Help with interventions!!

[carolina1985]

Here is a senario, what type of interventions would you do?

Cindy is a 60 year old who is a manager at a major company and underwent a left lung lobectomy 4 months ago for large-cell an aplastic carcinoma; up until one month ago, she had been feeling fine. At that time, Cindy began having right-sided headaches and increasing irritability, and during the past week, she has had difficulty concentrating and staying alert. Tody, during work she becomes so confused and drowsy that the nurse practitioner at teh conpany is called in. After a brief assessment, the nurse practitioner calls for an ambulance to transfer Cindy to a nearby Hospitial.

Assessment:

The admission assessment at the medical center reveals that Cindy is emaciated and lethargic, opens his eyes spontaneously, moves all extremitites on commonad (right side is stronger than left), and is oriented to person only. Both pupils are 3mm in diameter and demonstrate both direct and consensual reflex reactions to light. Testing of cranial nerves, III, IV and V reveals normal findings, except for decreased corneal reflex in left eye; testing of cranial nerves IX and X reveals a depressed gag reflex. Motor reflexes are normal on the right side; the left reflexs are hyperactive and who a positive Babinski reflex. CT scan of the skull demonstrates a large bifrontal mass with surrounding edema.

Initial Orders:

Admit to ICU

O2 at 40% via mask

Foley Catheter

Mannitol 25% 150 GM IV over 30 minutes

MEdrol IVP

NS @ 50ml/hr

Set up for epidural insertion at bedside for ICP monitoring. Prepared for possible frontal craniotomy for partial tumor removal this evening

You are the team of ICU nurses asssigned to care for this client for the next 8 hours.

[itsmejuli]

What do you have so far?

[dietsprite]

Based on the information you have given, I typically begin by developing some nursing diagnoses (actual, risk) and in this case collaborative problems first. Then, I take out my nursing care plan book and look up specific interventions. If you have taken pharmacology, you should use the knowledge learned to apply that to have some of your interventions be to look for potential adverse reactions, etc.

In this particular case, you definately also need to have interventions related to intake and output, electrolyte monitoring, etc. Rationale: catheter + diuretic.

She is on oxygen, monitoring of oxygenation levels, signs of proper tissue perfusion, checking for cyanosis in the oral mucosa, etc. Listening to her breathing, quality, rhythm, etc.

But as Juli said, what have you thought of yourself?