Patient in Mods
Assessments
The first assessment I would perform would be obtaining the patient’s vital signs, blood sugar and O2 sat. I would then either obtain an EKG or hook her up to continuous cardiac monitoring. Next, I would assess her pain level by asking her what her pain level is. However, if she is still unresponsive I would watch for any guarding, grimacing or sounds of discomfort. I would then check the doctor’s orders for ABGs to determine her gas exchange, a CMP to determine her kidney/liver function and to check her acid/base balance and her electrolytes. Radiographic images would also be useful in determining any internal images, particularly a CT of the head to rule out intracranial hemorrhage.
Tools
The tools I would use would include a blood pressure cuff and stethoscope for determining the blood pressure, pulse and breath sounds. The blood pressure cuff and stethoscope are more reliable tools than an automated machine that does vital signs such as a Dinamap. Next, I would use a glucometer for checking her blood sugar since she has a history of diabetes. The glucometer is a fast, reliable and effective tool for checking blood glucose levels. Also, an EKG or continuous cardiac monitoring are quick and efficient tools to assure patient is not in a fatal rhythm.
Data Collection
The first thing I would do is listen to the patient’s breath sounds to ensure they were normal. Next I got her O2 sat and put the oxygen on per the doctor’s order. I then got her vital signs manually and assessed her pain level. Lastly, I used the glucometer to determine her blood glucose level.
Assessing Pain
To assess the pain level in the older adult who is alert and able to express his or her needs I would begin by asking them what their pain level was on a scale of zero to 10, if it was constant or intermittent and what quality it was. In the geriatric patient who isn’t alert I would watch for grimacing, listen for any sounds of discomfort, such as moaning or whimpering, and I would check the pulse and blood pressure to see if they were elevated.
Pain Management
I would not give any of the medications on the standing