need help prioritizing interventions

Nursing Students Student Assist

Published

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

Resp 32

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.

Specializes in Postpartum/Nursery about to enter NICU I.

When setting your priority remember your ABCs Airway, Brething, Circulation.

Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

F. Inform physician

B. Administer antipyretic if ordered

C. Provide cooling measures

D. Check oxygen saturation level

A. Auscultate lung sounds

E. Retake VS in 2 hours

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.

+ Add a Comment