Why Is Mrs. Beck Likely Becoming Light-Household?
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. Why is Mrs. Beck likely becoming light-headed? When should you expect this to resolve?
Answer: Mrs. Beck became light-headed because she has fluid volume deficit in her vascular compartment. Because of her the vomiting and diarrhea over 24 hours she has extracellular volume deficit.
The deficit should be resolved when Mrs. Hilda’s fluid volume is restored with IV …show more content…
isotonic sodium-containing fluid (Potter & Perry, 2013).
2. Mrs. Beck's IV fluid order is 1000 mL 0.9% sodium chloride to run over 8 hours. Calculate the milliliters per hour that you should program into her infusion pump.
Answer: 1000 mL/8 hrs = 125 mL/ hr.
3. You auscultate crackles in Mrs. Beck's lung bases while her IV is infusing. What is your next action?
Answer: When there is a presence of crackles upon auscultation the nurse should reduce the flow rate of the IV, raise the head of the bed, and notify the patient’s health care provider. The nurse should also monitor the for the ease of breathing and prepare to administer oxygen and diuretics if ordered by the health care provider (Potter & Perry, 2013).
Chapter 42: Sleep
Julie returns to the neighborhood health clinic with her husband, David, for a follow-up visit. She tells you that since she started her sleep hygiene plan she feels more rested but is still having some problems sleeping because of her husband's loud snoring. Besides Julie's report of David's snoring, you note that he is overweight.1. Based on Julie's report of David's snoring, which additional assessment data should you gather from David?
Answer: Based on Julie’s report of David including snoring and David being overweight, you should complete a thorough sleep history assessment which includes; bedtime routines, bedtime rituals, preferred environment for sleeping, presence of any physical or psychological illnesses, current life events changes, emotional or mental status, and about medications that David might be taking (Potter & Perry, 2013).
You can also question them about: a. Nature of the problem.b. Signs and symptoms.c. Onset and duration of signs and symptoms.d. Severity.e. Predisposing factors. f. Effect on patient.2. Based on David's reported symptoms, what problem do you suspect he might have? What recommendations do you give David to improve his sleeping?
Answer: Based on the assessment and findings of David being overweight; David might have obstructive sleep apnea. Which is caused by risk factors such as hypertension and obesity. To help David improve his sleeping pattern, you can develop a sleep hygiene program.
The recommendations for David to improve his sleeping patterns would be to help him develop a weight-loss program, as weight loss improves sleep. Teaching the patient to try elevating the head of his bed using extra pillows to prevent him from sleeping on his back, encouraging him to avoid or limit the consumption of alcohol, caffeine, and, nicotine before bedtime which can make the problem worse (Potter & Perry, 2013, p. 954). 3. Julie and David tell you that they are concerned about their 6-year-old daughter. She just started school and is having sleep problems. List at least four interventions for Julie and David to use to improve their daughter's sleep patterns.Answer: Some interventions for David and Julie to help improve their daughter's sleep patterns would be:
• Establishing a consistent bedtime routine (Potter & Perry, 2013, p. 954).• Environment controls: such as keeping the room well ventilated, adequate darkening of room, reduction of noise, and maintenance of comfortable room temperature (Potter & Perry, 2013, p. 954).• Encouraging her to avoid eating any heavy meals for 3 hours before bedtime (Potter & Perry, 2013, p. 954).
• Encourage her to do quiet activities such as listening to music, coloring, or reading a bedtime story (Potter & Perry, 2013, p. 954).• Encouraging her for activity and exercise during the morning or afternoon hours and avoid vigorous activities 2 hours before …show more content…
bedtime (Potter & Perry, 2013, p. 954).
Chapter 48: Skin Integrity and Wound Care
1. Because of the foul-smelling tan-colored drainage from Mrs. Stein's hip incision, the staples were removed by the health care provider, and an order was written for moist saline gauze dressing to the area 3 times a day. When the dressing is removed, which factors are critical to assess?
Answer: When the dressing is removed the factors that are critical to assess the appearance of the wound looking for any signs of redness, warmth, and edema around the wound.
It is very much important to measure the length, width, and depth of the wound once in every 24 hours. It is important to assess for presence of odor, signs of excessive wound drainage, and number of gauzes saturated (Potter & Perry, 2013, p. 1204)
2. A head-to-toe skin assessment is done per institutional policy on a daily basis. At the most recent assessment of Mrs. Stein's skin, redness was noted over the sacral area; on direct examination, a small area of denuded tissue was noted. The area was assessed and was found to have minimal depth and a red, moist base. How would you describe the impairment in skin integrity in your charting?
Answer: In the charting, the impairment of skin integrity will be classified as Stage II (Partial thickness skin loss) under depth of injury. The risk factors would be friction and impaired mobility. A pain assessment for any pain on a scale of 0 to 10, and color and type of tissue in wound (red, moist tissue, granulation tissue) (Potter & Perry, 2013, p. 1179).
3. What will you include in your plan of care for Mrs. Stein to address the impairment in skin integrity in the sacral
area?
Answer: The interventions to include in the plan of care of Mrs. Stein would include:
. Assess her pain level at frequent intervals and offer pain medication before helping her move (Potter & Perry, 2013, p. 1194).
. Monitor and ensure adequate nutritional status and fluid intake (Potter & Perry, 2013, p. 1194).
. Use a moisture barrier ointment to decrease further tissue damage and decrease friction to the area (Potter & Perry, 2013, p. 1194).
. Keep the skin dry and clean and provide thorough perineal care (Potter & Perry, 2013, p. 1194).
4. Mrs. Stein will be discharged tomorrow. Which issues must be assessed regarding her care before discharge? Describe why these issues are of importance.
Answer: The issues that must be assessed before Mrs. Stein’s discharge includes:a. Assessing the patient's ability to transfer and reposition correctly and with minimal assistance because her independence determines if she is ready to return her home (Potter & Perry, 2013, p. 1196).b. Assessing the patient’s pain control because she should be able to control pain to increase her mobility and ambulation (Potter & Perry, 2013, p. 1185).c. Nutritional assessment: nutrition and fluid intake must be adequate to support healing of her incisional area (Potter & Perry, 2013, p. 1200).d. Provide patient and family teaching regarding the instructions needed for her caregivers in helping her ambulate and providing care for the surgical wound and evaluate caregivers for their ability to implement and comprehend and they need to be evaluated for their strength and endurance (Potter & Perry, 2013, p. 1196).
References:
Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2013). Fundamentals of nursing. St. Louis, MO: Mosby Elsevier.
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. Why is Mrs. Beck likely becoming light-headed? When should you expect this to resolve?
Answer: Mrs. Beck became light-headed because she has fluid volume deficit in her vascular compartment. Because of her the vomiting and diarrhea over 24 hours she has extracellular volume deficit.
The deficit should be resolved when Mrs. Hilda’s fluid volume is restored with IV …show more content…
isotonic sodium-containing fluid (Potter & Perry, 2013).
2. Mrs. Beck's IV fluid order is 1000 mL 0.9% sodium chloride to run over 8 hours. Calculate the milliliters per hour that you should program into her infusion pump.
Answer: 1000 mL/8 hrs = 125 mL/ hr.
3. You auscultate crackles in Mrs. Beck's lung bases while her IV is infusing. What is your next action?
Answer: When there is a presence of crackles upon auscultation the nurse should reduce the flow rate of the IV, raise the head of the bed, and notify the patient’s health care provider. The nurse should also monitor the for the ease of breathing and prepare to administer oxygen and diuretics if ordered by the health care provider (Potter & Perry, 2013).
Chapter 42: Sleep
Julie returns to the neighborhood health clinic with her husband, David, for a follow-up visit. She tells you that since she started her sleep hygiene plan she feels more rested but is still having some problems sleeping because of her husband's loud snoring. Besides Julie's report of David's snoring, you note that he is overweight.1. Based on Julie's report of David's snoring, which additional assessment data should you gather from David?
Answer: Based on Julie’s report of David including snoring and David being overweight, you should complete a thorough sleep history assessment which includes; bedtime routines, bedtime rituals, preferred environment for sleeping, presence of any physical or psychological illnesses, current life events changes, emotional or mental status, and about medications that David might be taking (Potter & Perry, 2013).
You can also question them about: a. Nature of the problem.b. Signs and symptoms.c. Onset and duration of signs and symptoms.d. Severity.e. Predisposing factors. f. Effect on patient.2. Based on David's reported symptoms, what problem do you suspect he might have? What recommendations do you give David to improve his sleeping?
Answer: Based on the assessment and findings of David being overweight; David might have obstructive sleep apnea. Which is caused by risk factors such as hypertension and obesity. To help David improve his sleeping pattern, you can develop a sleep hygiene program.
The recommendations for David to improve his sleeping patterns would be to help him develop a weight-loss program, as weight loss improves sleep. Teaching the patient to try elevating the head of his bed using extra pillows to prevent him from sleeping on his back, encouraging him to avoid or limit the consumption of alcohol, caffeine, and, nicotine before bedtime which can make the problem worse (Potter & Perry, 2013, p. 954). 3. Julie and David tell you that they are concerned about their 6-year-old daughter. She just started school and is having sleep problems. List at least four interventions for Julie and David to use to improve their daughter's sleep patterns.Answer: Some interventions for David and Julie to help improve their daughter's sleep patterns would be:
• Establishing a consistent bedtime routine (Potter & Perry, 2013, p. 954).• Environment controls: such as keeping the room well ventilated, adequate darkening of room, reduction of noise, and maintenance of comfortable room temperature (Potter & Perry, 2013, p. 954).• Encouraging her to avoid eating any heavy meals for 3 hours before bedtime (Potter & Perry, 2013, p. 954).
• Encourage her to do quiet activities such as listening to music, coloring, or reading a bedtime story (Potter & Perry, 2013, p. 954).• Encouraging her for activity and exercise during the morning or afternoon hours and avoid vigorous activities 2 hours before …show more content…
bedtime (Potter & Perry, 2013, p. 954).
Chapter 48: Skin Integrity and Wound Care
1. Because of the foul-smelling tan-colored drainage from Mrs. Stein's hip incision, the staples were removed by the health care provider, and an order was written for moist saline gauze dressing to the area 3 times a day. When the dressing is removed, which factors are critical to assess?
Answer: When the dressing is removed the factors that are critical to assess the appearance of the wound looking for any signs of redness, warmth, and edema around the wound.
It is very much important to measure the length, width, and depth of the wound once in every 24 hours. It is important to assess for presence of odor, signs of excessive wound drainage, and number of gauzes saturated (Potter & Perry, 2013, p. 1204)
2. A head-to-toe skin assessment is done per institutional policy on a daily basis. At the most recent assessment of Mrs. Stein's skin, redness was noted over the sacral area; on direct examination, a small area of denuded tissue was noted. The area was assessed and was found to have minimal depth and a red, moist base. How would you describe the impairment in skin integrity in your charting?
Answer: In the charting, the impairment of skin integrity will be classified as Stage II (Partial thickness skin loss) under depth of injury. The risk factors would be friction and impaired mobility. A pain assessment for any pain on a scale of 0 to 10, and color and type of tissue in wound (red, moist tissue, granulation tissue) (Potter & Perry, 2013, p. 1179).
3. What will you include in your plan of care for Mrs. Stein to address the impairment in skin integrity in the sacral
area?
Answer: The interventions to include in the plan of care of Mrs. Stein would include:
. Assess her pain level at frequent intervals and offer pain medication before helping her move (Potter & Perry, 2013, p. 1194).
. Monitor and ensure adequate nutritional status and fluid intake (Potter & Perry, 2013, p. 1194).
. Use a moisture barrier ointment to decrease further tissue damage and decrease friction to the area (Potter & Perry, 2013, p. 1194).
. Keep the skin dry and clean and provide thorough perineal care (Potter & Perry, 2013, p. 1194).
4. Mrs. Stein will be discharged tomorrow. Which issues must be assessed regarding her care before discharge? Describe why these issues are of importance.
Answer: The issues that must be assessed before Mrs. Stein’s discharge includes:a. Assessing the patient's ability to transfer and reposition correctly and with minimal assistance because her independence determines if she is ready to return her home (Potter & Perry, 2013, p. 1196).b. Assessing the patient’s pain control because she should be able to control pain to increase her mobility and ambulation (Potter & Perry, 2013, p. 1185).c. Nutritional assessment: nutrition and fluid intake must be adequate to support healing of her incisional area (Potter & Perry, 2013, p. 1200).d. Provide patient and family teaching regarding the instructions needed for her caregivers in helping her ambulate and providing care for the surgical wound and evaluate caregivers for their ability to implement and comprehend and they need to be evaluated for their strength and endurance (Potter & Perry, 2013, p. 1196).
References:
Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2013). Fundamentals of nursing. St. Louis, MO: Mosby Elsevier.