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Assessment Of Mrs Baker Nursing Essay

Paper Type: Free Essay Subject: Nursing
Wordcount: 2514 words Published: 1st Jan 2015

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Upon admitting Mrs. Baker to the ER assist her into a gown. While assisting into the gown notice any skin issues, such as injury from the fall, or irritation from possible prior falls or injuries. Elderly people often have issues such as dehydration, of which the signs may be skin tenting, poor turgor, and red areas from pressure, ask about fluid intake and record capillary refill. Mrs. Baker, as a known diabetic, could have unhealed sores or ulcerations and signs of neuropathy, ask about any numbness or tingling. Assisting the patient into a gown may also determine if there are bladder and bowel continence issues. While assisting to gown use the opportunity to question the patient about what, in her opinion, happened. While asking about the incident, ask if there have been periods of light headedness or dizziness, apply a cardiac monitor and pulse oximeter, for observation. Ask the patient if there are any areas that hurt, or if there is any pain even unassociated with the fall. While questioning the patient about what happened and the patient’s theory of why, evaluate speech pattern and level of orientation, the patient’s awareness of time and cognitive ability may be assessed at this time. Determine if the patient can provide an accurate account of the fall and what preceded the fall. While assessing the patient, it is essential to look at each system and watch for nonverbal signs of pain. Observe the patient, for signs of confusion and check for pupil response to light. Auscultating lung sounds, listen for adventitious sounds such as rhonchi, rales, or wheezes. Listen to determine if lung sounds are present in all lung fields. Auscultate heart sounds, listen for irregularities, is there a murmur noted. Evaluate cardiac monitor for arrhythmias. Question the patient about any chest pain, tightness, or heaviness. Palpate peripheral pulses, note if they are equal, note the quality if they are thread /bounding, and are pulses even on each side. Obtain vital signs such as blood pressure, orthostatic if possible as this is common with HCTZ and Lisinopril; maintain a 30 minute check on blood pressure readings, note rate and quality of respiratory effort along with oxygen readings. Ask again if the patient has any pain as pain may increase readings in blood pressure, respiratory rate, and pulse. The elderly are sometimes reluctant to report pain, thinking it is all part of the aging process and accepts it as a part of life. Many may not report physical discomfort due to the fear that they may lose independence or the risk of being viewed as a burden. Anxiety may also raise vital sign readings; attempt to explain all procedures to the patient. This not only contributes to trust from the patient, but also reduces some of the fear from the unknown. Listen to bowel sounds, indicate the presence of or lack of in all quadrants. Ask the patient about bowel pattern if possible when the last bowel movement was, palpate for any sign of tenderness or guarding. Examine the face, hands, and feet for edema. While checking the lower extremities for edema, indicate the quality of pulses in the legs. Pay attention to color and texture of the skin in the legs and feet, note any sores or red areas, note capillary refill. Pay attention to the temperature of the legs as lower extremities blood clots is common. Again, it is necessary to explain the examination to the patient in order to reduce anxiety and to reassure the patient. If the patient is able, ask about medications and when was the last time they were taken. Ask about the time the last meal was eaten. Once the initial assessment is completed, explain to the patient that there will be some tests to assist in determining the medical problems at present. It is advisable to ask if the patient has questions for the nurse; this may aid in preventing any misunderstandings.

Technological tools, uses, and benefits

Some of the tools frequently used in the assessment, of any patient, start with auscultation and palpation. Listening to the patient’s verbal response is an advantage to the assessment; however, listening to the heart, lungs, and abdomen is required. To begin, start an IV site and obtain the needed blood for testing, this may prevent a delay in treatment. Be aware of the length of time the tourniquet is applied to the patient, quality of the lab draw is also a factor in the values obtained. After obtaining the blood work, begin a physical assessment. Listening to heart sounds may provide information about various cardiac problems such as a heart murmur; deviation in heart sounds may indicate a cardiac condition. Lung sounds may determine if there are pulmonary issues such as bronchitis, pneumonia, or pulmonary edema. Listening and palpation of the abdomen may indicate irregularities in the gut, such as an obstruction or potential aneurysm. Asking about pain or tightness in the chest may also indicate a possible cardiac condition. Ask about any history of chest pain or tightness. Noting the rate and respiratory effort, along with a continuous pulse oximeter, assist in determining pulmonary problems. Ask if there have been any problems with shortness of breath. Blood pressure readings, especially orthostatic in a falls patient may lead to indications leading to the fall. Along with the possible reason for the fall, this may also assist in the determination of medication misuse. The elderly may sometimes forget they have taken their medication and repeat the dosage. Obtaining a blood glucose level may also determine if the fall is related to hypoglycemia. Knowing or having an idea of when the last meal was eaten, and when the medications were taken, also assist in determining possible reasons for the fall. Having knowledge of the estimated fluid intake may also be useful as a tool in the analysis of causative agents. Dehydration in the elderly can cause confusion and light headedness. The continuous cardiac, oxygen, and blood pressure readings are necessary to watch for sudden changes that may occur. Cardiac monitors assist in determining if there are irregularities in the electrical conduction, in the heart, early detection and treatment may prevent further complications. Oxygen readings assist in determining the amount of capillary oxygen and profusion difficulty; this may indicate the need for supplemental oxygen before further decompensation. Frequent checks in blood pressure may be the first sign of sepsis in an elderly person. Other testing and tools used is a chest X-ray, viewing a chest X-ray aids in determining pulmonary issues not noted during the physical examine treatment for pulmonary issues can quickly be obtained. A CT scan of the brain, without contrast, may be used to rule out a brain bleed. A CT scan of the lungs, without contrast, will assess for possible pulmonary embolus. To use contrast, the results of the renal function are needed. Blood testing is critical in determining the bodily functions. Obtaining a complete blood count tells the general hydration, amount of volume and signs of infection with an elevated white blood count, hypervolemia can be promptly corrected; low red blood count indicates the lack of oxygen carrying capacity and may require a transfusion. A complete metabolic profile lends details of renal and hepatic function, as well as levels for key electrolytes such as potassium, sodium, magnesium, and glucose, this also aids in monitoring for metabolic acidosis or alkalosis. With lisinopril, it is common to see an elevation in bun, creatinine, and lowering of glucose levels. HCTZ is known for lowering the potassium, sodium, and magnesium levels. The combination of HCTZ and lisinopril are known to cause dizziness, and palpations and should be monitored closely especially in people with renal impairment and /or of advanced age. Cardiac enzymes are drawn to evaluate the cardiac muscle, to determine if there are cardiac issues. Arterial blood gases assist in determining the pulmonary system function, this also aids in determining respiratory acidosis or alkalosis. Another lab test highly beneficial is a urinalysis with culture and sensitivity. When there is a urinary infection in an elderly person, it may cause dizziness and confusion. The culture helps to determine the proper medication for the organism responsible for the infection. The urine tests also indicate if there are ketones or proteins being spilled in the urine; this is a frequent problem in diabetic patients. Obtaining a twelve lead EKG aids in determining any irregularities in the cardiac conduction, such as heart blocks and ventricular ectopy that are often seen as a result of low potassium. Blood cultures may also be required to determine if there is an infection. Frequently an opportunistic infection may lead to sepsis, and the elderly often do not present that ill until the infection is severe. The elderly may not always present with an elevated temperature; this cannot be the only sign of illness. All the testing and the physical analysis will help to determine potential health issues, but the best source of information is to monitor the patient. Being aware of changes in the patient status and comfort level is required. Continuous visual monitoring may assist in treating sudden changes in the patient. Frequent questions pertaining to the comfort level are required in the elderly as they may be reluctant to admit pain. Explain that pain, of any level, can be addressed, and that comfort may assist in the treatment.

Data collection prioritization

It is essential to prioritize the data collection and report findings to the physician. The application of monitoring devices, such as a cardiac monitor, blood pressure machines, and pulse oximeter, may be done as the patient is being gowned. Visual inspection of the skin may also be done at this time. While gowning the patient, asking about medications and history may also be accomplished. Starting the IV site and obtaining blood work will get information to the physician quickly and should be done as soon as possible. Collect a finger stick for blood glucose, as this may determine if the patient is hypoglycemic. The EKG and ABGs are also critical information needed as soon as possible. A chest X-ray may be done next, along with a CT scan of the brain and lungs, without contrast. Collection of the urine for testing can be collected after the other departments have finished what needs to be done. As the patient is on a continuous monitor for cardiac, respiratory, and blood pressure it is easy to monitor for changes. It is now appropriate to complete the physical assessment of the patient. This saves time while awaiting the results from lab, x-ray, and cardiopulmonary departments. Report any irregularity in the assessment to the doctor as soon as possible. While obtaining information from the patient, it is necessary to ask about pain and monitor for nonverbal cues during the assessment. Morphine, low dose (0.05mg/kg IV) for pain may be appropriate at this time as it decreases the oxygen demand from the heart and may reduce anxiety. Tylenol may not be the medication of choice until liver function is established. Advise the physician that the patient has been taking HCTZ, Lisinopril, and metformin. The combination of HCTZ and Lisinopril may cause dizziness and dehydration. Lisinopril also aids in lowering blood glucose levels, and should be monitored closely especially in people with renal impairment and/or of advanced age. This combination may also cause palpations and dizziness. HCTZ can cause electrolyte imbalances leading to alkalosis. The patient may also be experiencing a drug hypersensitivity to the lisinopril. Signs would include dyspnea, chest tightness, and arterial acidosis, requiring intubation (Hydrochlorothiazide and Lisinopril side effects, Drugs.com). If the patient was medicated for pain, check for relief of symptoms. Verbal affirmation should be listed on a scale of 1-10 according to the flacc scale. If the patient has pain relief, note this with the physician. Monitor for lab results and report any findings outside the normal range, the same with EKG, ABGs, x-ray, and CT scan. Monitor the patient for changes in mentation, and visible signs of changes. The elderly may have sudden changes; it is advisable to monitor closely.

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With continuous monitoring, and noting the change in status of Mrs. Baker, there would be more aggressive measures taken. A rapid response from respiratory therapy would be needed, and a request for the attending physician, for the mental status and respiratory changes and the possible need for increased measures such as intubation. A repeat of ABGs would be needed; STAT results are indicated. Radiology should be available for potential tube placement. All team members should be alerted for the possibility of a code blue alert. The staff needs to be monitoring the cardiac status at all times. With respiratory arrest, cardiac is soon to follow. Rapid response to changes in respiratory status can prevent further complications. Constant monitoring of the flacc scale may assist in monitoring the patient’s comfort level. A patient may show signs of discomfort by moaning, thrashing about, or facial grimace. Being aware of this may aid in the quality of patient care. The patient may not be able to tell that they hurt, but body language speaks volumes. If the patient is indicating that they are in pain, morphine at a low dose may be used (0.05mg /kg IV). Considering the slower metabolism of the elderly, it is necessary to medicate accordingly. This not only aids in pain relief, but also lowers the oxygen demand by the heart. Close observation of the patient is mandatory. If the medication is effective the signs observed will diminish and the patient will appear more relaxed, with little or no signs of pain (possible lower BP and heart rate, no facial grimace, more relaxed, less restlessness). The alert patient can verbalize the effectiveness of pain medications, with an unresponsive person we must rely on physical cues that are presented. Again, it is important to report pain relief to the physician and continue to watch for changes in the patient. Rapid evaluation and assessment, accurate data, and concise information are imperative to patient care.

When assessing the elderly it is necessary to remember that due to the aging process, metabolism of medications may be slowed. With advanced age, there is also a reduction in renal and hepatic filtering. The elderly may also be reluctant to report pain. When caring for the elderly, it is necessary to keep their viewpoint in mind, and to explain procedures prior to the procedure. A reduction in anxiety may assist in a trusting relationship and aid in lowering blood pressure and heart rate. It is also helpful to remember that changes can occur rapidly with the elderly and that they may not always present as with a younger person. Keep an open mind and alert at all times.


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