Multi Organ Failure

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multi organ failure There are many key assessments a nurse may utilize to assist in assessing a patient’s homeostasis, oxygenation, and level of pain. The first thing a nurse does in the emergency room is to establish vascular access by inserting and I.V. for administration of crystalloids such as lactated ringers or normal saline for volume depletion and dehydration. The nurse must remember the ABC’s of an initial assessment, which stands for airway, breathing and circulation. The very first thing a nurse must do is look at her patient, and assess whether the breathing is within normal limits, or if it is labored. Then assess the chest movements for even respirations, if uneven the patient may have a pneumothorax. Then blood glucose should be done since some patients don’t know the signs of hypoglycemia or hyperglycemia. This is done with a glucometer, a small hand held device that assess a drop of blood and then gives a reading of the patient’s blood glucose level. Normal levels are between 70-110. If the patient’s blood sugar is below 65 then glucose can be given orally or intravenously. If the blood sugar is over 150 then supplemental insulin can be given subcutaneously. The nurse must also assess for jugular vein distention, and mediastinal shift for signs of pneumothorax. There may also be breath sounds on one side of the chest only, lung sounds are heard with a stethoscope. By looking at the patient the nurse can also assess the color of the skin, and if there is any cyanosis around the lips or nail beds. The next step is to get a set of accurate vital signs, the nurse can utilize a vital signs machine such as the dynamap machine that can take the blood pressure, pulse, oxygen saturation, mean arterial pressure and temperature. The pulse and oxygen saturation are measured with a pulse oximeter that is placed on the patient’s finger, if the fingers are

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