrasounds, MRIs and CT scans are performed in the radiology department.
A MRI is a very strong magnet that uses radio waves and magnetic fields to produce images of various parts of the body. CT scans use x-rays taken at different angles that are fed into a computer to create cross sectional images of soft tissue and bones. Doppler ultrasounds evaluate the blood flow and structures in the body and an echocardiogram show images of the heart by utilizing sound waves. VQ scans are lung scans that evaluate the circulation of blood and air in the lungs. Oxygen is administered through a nasal cannula, which is thin plastic tubing with two prongs that fit into the nares and is attached to a flowmeter.
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This flowmeter allows the nurse to regulate the amount of oxygen delivered. An IV pump is used to regulate the amount and speed of fluids and/or medications are that delivered. This improves the accuracy and predictability of administration and alerts the nurse if there is a problem with the flow. Use and Benefits of Tools The basic assessment tools, such as the spot vital signs monitor and pulse oximeter, are used to obtain baseline vital signs. The spot monitor usually has add on capabilities for a pulse oximeter and thermometer and is used to continuously monitor the blood pressure, heart rate, and oxygen saturation.
Increased respiratory and heart rate are some of the first changes seen when there is deteriorating physiological changes. The body attempts to increase the oxygen intake to compensate for poor organ perfusion (Adam, 2010).
Reduction in peripheral perfusion and urine output is the body’s compensatory method of preserving body fluid so adequate blood pressure will be maintained. This is why the assessment of the skin temperature is important. The extremities will feel cool and clammy instead of warm and dry. Capillary refill, which is an indicator of peripheral perfusion, can be easured by blanching the fingernail for 4 or 5 seconds and measuring the time it takes for the color to return. This should be no more than 3 seconds. The thermometer is used to measure the body temperature. An increase in temperature may indicate some type of infectious disease and would warrant investigating for sources of infection. The stethoscope is used to listen to the heart, lungs and abdomen. When auscultating the lungs, the nurse is listening for the presence or absence of breath sounds or if there are any additional sounds such as rales, rhonchi, stridor or crackles.
When listening to the heart, the nurse is evaluating additional and irregular beats which can indicate murmurs or mitral regurgitation. Palpating the radial pulse will also allow you to identify irregular heart rhythms. The EKG machine alerts you to rhythm abnormalities and acute coronary conditions as well as provides historical data for referencing. The various imaging studies give the provider a more detailed picture of internal organs and their level of functioning. Chest x-ray and VQ scan are useful in the diagnosis of a pulmonary embolus with the VQ scan being the most useful screening tool.
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Doppler ultrasounds are used to evaluate for deep vein thrombosis which could lead to pulmonary emboli. The chest x-ray is also useful in diagnosing cardiac tampanode, pneumothorax, and pulmonary edema. Echocardiograms are used to diagnosis pericardial effusion, aneurysms, and right ventricular abnormalities. CT scans are used to diagnosis cerebral bleeding and are routinely performed on the unresponsive patient that has no confirmed diagnosis. Mrs. Baker has a history of diabetes so the glucose level should be monitored as quickly as possible.
Additionally, her kidney and liver function should be monitored because she is on lisinopril. The complete metabolic panel consists of glucose serum, calcium, serum albumin, serum total protein, sodium, potassium, carbon dioxide, chloride, BUN, creatinine, alkaline phosphatase, alanine amino transferase, asparate amino transferase, and bilirubin. These tests are helpful in identifying problems such as kidney and liver disease, electrolyte and fluid balance, and glucose level. Arterial blood gasses are ordered to assess the level of oxygen, pH and carbon dioxide in the blood.
A sample of blood is taken from an artery using a syringe with a small amount of heparin in it to prevent clotting. If the patient is on supplemental oxygen it will affect the results and should be documented. The CBC measures the red and white blood cells and the platelets and consists of the white and red blood count, hematocrit, hemoglobin, mean corpuscular value, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cell distribution width and mean platelet volume. The white blood count is one of the most useful components of the CBC. It is used in the diagnosis of infections and inflammatory diseases.
Blood cultures are also used for detection of septicemia or bacteria in the bloodstream. Troponin levels are drawn to determine myocardial damage. These levels usually rise within 4 – 8 hours after the onset of chest pain and are usually at their highest levels between 12-16 hours. The urinalysis is performed to determine if there is a urinary tract infection and is evaluated for the presence of glucose and protein. These levels may be elevated with hypertension and diabetes and “end organ damage may be reflected through the presence of glucose and protein respectively” (Abraham, Madhu, & Provan, 2010, p. 17).
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The disability portion of the assessment utilizes the AVPU system for a neurological evaluation. When the patient’s responses are delayed or they are unresponsive, pupillary response is also assessed. Hypoxemia and hypoglycemia are primary concerns in the unresponsive patient and must be addressed immediately. In the final exposure and examination portion of the assessment, the nurse exposes the body so a head to toe and front to back examination can be performed. Bruising, bleeding, open wounds, swelling, rashes, and sores are some of the items the nurse is looking for.
It is imperative to not expose all areas simultaneously so the patient does not get too cool. Data Collection Prioritization This A-B-C-D-E approach lends a systemic approach to the initial assessment of all acutely ill patients. In the primary assessment, the objective of the nurse is to identify and treat any life threatening conditions. Mrs. Baker complained of shortness of breath so airway assessment is the first thing that should be performed. Even though Mrs. Baker appears to have a patent airway, this does not guarantee that she has adequate ventilation.
The nurse should examine the symmetry of the chest movement, respiratory rate and effort in addition to listening to breath sounds. After the confirmation of a patent airway and adequate respiratory function, oxygen should be initiated and vital signs obtained. . Circulatory assessment overlaps some of the assessments done for breathing because they are so closely interconnected but this should be done next. There must be adequate transportation of the blood for proper oxygen to be delivered to the tissues and elimination of waste products and carbon dioxide (Adam, 2010).
Earlier assessment of the patient’s color and skin temperature are important indicators of adequate circulation. The nurse should palpate the radial pulse and document the rhythm and strength of the pulse. If a radial pulse cannot be palpated, palpitation of the carotid artery should be performed. This is important because without adequate circulation, a patient can go into shock. Mrs. Baker presented with an increased respiratory and heart rate which should be a red flat to the nurse that she could be going into shock.
At least one IV using a large bore cannula should be started at this point for fluid resuscitation if indicated and blood can be drawn for the labs. Because of Mrs. Baker’s history of diabetes and recent confusion, a bedside finger-stick glucose would be indicated to quickly determine if Mrs. Baker was hypoglycemic instead of waiting for the lab results. This would also assist in determining the type of fluids to administer. Once these have been completed, the EKG leads could be placed to monitor the cardiac rhythm. While the nurse is performing the above mentioned assessments, she would be able to determine Mrs.
Baker’s basic level of consciousness and pain by using the AVPU system and asking her to rate her pain using the VAS. It is of utmost importance for the nurse to immediately return to the beginning of this system and reassess the airway and breathing if the patient’s condition starts to deteriorate at any point. When Mrs. Baker became unresponsive, this should be implemented immediately and then proceed with the CT scan to determine if there is any hemorrhage in the brain which could be the cause for the change in consciousness. The other imaging studies would be performed after this if needed. Pain Assessment Comparison
Pain significantly affects the development of the treatment plan for a patient and must be assessed continually. Self-reporting from the alert and communicative patient is the most reliable indicator. The nurse must be aware of the patient’s developmental and physical condition when determining which assessment tool to utilize. For the alert and communicative patient with no developmental concerns, the VAS is a widely recognized and acceptable pain scale to use. The nurse asks the patient to rate their pain on a scale of 1 to 10 with 10 being the worst pain imaginable by using a picture of this scale for them to point to.
It is helpful to know the type of pain the patient has such as visceral, somatic or neuropathic because this assists with determining the best type of medication to use for treatment. Although subjective, it is still possible to assess pain in the unresponsive patient but a different assessment tool must be used. The FLACC (Face, Legs, Activity, Cry, Consolability) Behavioral Scale is widely recognized and has high validity (Lewis, Zanotti, Dammeyer, & Merkel, 2012).
The nurse watches for non-verbal indicators of pain such as grimacing, guarding, squirming, restlessness, and moaning and assigns a numerical score.
Pain Management Pain management in the nonverbal patient is handled slightly differently than in the verbally responsive patient. The decision of whether to administer acetaminophen or morphine should be based on the VAS or FLACC score and the type of pain the patient has. With all elderly patients the guidelines are to “start low and go slow” and many use a ladder approach that is recommended by World Health Organization for treatment of pain. Step 1 is for mild pain and should be treated with acetaminophen and NSAIDs.
Step 2 is for moderate pain and should be treated with low dose opioids combined with acetaminophen or NSAIDs. Step 3 is for severe pain and is treated with high doses of opioids (Mauk, 2010).
The case study indicates that there is a standing order for acetaminophen to be given orally but because the patient is non-responsive, this is not an option. The nurse should begin with the lower dose of morphine and administer 0. 05 mg/kg IV. Studies indicate that the pain relief is much faster in the IV dosing than in the IM dosing and it does not usually cause severe respiratory depression (Tveita et al. 2008).
Oxygen saturation is being monitored so if this respiratory depression does occur, it can be treated with naxolone. Since the nonverbal patient cannot communicate their level of pain, it is often advised to maintain continual dosing of pain medication and titrate the strength based on the repeated pain score. The alert patient should be educated on the benefits of identifying pain early instead of waiting for the pain to become severe. Regularly scheduled dosing will require less pain medication to provide adequate relief than trying to get it back under control when the pain becomes severe.
Success of Pain Management The patient should be reassessed regularly to determine the effectiveness of the pain management. In the verbally responsive patient, the nurse would ask them to rate their pain after being medicated to see if there is a change in the intensity, pattern, frequency or duration of the pain. In the nonverbal patient, the nurse would reassess using the FLACC scale and determine if there is any reduction in the original score. Physiological factors such as increased or decreased pulse, respiration and blood pressure should also be noted.
Administration of the medication should be adjusted based on all of the above. Learning Advanced medical care has contributed to an aging population and consequently the number of admissions to hospitals in patients over 65 is increasing. This requires nurses to remain competent in the anatomy and physiology of the human body so they are able to understand how interrelated the multiple organs are in the body. A condition in an older patient can be much harder to diagnose and treat because of the domino effect associated with multi organ failure.
The body is much more forgiving in a younger patient and conditions do not become critical as quickly as in an elderly patient. In addition to this, decreases in cognitive skills exacerbate many of the situations. Nurses dealing with the elderly must be well prepared to perform detailed assessments very quickly to address life threatening conditions. With little or no feedback from the patient, their assessment skills must remain sharp. In addition to this, the metabolism of the elderly is slower so the awareness of the potential for medications to build up is important.
It is not uncommon for a benefit for one issue to cause a new problem in another area. This requires a delicate balance that must constantly be reassessed. Team Members Because caring for the elderly is multi-faceted, the staff involved must be also. The emergency room nurse, EMT and physician are the initial team members. The team can expand quickly depending on the state of the patient. In Mrs. Bakers’ case, a multi-care tech, lab tech, and pharmacist are involved shortly after admission. When Mrs. Baker becomes unresponsive, a rapid response team should be deployed quickly.
This team normally consists of a respiratory therapist, ICU nurse, anesthesiologist or certified registered nurse anesthetist, hospitalist or chief resident, and house supervisor. A radiology tech is also involved if diagnostic imaging is required. Each member has a specific role in response to a deteriorating condition and must be prepared to work closely with other disciplines. References Abraham, S. , Madhu, R. , & Provan, D. (2010).
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