This paper examines the nursing assessment and management of a geriatric patient presenting with multisystem failure in an emergency room setting. It covers key immediate assessments for homeostasis, oxygenation, and pain; technological and clinical tools used to evaluate and treat fluid and electrolyte imbalances; and prioritization of interventions. The paper also compares pain assessment approaches for alert versus non-alert elderly patients, discusses pain management strategies with standing medication orders, and identifies the collaborative care team members essential to this patient's care. The discussion draws on established pain scales and geriatric nursing principles.
A patient appearing dyspneic or mentally confused may show signs of deficient oxygenation. Skin color should also be checked for pallor, and pulse oximetry — a medical device that indirectly measures oxygen levels in the blood — should be monitored. Cyanosis, drowsiness, and lethargy are additional signs of poor oxygenation. Because these signs are often difficult to assess by observation alone, blood gas measurements and a chest X-ray are necessary for a more accurate evaluation.
Homeostasis is assessed by checking the patient's vital signs, pulse oximetry, heart response, and neuromuscular function. A nurse can also evaluate homeostasis by checking fluid volume status.
Signs of fluid volume excess include dyspnea, sudden weight gain, edema, hypertension, bounding pulse, and crackles on auscultation.
Signs of fluid volume deficit include dizziness, confusion, sudden weight loss, weak pulse, shortness of breath, and orthostatic hypotension. Urine output of less than 30 ml per hour for two consecutive hours warrants attention, as does excessive output greater than 2,500 ml in 24 hours.
Signs of acute pain in this patient include restlessness, legs drawn up to the chest, dilated pupils, a heart rate of approximately 90 beats per minute, blood pressure of 158/82 mmHg, respiration rate of 24, and skin that is pale and moist. The CXR and urinalysis are negative, and the WBC is 12,000.
Mild to moderate pain, by contrast, is indicated by the absence of protective body positioning, no pupil dilation, an ability to verbalize pain and discomfort, and lower readings across vital sign parameters.
The McGill Pain Questionnaire is widely used for comprehensively evaluating the sensory, evaluative, and affective aspects of pain intensity (Melzack, 1975). This tool is important because healthcare providers tend to underestimate a patient's pain, making objective measurement essential. By eliciting the patient's feedback across all possible components of pain, this instrument is more effective than the visual analog scale, which relies more heavily on the nurse's subjective assessment (Marvin, 1995).
The Thermometer Pain Scale may also be used, particularly if the patient is unable to communicate or demonstrates diminished cognitive abilities.
The Pain Intensity Scales developed by the National Institutes of Health represent another option. Commonly used with elderly patients, these five pain intensity scales also include a checklist of nonverbal indicators for patients who have difficulty communicating.
The Multilanguage Numerical Pain Rating Scale (British Pain Society) presents a six-question instrument using a 0–10 scale with a single prompt in 18 languages: "Please point to the number that best describes your pain." This is especially useful when language barriers are present.
Another authoritative resource is "The Assessment of Pain in Older People" (Royal College of Physicians of London, October 2007). The pain drawing instrument, in which the patient is provided with a one-page anatomical diagram and marks each painful location with a symbol according to symptom type, may be particularly helpful in this scenario, since the patient may have difficulty responding verbally and may be fatigued.
To reduce or eliminate factors that induce pain, the nurse should assess the patient's willingness to use relaxation techniques, then demonstrate and practice those techniques. The appropriate analgesic should be determined based on the pain assessment. The nurse should evaluate the effectiveness of the analgesic, instruct the patient to request medication at the onset of pain, and treat the patient's pain with morphine by IV or acetaminophen by mouth per the physician's instructions.
A physical examination measuring respiration and urine output is essential to determine whether the patient is retaining fluid. Blood pressure should also be assessed. A dry oral mucosa, cracked lips, and a furrowed tongue are indicators of fluid depletion. A chest X-ray should be obtained as well.
Decreased urine output, increased pulse rate, decreased blood pressure, weakness, fever, and dry mucous membranes are all consistent with fluid volume deficit.
The nurse should obtain specimens for analysis of altered potassium levels and administer prescribed supplemental potassium per institutional policy. Neurological and neuromuscular manifestations of hypokalemia — including lethargy, altered levels of consciousness, and muscle weakness — should be monitored. The nurse should also provide frequent oral hygiene and fluids as appropriate; monitor for lethargy, irritability, and hyperreflexia; and watch for cardiac manifestations of hypernatremia. Accurate intake and output records should be maintained, vital signs monitored, and IV therapy administered as prescribed.
As noted above, dyspnea, mental confusion, pallor, cyanosis, drowsiness, and lethargy are all observable signs of deficient oxygenation. Blood gas measurements and a chest X-ray are required for precise assessment, as direct visual evaluation alone is insufficient.
The nurse should monitor respiratory status and the results of blood gases, chest X-ray studies, and incentive spirometer volume. Level of consciousness and vital signs — including blood pressure, pulse oximetry, and temperature, pulse, and respiration (TPR) — should be checked continuously.
The patient should be directed in breathing and coughing techniques to help clear the respiratory passageway, and should be reminded to perform them regularly. The prescribed expectorant should be administered, and the patient should be helped to maintain the Fowler or semi-Fowler position. The prescribed analgesic should be administered, and the physician notified if pain is not being adequately controlled.
The patient in this scenario is experiencing fluid and electrolyte imbalance, acid-base imbalance, oxygenation imbalance, and blood glucose imbalance. Upon arrival in the emergency room, the patient shows an increased respiratory rate and pulse. Her medical history includes diabetes and hypertension, and her current medications include lisinopril, metformin, and hydrochlorothiazide. The patient was initially able to answer questions but subsequently became unresponsive and began having difficulty breathing.
Oxygenation concerns would be addressed first, as this is the most immediately life-threatening issue — the patient would be connected to IV oxygen support. Fluid intake would be addressed next, after which morphine or acetaminophen would be administered to alleviate pain. Each of these interventions would be monitored consistently to assess outcomes and guide adjustment of the care plan.
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