ok, the answers to your questions lie below.
you find the keep open iv empty after getting an iv count of 900 cc at shift report.
first, assess your patient. (your instinct is to run for help.) all physicians want accurate vs that are recent. pts are to be assessed for fluid overload, adequate urine output. assess the iv site for patency and put up a new bag of fluid infusing at the proper rate. (remember the 5 rights.) report to the charge nurse and quickly provide vs, assessment findings and intervention. if you notify the physician, he will most likely say to continue to monitor the patient.
pt has vaso vagal episode and faints, which sometimes happens during evaluation of postural hypotension
this is a preventive strategy. if the pt is in bed, assess your pt in lying position. have the pt sit forward for lung auscultation and initial bp, pulse. if that is wnl for that person, let them dangle at the bedside to allow their bodies to gradually acclimate to the change. most of these patients are hypovolemic, anemic or having a response to medication. dangling is not really sitting. it is like pre-sitting. re check bp, pulse, respirations. sitting is when they are stable on the side of the bed, and more likely to hit the dirt. if they have an ambulatory aide, such as a walker, get it and let the pt use it. but not before checking their bp again. when they are no longer dizzy, assist them to standing. if the pt becomes dizzy at any point, safety is first. this is where the art of nursing comes in. once the patient is back in bed and safe, call another nurse using the call light. or, if the person recovers quickly, offer clear liquids per unit procedure and evaluate meds that are ordered for that pt. based on your assessment and information from the physician and charge nurse, you can plan your care for the patient, which includes checking out meds for effects, side effects that might make your patient worse. review all antihypertensive, diuretic and cardiotonic drugs, previous vs, intake and output before notifying the physician. expect medication changes. if the pt has low bp you might ask if the physician would like to hold any meds; clarify this order by reading it back to him/her verbatim. no excuses. you know how to do the rest.
note to self: don’t forget that diabetics' blood glucose levels can fluctuate wildly when they are ill. adjust your plan of care accordingly.
pt falls when getting out of bed
pt has pulled out his iv, twice
pt falls down in bathroom
all of the above heart stopping events are really the same thing. bad. again, take a deep breath and focus on the patient. do not flee the scene. you are the best bet right now. evaluate for injuries. apply pressure to any bleeding. check the foley, if applicable. pull the emergency cord and stay with the patient. do not move her/him until help arrives. check the pt's pulse, respirations and bp if possible. (check your own pulse.) turn the head to avoid aspiration, if applicable. pray. for kindness, for wisdom, for the patient. then help will come and another nurse can help you make the next decision. write down all the vs that you took so that your charting will accurately reflect the event. that is why nurses wear such big watches. check the time. usually this sequence of events will result in a visit by a physician. expect to do vs every 15 minutes and receive new orders, including, but not limited to transfer to a higher level of care, draw blood, check blood sugar. make sure they aren’t septic. so if they have a catheter, iv site, surgical incision, any disruption of their integumentary system, assess it immediately for signs of infection.
i get tired, just writing about it, but it is so nice of you to ask me for follow up. please remember that these are skills honed over several decades and two separate centuries. we all have our own style, and this is how mine has turned out.
thank you for asking me to expound.