It is your first day of clinical placement as a nursing student, on the accident and emergency ward. An elderly male Mrs. X has just been admitted he is unconscious, not bleeding and shows no obvious physical damage such as broken limb.A series of routine measurements and clinical tests are done later in the day clinical nurse consultant takes the time to show you the results:
Height= 178.5 cm, weight= 109 kg, temp= 39.7, blood glucose 5mmol/L, BP=120/90, Cardiac output= 4.8L/min, RBC= 1,000,000mm3

Question:
a.which of the readings if any show cause alarm?
b. what cues do they provide about Mrs.X condition..

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Joined: Jun '09; Posts: 5

3. you are being asked to recognize abnormal findings from assessment data. this is the first step in learning to determine problems (nursing diagnoses) that patient's have. i used measurement conversion charts (because i am not accustomed to dealing with kilograms and centigrade temperature):
a lab reference to look up normal values but you can use these websites:
and this website to verify normal cardiac output: http://en.wikipedia.org/wiki/cardiac_output

the data from the scenario is (highlighed data is abnormal):
• unconscious
• weight= 109 kg (239.8 lbs)
• temp= 39.7 (103.46 f)
• blood glucose 5mmol/l
• bp=120/90
• cardiac output= 4.8l/min
• rbc= 1,000,000mm3
question:
a.which of the readings if any show cause alarm?
now, that i have highlighted 4 of the items from the scenario that were abnormal, which do you think are cause for alarm?
b. what cues do they provide about mrs.x condition.
a cue is a sign or symptom. you are being asked to diagnose the patient. i am not sure that you are to provide a medical diagnosis or a nursing diagnosis. because you are told these are cues i would assume you are being asked to provide nursing diagnoses since physicians don't use that term.
4. Thanks a lot daytonite.im sorry about the questions that i type i meant clues intead of cues.The question was what clues do they provide about Mr. D condition?thanks alot
5. Quote from daytonite
you are being asked to recognize abnormal findings from assessment data. this is the first step in learning to determine problems (nursing diagnoses) that patient's have. i used measurement conversion charts (because i am not accustomed to dealing with kilograms and centigrade temperature):
a lab reference to look up normal values but you can use these websites:
and this website to verify normal cardiac output: http://en.wikipedia.org/wiki/cardiac_output

the data from the scenario is (highlighed data is abnormal):
• unconscious
• weight= 109 kg (239.8 lbs)
• temp= 39.7 (103.46 f)
• blood glucose 5mmol/l
• bp=120/90
• cardiac output= 4.8l/min
• rbc= 1,000,000mm3
question:
a.which of the readings if any show cause alarm?
now, that i have highlighted 4 of the items from the scenario that were abnormal, which do you think are cause for alarm?
b. what cues do they provide about mrs.x condition.
a cue is a sign or symptom. you are being asked to diagnose the patient. i am not sure that you are to provide a medical diagnosis or a nursing diagnosis. because you are told these are cues i would assume you are being asked to provide nursing diagnoses since physicians don't use that term.
thanks a lot daytonite.im sorry about the questions that i type i meant clues intead of cues.the question was what clues do they provide about mr. d condition?thanks alot
6. I tried to answer letter B but im not sure if im doing it right.since i find the temperature abnormal i think it may be caused by a damage to the hypothalamus. While low RBC may be a signs and symptoms of hemorrhage, internal bleeding and a low 02 status.but imnot sure if im really answering the question on letter B.
7. Clue or cue--same thing.

I think you are correct. Low RBCs are a sign of internal hemorrhage. The unconsciousness and elevated temperature indicate the bleeding is probably in the brain. The reason this is all a cause for alarm is because bleeding into the brain has nowhere to go and causes pressure buildup in the cranial cavity which, if not treated quickly, will result in brain damage and death.

I don't know where you are getting a low O2 from since it was not mentioned in the scenario. Don't insert facts into the situation that are not given to you.
8. Thanks a lot again i really appreciate taking your time on our questions..im really not sure about the o2,i was only thinking maybe because of their relationship in delivering 02 into the body tissues.thanks again...
9. hi daytonite, i was wondering if u could be so kind as to help me with an assignment i have been presented with any feedback would be wonderful i basically need to explain what nursing interventions this woman needs and what could have possible caused her condition??? thank you in advance for any help

catherine wilkes a 22 year old unemployed single mother was admitted 2 days ago through emergency department for collapse for investigation. on arrival at triage it was noted that catherine had her two-year old child at her side and both appeared unkempt. catherine’s observations were taken at triage and her blood pressure was report as 75 mmhg / not detectable. her speech was incomprehensible, but all limbs were equal in power and pupils were equal and reacting to light. she was promptly transferred to the cubicle area.

whilst in emergency department she underwent a physical examination and blood work up. her speech at this time had improved but was slurred. she was reluctant to discuss her family history.

health status: non smoker
moderate alcohol intake
ulcerative colitis for 6 years
ileoanal anastomosis 14 months ago

observations: temperature 360c
bp now 90/60
respirations 22 breaths per minute
pulse 130 beats per minute
o2 saturation 100% on room air

physical assessment: weight 45kg
height 160 cm
bruises to lower limbs
chest clear
abdomen soft, non tender

blood results:

bgl 7.2 mmol sodium 124 mmol/l
hb 116 g/l potassium 5.2 mmol/l
hct 0.38l/l chloride 89 mmol/l
rcc 4.8 x 1012/l bicarbonate 23 mmol/l
mcv 78 fl anion gap 17
wcc 16 x 109/l urea 10.3 mmoml/l
esr 34 mm/hr creatinine 0.12 mmol/l
crp 31 mg/l

catherine reported to the medical officer that she had felt nauseous and dizzy all day and that she had not voided the entire day.

while catherine was getting into a hospital gown her medications fell out of her pocket. the nurse asked her if she was taking the medications but catherine did not reply. the nurse took the medications to the medical office and they both noted that the medications were:

prednisolone 25mg bd orally
medazine 1 gram bd orally

part two

further blood tests revealed:

prolactin 1211mu/l
cortisol 1066 nmol/l
protein 86 g/l
albumin 31.6 g/l
ggt 113 u/l
alt 36 u/l

it was noted by the nurse that catherine was previously on mesalazine 250 mg orally tds for ulcerative colitis. she discussed this with the medical officer who withdrew the order for medazine 1 gram and recommenced her on her previous dose of mesalazine

the medical officer reported that catherine to undertake a short synacthen test (sst).
10. Quote from lovelylia
hi daytonite, i was wondering if u could be so kind as to help me with an assignment i have been presented with any feedback would be wonderful i basically need to explain what nursing interventions this woman needs and what could have possible caused her condition??? thank you in advance for any help

catherine wilkes a 22 year old unemployed single mother was admitted 2 days ago through emergency department for collapse for investigation. on arrival at triage it was noted that catherine had her two-year old child at her side and both appeared unkempt. catherine's observations were taken at triage and her blood pressure was report as 75 mmhg / not detectable. her speech was incomprehensible, but all limbs were equal in power and pupils were equal and reacting to light. she was promptly transferred to the cubicle area.

whilst in emergency department she underwent a physical examination and blood work up. her speech at this time had improved but was slurred. she was reluctant to discuss her family history.

health status: non smoker
moderate alcohol intake
ulcerative colitis for 6 years
ileoanal anastomosis 14 months ago

observations: temperature 360c
bp now 90/60
respirations 22 breaths per minute
pulse 130 beats per minute
o2 saturation 100% on room air

physical assessment: weight 45kg
height 160 cm
bruises to lower limbs
chest clear
abdomen soft, non tender

blood results:

bgl 7.2 mmol sodium 124 mmol/l
hb 116 g/l potassium 5.2 mmol/l
hct 0.38l/l chloride 89 mmol/l
rcc 4.8 x 1012/l bicarbonate 23 mmol/l
mcv 78 fl anion gap 17
wcc 16 x 109/l urea 10.3 mmoml/l
esr 34 mm/hr creatinine 0.12 mmol/l
crp 31 mg/l

catherine reported to the medical officer that she had felt nauseous and dizzy all day and that she had not voided the entire day.

while catherine was getting into a hospital gown her medications fell out of her pocket. the nurse asked her if she was taking the medications but catherine did not reply. the nurse took the medications to the medical office and they both noted that the medications were:

prednisolone 25mg bd orally
medazine 1 gram bd orally

part two

further blood tests revealed:

prolactin 1211mu/l
cortisol 1066 nmol/l
protein 86 g/l
albumin 31.6 g/l
ggt 113 u/l
alt 36 u/l

it was noted by the nurse that catherine was previously on mesalazine 250 mg orally tds for ulcerative colitis. she discussed this with the medical officer who withdrew the order for medazine 1 gram and recommenced her on her previous dose of mesalazine

the medical officer reported that catherine to undertake a short synacthen test (sst).
before you can do any interventions you have to look at all the data and determine what nursing problems you have going on. the case study is really nicely organized. what you need to do is make a list of all that data and look at it. doctors, as well as us nurses, will address (interventions) signs and symptoms that are abnormal. the most important in terms of priority have to do with those that affect the most important body systems first (see maslow's hierarchy of needs: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). to determine cause of her condition you have to look at all the symptoms and play doctor. what disease or condition do the symptoms seem to point to?

i would like you to attempt to work on this so i can see what you do know about the nursing process rather than me do all your work for you.

see http://allnurses.com/general-nursing...ns-286986.html - help with care plans for how to apply the steps of the nursing process in doing this assignment.