On arrival at the ED, the physician auscultates muffled heart tones, no breath sounds on the right, and faint sounds on the left. A.W. is stuporous, tachycardic, and cyanotic. The paramedics inform the physician that it was difficult to ventilate A.W. A STAT portable chest x-ray (CXR) and arterial blood gases (ABGs) are obtained. A.W. has an 80% pneumothorax on the right, and her ABGs on 100%…
4. How will T.V.’s respiratory disorder likely be treated? a. Some form of oxygen supplementation or mechanical ventilation will most likely treat the patient’s respiratory disorder. For more self-care forms of treatment, the patient should be informed and proficient in the breathing techniques to aid in proper ventilation. Lastly, anticoagulant therapy should proceed to…
Assessed for presence of edema, I & Os, lab values of sodium and potassium, vital signs performed q hour, breath sounds assessed, cardiac monitoring.…
b. Breathing- determines if breathing is adequate or inadequate (lung sounds, O2 sat). Asses breathing by looking listening and feeling for amount of air in/out (tidal volume, place hand on chest) and the rate of breathing. Look for any obvious signs such as JVD, apnea, nasal flaring, trachea tugging, outside the rate 8-24 adult and unequal movement. If adequate o2 therapy if not BVM. Assess, intervene, reassess.…
Provide non pharmacological activity measures like repositioning and offering comfort measures Nursing Intervention 2 Administer analgesics as indicated and also Inform patient of the expected therapeutic effects and discuss management of side effects…
Other intervention by the nurse The nurse monitor level of consciousness, vital signs especially monitoring temperature because of the neurological deficit with the hypothalamus in the temperature regulation system has caused a dysfunction of the autonomic nervous system. Monitor pain level on a scale from zero means no pain to ten is the worst pain, the severity, if it radiates, sensation, if T.W. able to move leg, feeling or any movement. Continue to monitor for any changes, perform range of motion for all joints to prevent mobility loss and contractures. In addition, psychosocial assessment for T.W. well-being and include family members to provide comfort and support. Furthermore, continue IV fluid as order to prevent and decrease risk of neurologic shock. Cover with warm blanket as needed to prevent hypothermia.…
Her being in ICU is nice because she needs all the intensive care needed to prevent her condition from having a negative outcome. Using the vital signs that is already given, the ICU nurse will now reassess her again, compare the vital and then create a baseline. With all the information she collected, she already is aware of the breathing issue first since airway is our priority, she will be position in a cardiac position to ease pressure off her lungs so she can breathe. The nurse will establish a relationship with Mrs. J that will help calm down her anxiety that she is in safe hands. When doing that, the nurse will look into the physician order and have all Mrs. J medication given in a timely manner. Perform all screening if order by the physician, wait for results and give the physician a feedback for further follow-up.…
The physician has indicated that if Darlene does not respond to medication over the next 2-3 days, he will order ECT. Darlene has a history of hypertension but has not been taking medication. On admission her pulse is 98, Temperature…
MSC: NCLEX: Physiological Integrity 3. The nurse is planning care for a patient with severe heart failure who has developed elevated…
After successful removal of the gallbladder and an unremarkable anesthetic reversal, Mr. F is transported to the post anesthesia care unit (PACU) and monitored before being transferred to medical-surgical unit. Vital signs are as follows: heart rate, 75/min; blood pressure, 127/82 mm Hg; respiratory rate, 16/min; oxygen saturation, 100% on 2L of O² via nasal cannula; body temperature, 36.9°C. When Mr. F arrives to the PACU, the receiving nurse notices an increase in his heart rate to 91/min and an increase in respirations to 21/min. After administering a 3-mg IV bolus of morphine sulfate for pain and increasing oxygen delivery to 4L/min via nasal cannula, the nurse continues to see a gradual increase in heart rate and respirations as well as an increase in blood pressure and body temperature. Ten minutes later, Mr. F’s vital signs are now as follows: heart rate, 114/min; blood pressure 147/92 mm Hg; respirations, 25/min; oxygen saturation, 98% on 4L of oxygen via nasal cannula; and body temperature, 38.8°C. The nurse again treats with a 3-mg IV bolus of morphine sulfate and increases his oxygen to 5L by mask.…
Today’s clinical experience allowed for new education and skill practice. I was able to precept in post-op, which was a great change. Being in pre-op, we are responsible for receiving clients from the OR. We then monitor them, reeducate, prepare for and perform discharge, and cleaning the area that was used by disinfecting, tossing and replacing linens, and moving the bed to an empty room in pre-op. We receive report from the circulating nurse and the nurse anesthetist when they first bring the patient to recovery. Together we hook the patient up to the monitors and record the first set of vitals together. These include: blood pressure, heart rate, respirations, temperature, pulse ox, pain (if patient is conscious), and an ECG reading if they were general.…
According to the information in the scenario, the action I will take next will be to ask Mrs. Henderson ask her about her pain level from the scale of 0-10 and if she verbalize she is still in pain I will administer her pain medication. I will use option A (I will the ordered pain medication and administer it). I will ask Mrs. Henderson question about her family history regarding asthma, bronchitis, and rheumatoid arthritis. I will ask questions about the medication she was using, I will reassess the breath sound and reassess her vitals sign, most importantly the blood pressure and respiration which are too high, I will assess her abdomen for bowel sound and palpate her abdomen for masses, bulges or pain. I will also perform active range of…
Your blood pressure, heart rate, breathing rate, and blood oxygen level will be monitored until the medicines you were given have worn off.…
4. Assess blood pressure and teach patient how to adequately take weekly blood pressure. RATIONAL: Ensure medication is doing its job and another drug is not needed and to monitor BP levels. Good indicator if pt must contact physician.…
i. Paper /Pencil test ii. Project iii. Assignment (class/home assignment) iv. Field Visit v. Survey…
