What Do You Do....

TxPonyChic · Jan 26, 2008

1. your patient is complaining of shortness of breath or feeling faint.

what do you do? what is your priority?

airway-listen to lungs, head to toe assess for possibilities (bleeding, overdose, diabetic?)

2. your patient's blood pressure is low, ex. 91/45.

what is the first thing you do? do you go ahead and hang a bolus of ns automatically?

take it manually-still low-tilt, o2, auscultate-still low-rapid response- call dr.

3. your patient's respirations are labored.

what do you do?

depends of medical history/diagnosis-if unknown-o2, postion for maximal lung expansion-assess reasons for labored breathing (asthma, chf, chemical inhalation, etc..)

4. your patient's respirations are low. example 9/minute.

what do you do?

airway, neuro check, vital signs/ od-narcan

5. your patient is complaining of pain...say 9/10. however, they appear to be in no pain. vitals normal, body language gives no clue to pain. do you give the 1 tab of vicodin or the 2 tabs? do you choose the morphine instead? or what about 650 of tylenol?

what do you do?

start with the smallest least potent medication and dose, pain is subjective, titrate up as needed so long as vs are stable

6. the patient grimaces when you flush the iv. what is your first action?

stop, assess iv site for hardness, edema, erythema

7. your patient is coding. you're in the room doing cpr, bagging them (until respiratory shows), starting an iv, etc. all of a sudden there are 20+ people in the room, you've given report to the physician in the room. you feel like the situation is under control as everyone has roles but you.

what do you do?

step back and let them do their job, once reported off unless asked to do something else u have done your job

8. patient wants water/fresh linen/ lotion. all of this will take you about 5 minutes to do yourself. do you do it yourself or do you tell the patient you'll send for help?

what do you do?

is it a priority? do i have more critical patients to tend to? may be time to delegate, if not busy of course i do it

9. your patient is wandering, non-redirectable. you have 7 other patients as well and cannot sit with this patient around the clock. what is your first action?

vss, no threat to self or others, have na sit with patient until i can get back to them

10. your patient has a complaint that...well...can't be resolved. she has stubbed her toe on the bedside table, she has an itch that wont stop itching, she is concerned about a hangnail and she never gets hangnails. after assessing the stubbed toe and seeing there is no break in skin integrity, after assessing the itch and seeing there's no rash only redness from itching, and after "looking" at the hangnail in question...what do you do?

trim the hangnail for crying out loud!

twarlik · Jan 26, 2008

Good answers, TxPonyChic.

I would add that for the 2nd question (low BP), I would first look at the patient and see how they're doing. Are they walking around and doing fine, or are they feeling faint? How does this blood pressure look when compared with their previous pressures? People walk around with pressures in the 90's, so I don't think it would be necessary to call a RRT for that. I frequently see patients with BP's in the 70's and 80's after dialysis who are doing fine, so it's always important to evaluate the information you have while looking at the whole picture. A BP doesn't tell you anything without looking at the patient first.

Valerie Salva, BSN, RN · Jan 26, 2008

For the pt feeling faint, if they are up, the first thing I would do is stay with them, hollar for someone to bring a w/c, pop them in it, put them to bed, head elevated, but elevate the legs a little, start 02 @ 2 lpm, have them take some slow, deep breaths.