Published Oct 4, 2009
myknucklehurts
14 Posts
I am a first year/first semester student working on my first case study and have reached the last part of the assignment. I won't go into all of the medications and details because I think I've already dealt with that portion of my assignment but this is a summary of the most relevant information about the patient that I am dealing with now:
-Admitted for COPD
-VS at 0600:
Temp 98.8
Pulse 102
Resp 32
BP 146/98
-Pulse Ox 89%
-VS at 12:00 noon
Temp 102
Pulse 98
BP 140/84
-He is now expectorating thick, yellow-colored sputum
My assignment is to prioritize the following nursing interventions:
A. Auscultate lung sounds
B. Administer antipyretic if ordered
C. Provide cooling measures
D. Check oxygen saturation level
E. Retake VS in 2 hours
F. Inform physician
This is what I believe the proper order is but I would appreciate any guidance.
#1-F #2-B #3-C #4-A #5-D #6-E
Thanks in advance for help.
JJRN09
72 Posts
When setting your priority remember your ABCs Airway, Brething, Circulation.
Daytonite, BSN, RN
1 Article; 14,604 Posts
I would agree with the order of your interventions since the patient had a spike in temperature. The only item I might disagree with would be the sequence of A and D.
I would probably check the oxygen saturation level before auscultating lung sounds. After auscutating lung sounds the saturation levels are going to change.
Thanks. I didn't know that ascultating the lungs would affect the oxygen saturation level.