Pain Assessment, Pain Management and Homeostasis in a Geriatric Patient Experiencing Multisystem Issues

Key immediate assessments of patient’s homeostasis, oxygenation, and pain level 

The patient arriving in the ER is a 73-year-old female who was conscious and in pain, and able to answer only a few questions before becoming unresponsive.  Consequently, an assessment of the patient had to be performed immediately. The first step was to check the patient’s airway for any obstructions and her breathing, and then make sure the patient had a pulse.  Confirming these, the next step was to check her oxygen saturation and blood pressure. Her pulse was 108 and her respiratory rate was 32.  Her blood pressure was measured at 87/56 and her oxygen saturation on ambient air was 81%.  Using a bedside blood pressure device that continuously assesses oxygen saturation is critical to maintaining oxygenation and homeostasis.  In this case, a suggested course would be to place the patient on 2-3 liters of oxygen through a nasal cannula and immediately notify the ER physician of the patient’s condition. It is also very important to check the patient’s capillary refill and color since that is an excellent indicator of the status of circulation.  

Being advised of the patient’s medications (metformin, hydrochlorothiazide and recently lisinopril) would reveal she is a diabetic and highlight the possibility of some adverse reaction from the combination of these medications, in particular, the lisinopril and hydrochlorothiazide, which when lisinopril is first taken could lead to severe acute hypotension and hypovolemia. Though widely prescribed, hydrochlorothiazide was found recently in a national study to be less effective alone than other blood pressure treatments, such as beta-blockers and ACE inhibitors (Messerli et al., 2011), and when taken together with them, also might exacerbate certain symptoms of diabetes, such as acidosis and respiratory failure.

As for assessing the patient’s pain level, initially, during the few moments, the patient was able to speak, it would behave been best to ask the patient about her level of pain on a scale of 1-10. When unresponsive, pain can be determined from a number of factors, such as grimacing, facial expression, guarding and other activity, such as pulse and respiration.  If unable to answer, as the hypothetical suggests, the steps described in more detail below in Section D. would be best to follow, such as the Wong-Baker FACES pain scale, CPOT or the NVPS scale.

Technological tools used for assessment and treatment

As mentioned above, one technological tool important to use for assessment in a case such as this hypothetical would be a blood pressure device that measures oxygenation saturation continuously. Also, it is suggested that providing 2-3 liters of oxygen through a nasal cannula would be appropriate in this case to improve and maintain oxygenation. Because the patient is a diabetic (indicated initially by the medication Metformin), it would be appropriate to check the patient’s blood sugar. Also, the doctor would likely order certain labs, probably including an ABG (arterial blood gas) test, to check for breathing problems, determine if additional oxygen is needed or mechanical ventilation is required, check on whether the level of oxygen supplied via the nasal cannula is correct, and measure the acid and base level in the blood to assess the patient’s diabetes. The doctor would also likely order labs, including a CMP (Comprehensive Metabolic Panel), which includes blood levels of sodium, potassium, calcium, chloride, carbon dioxide, glucose, BUN (blood urea nitrogen), creatinine, protein, albumin, bilirubin, and liver enzymes, ALP (alkaline phosphatase), AST (Aspartate Aminotransferase) and ALT (Alanine Aminotransferase), and also order urinalysis, and also a chest X-ray, and a CBC (Complete blood count), measuring red blood cells, white blood cells, hemoglobin, hematocrit and platelets. 

A nurse could expect the attending physician to order the nurse here to give this patient a bolus of normal saline to increase her low blood pressure. The lab results here showed potassium of 3.1, the glucose of 68, sodium 135 and a slightly elevated alkaline phosphate (although that might be expected with advanced age). The patient’s BUN is 44, and creatinine is 2.1, which appear to indicate this patient could be moving towards renal failure, a common complication of diabetes. A foley catheter was inserted to acquire the specimen for a urinalysis and also to keep track of urine output. During the procedures discussed, the patient did not grimace or withdraw, indicating the patient was not experiencing pain.

Prioritization of data collection

In this case, prioritization would follow the normal procedure. ABC’s would be used, assessing airway, breathing and circulation. The patient here was not using accessory muscles or abdominal muscles in order to breathe. The patient’s airway was not obstructed, and it appeared that her capillary refill was less than 2 seconds. Pain assessment was performed while the patient was able to speak, and observations continued during procedures while the patient was non-responsive. The blood pressure device with oxygenation saturation monitoring was hooked up, and readings were taken for assessment, the catheterization was performed for urinalysis, and blood was taken for lab work. The patient’s oxygen saturation climbed to 90% on 2.5 liters of oxygen. Her blood pressure normalized at 105/70 after giving her the bolus, and she was given an IV drip of D5W with mEq potassium at 50 ml/hr to assist in bringing her blood sugar to normal, increasing her serum sodium and replacing potassium. 

Pain assessment for a geriatric patient who is alert and conversant vs. non-responsive

In a geriatric patient who is alert and conversant, the pain level can be assessed by simply asking the patient to estimate the level of pain based on a scale of 1-10, with 10 being the worst pain they have ever experienced, and 0 being no pain. The fact the patient is geriatric does not prevent them from accurately describing the level of pain they are experiencing. While there is a tendency in elderly patients not to report pain for fear of inducing further procedures, they can still generally describe the discomfort they are having on a scale of 1-10. 

In a geriatric patient who is unresponsive, there are several pain assessment tools available to the ER nurse.  One tool is the Wong-Baker FACES pain scale, which involves making a determination of the level of pain from 0 to 5 based on the patient’s facial expressions. While the scale was developed for use in pediatric cases, where children were asked to point to the face that represented the way they felt, it was extended to apply to nonresponsive patients based on observations of the patient’s facial expressions in comparison to the pictorial levels described in the scale.

Another tool is the NVPS (nonverbal pain scale) which involves observing and assessing facial expressions, guarding level of activity/movement, and vital signs. Assessment is also made of the patient’s respirations, rated on 0-2 Likert scales. NVPS can be useful because some aspect of it is based on vital signs, which are objective criteria. However, it is key for the nurse to observe the vital signs before, during and after any procedure to gain the most from any changes in the vital signs for assessment purposes. Scores range from 1 to 10 (Odhner, Wegman, Freeland, Steinmetz, & Ingersoll 2003).

Another tool is the CPOT (Critical-Care Pain Observation Tool). CPOT measures four items, face, body movements, muscle tension, and compliance with ventilator or vocalization on 0-2 Likert scales. Scores range from 1 to 8 (Marmo & Fowler, 2009, p. 135).

Managing pain in a non-alert geriatric patient with multisystem failure and showing signs of pain

Where the nurse has the option of administering pain medication intravenously, orally or intramuscularly, the mental condition of the patient significantly affects the method of administering the medication. However, if the patient is unresponsive, it is inappropriate to administer oral medication. Evidence-based practice is critical here. This leaves determining whether to administer pain medication by IV or IM. If a pain assessment is taken, using the methods discussed above, if the patient is guarding or grimacing, it would be appropriate to administer medication by IM or IV, although IV would be the first choice because administering by IM would cause more pain itself. 

If the patient is responsive, their assessed level of pain would guide administration and type of pain medication. If the pain level is 1-3 on a scale of 10, Tylenol or its comparable would be a good first choice. If the pain level exceeds 5 on a scale of 10, Morphine IV or IM would commonly be administered.  IV medication is quick but effective for a shorter time than IM administration. 

When the next assessment is made, the same scale should be used and a responsive patient can be asked to once again assess their pain on that scale.  For the unresponsive patient, observations should be made of guarding and grimacing by checking facial expressions and checking respiration and pulse. Increased pulse and respiration can indicate a patient is experiencing some amount of pain.

Collaborative team members

In the hypothetical ER scenario here, the collaborative team would consist initially of the ER nurse and the team that delivers the patient to the ER, and all would be focused on ensuring the pass-off is as speedy and comprehensive as possible, in particular, any statements made or answers given by the patient during the process and emergency transit to the hospital, and any changes in status during the period of transit to the ER. In the ER, the ER nurse, the ER physician and in this case, a respiratory therapist would form the collaborative team. The ER nurse would initially stabilize the patient’s respiration by placing her on oxygen, as described above, and notifying the doctor immediately when the patient becomes unresponsive, giving as much data as possible, including medication history and current status. The function of the ER nurse would include carrying out the doctor’s orders, which is a critical part of a nurse’s duty, and doing so well might make the difference between a patient’s life and death.

References

Messerli, F. H., Makani, H., Benjo, A., Romero, J., Alviar, C., & Bangalore, S. (2011) Antihypertensive efficacy of hydrochlorothiazide as evaluated by ambulatory blood pressure monitoring. J Am Coll Cardiol, 57(5), 590-600. doi:10.1016/j.jacc.2010.07.053

Odhner, M., Wegman, D., Freeland, N., Steinmetz, A., & Ingersoll, G. L. (2003). Assessing pain control in nonverbal critically ill adults. Dimensions in Critical Care Nursing, 22(6), 260–267.

Marmo, L., & Fowler, S. (2010). Pain assessment tool in the critically ill post-open heart surgery patient population. Pain Manag Nurs., 11(3), 134-140.