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.…
What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?…
What are some of the specific health problems that can arise from an imbalance of electrolytes in the body?…
Clinical Application Questions Shanti Sharma RNSG 1413 May 25, 2018 Chapter 41: Fluid and ElectrolytesMrs. Hilda Beck is a 72-year-old seen by her health care provider this morning after falling at home because she became light-headed after vomiting and having diarrhea that has lasted over 24 hours. She was admitted for oral and intravenous (IV) fluid therapy. 1.…
Mr. M, 52, comes to the ED complaining of intermittent palpitations, shortness of breath, and lightheadedness. Triage takes Mr. M back into the treatment area after a quick evaluation. His vital signs are BP, 140/80; pulse, 148 and regular; respirations, 18; and SpO2, 97% on room air.…
Fluid Volume Deficit (Hypo-Volemia): shift from plasma into ICF with sodium loss, treat with isotonic fluids, blood products for blood loss, low BP, increase HR, weak thready pulse, no JVD, increase RR, decreased LOC, cool skin POOR SKIN TURGOR…
cardiac monitoring, k+ monitoring, monitor breathing and circulation. IV administration of calcium gluconate, glucose, and insulin, if ineffective possible dialysis (hemodialysis or peritoneal) Diuretics to assist with excretion of excess K+. Education regarding foods and complications ect. Assess patients understanding of appropriate salt substitutes and potassium replacements. Counseling for possible…
Report ABNORMAL assessment findings to the physician immediately, such as; cardiovascular status, respiratory status, kidney function, neurologic status, musculoskeletal status, nutritional status, skin appearance and psychosocial abnormalities.…
so by her oximetry and perfusion status review. As such the following would be the initial…
Since the patient has become unresponsive the nurse should begin with a neurological assessment by checking pupils for reaction and using a blunt needle on the extremities to insure a response from both the autonomic and peripheral nervous system. The respiratory and cardiovascular system can be assessed with the use of a stethoscope by listening to lung and heart sounds, as well as, checking peripheral pulses, capillary refill time, and checking for any discoloration of the skin especially around the mouth and extremities. To conclude the assessment of the integumentary system the nurse should check for any abrasions, bruising, or wounds sustained by the patient during the fall the patient reported. The nurse can continue to assess the patient’s pain level by looking for key expressions that would indicate the patient is in pain such as furrowing brow, flared nostrils, grimacing, or restlessness at the point of at which external pain factors are used to determine responsiveness of the patient such as a sterna rub or pinching of the knuckles. The scenario indicates that the patient has begun to have increased difficulty with breathing at…
She was transferred to the long-term care section of the hospital. Vital signs are: BP 96/62; pulse: 99 to 122 beats per minute and irregular; respirations: 20 breaths per minute. Heart sounds are irregular and distant; peripheral pulses are very weak; dorsalis pedis pulse is present in…
Mr. Debourg is 62 year old male. In 2013, during routine physical with his physician, he was referred to a cardiologist for further evaluation. Patient was diagnosed with high blood pressure and started on Lisinopril 10mg daily. Due to stress from work, he started having palpitation and shortness of breath. On 4/13/2014, patient started feeling hot and dizzy. When his wife noticed patient’s face was turning pale, she took his blood pressure. Patient states he’s blood pressure at that time was around 200/100, heart rate above 150. Mr. DeBourg drove himself to the hospital where he was admitted for further evaluation and tests. Angiogram showed 2 blocked arteries and he received Cardiac stent placement. Patient is now on 4 blood pressure medications and sees cardiologist…
The narrator uses similes, metaphor and imagery to describe Devon. This gives us a much better understanding of the narrator’s memories that he had in Devon school. For example the narrator says “I didn’t entirely like this new glossy new surface, because it made the school look like a museum,(1)”. In this the narrator uses a simile in which he says the glossy surface makes his school appear as a museum. Another example of the narrator using figure of speech to describe Devon is when he says “ It had loomed in my memory as a huge lone spike dominating the river bank forbidding as an artillery piece”(13). In this instance the narrator simile to describe the tree he thought he was looking for by calling it a forbidding piece of artillery. This means that the Narrator had a crucial connection with that tree.…
Assessed for presence of edema, I & Os, lab values of sodium and potassium, vital signs performed q hour, breath sounds assessed, cardiac monitoring.…
Mrs. Greenway is exhibiting symptoms of dehydration due to diarrhea. Based on the data available it is important to do her nutritional assessment of last few days to figure out the reason of severe diarrhea (Knight, Kais, Santaolalla, & Abreu, 2015). This may be helpful in determining certain types of food that causes flare ups and plan particular diet excluding those food items (Knight et al, 2015). It is important to cure acute diarrhea to prevent additional electrolyte imbalance. Whether she is taking adequate fluids is another equally important question to ask. Information on intake and output and weight gain the client of fluid is important to assess the severity of dehydration to start intravenous fluid administration to prevent hypovolemia…