Published Feb 19, 2015
imanursenow
45 Posts
I'm taking my first online class and there really hasn't been any direction so I'm a little frustrated. We are given these case studies and I'm having a hard time picking out the correct nursing diagnosis. Any help would be GREATLY appreciated!!
#1 I'm deciding between Hyperthermia or Tissue Integrity, Impaired can you tell me if I'm on the right track??
A 26-year-old young man was admitted per ambulance to the emergency room with a stab wound and underwent emergency surgery. He has a closed abdominal wound and the dressing was clean and dry when he is transferred to the nursing unit. Additional assessment data include: multiple abrasions to the face, hands, and arms, ecchymosis to his left eye, plus multiple minor wounds from stabbing attempts. His temperature is 100.5°F. Skin warm and dry; Foley output 520 ml for last 2 hours.
babbar
11 Posts
there is a electrolyte imbalance. Fluid was lost during surgery. Skin is warm, dry and has temp. hypovolemia and osmosis is a diffusion of water. ecchymosis cause by blood escaped into tissue from ruptured blood vessels. what is the blood pressure and heart rate.
Thank you so much for your help, that one paragraph is all the info that is given in this case study.
NurseKellyKMo
41 Posts
That's a lot of output in 2 hours for a febrile patient. Where exactly is the stab wound? What does the Foley output look like
lmccrn62, MSN, RN
384 Posts
He has ecchymosis to his eye? Does he have a head injury? Should you suspect that? What color is the urine? Is it dilute?