Nursing care priorities

[zipperhead105]

Mr Kelly is a 36 year old man, he has returned from theatre following laparoscopic appendectomy (removal of appendix using keyhole surgery).

2) Prior to theatre Mr Kelly's observations were Temperature 36.6◦c, pulse 62, respiratory rate 18, blood pressure 125/78 mmhg, oxygen saturations 98%.

Mr Kelly's observations are now a pulse rate of 92 bpm, B/P 95/58, temperature 36.5, respiratory rate 10, oxygen saturations 93% and he is complaining of pain.

With reference to the change in the patients observations identify the patient care priorities over the next 2 hours, describe how the observations have changed from baseline and what it may mean. (250 words)

Using the nursing process outline how you will care for this patient over the next two hours. (500-700 words)

this is an assignment question i got, and im having some trouble with it ! can anyone give me some pointers on the nursing process im kind of stuck i know ihave to monitor vital signs but basically after that i dont no what to write ! adn also a reason why the patients respiratory rate went down ? i cant find anything !! really appreciate if some one could help me !

[Flo., BSN, RN]

think about what his body went through during surgery and what medications he was given.

[systoly]

[GHGoonette, BSN, RN]

Quite so.

However, I will nibble; not bite, just nibble.

OP, what do you think is the possible primary reason for an elevated pulse and concomitant fall in BP? How often are you checking the wound site, and are you checking for abdominal distention? If there is a lot of red stuff on the dressing and/or the abdomen appears swollen, what do you think it could be?

Pain can produce similar symptoms. What have you done to address poor Mr. Kelly's pain? Is he breathing shallowly? If so, why do you think that would be?

Go on now, we've given you enough clues....

[classicdame, MSN, EdD]

decreased resp probably due to decreased BP. Can't pump the lungs. Now, why would his BP drop?

[Been there,done that, ASN, RN]

I apologize for the obtuse answers you have received so far. Some peeps forget that you are in a LEARNING mode. Basically, any drop in B/p, and increase in heart rate would indicate loss of blood or fluid volume.

The pressure drop is obvious, the heart rate increases in order to circulate the remaining volume ,a compensatory mechanism.

Pain can always be an indication of problems with bleeding.

The decreased respiratory rate, does not fit into the scenario because volume loss, and pain will usually increase repirations..

You would need to review the medications given peri-operatively and check for meds that would cause respiratory suppression.

Your nursing actions would depend on your standing orders.. FIRST notify the surgeon of the change in baseline vitals and your assessment of the operative site, dont forget urine output, very indicative of fluid volume.

1) Comfort your patient :including emotional support and position of comfort, you would of course need to keep them on strict bed rest and NPO in case they will return to surgery.

2) You would be expecting to administer oxygen and administer IV fluid boluses

Best of luck, you will put it all together someday, I promise.

[Belle Epoque]

Well now that you've done the assignment for the student, you might as well collect the mark.

[hiddencatRN, BSN, RN]

I apologize for the obtuse answers you have received so far. Some peeps forget that you are in a LEARNING mode.

No...I think people are remembering that the OP is in a DOING HOMEWORK mode. People are giving "obtuse" answers to encourage the student to think it through and thus LEARN.

[Been there,done that, ASN, RN]

man, if there ever was an answer to "do nurses eat ther young" ... here it is!She needed guidance, those crazy nursing process papers made it very difficult to find what the instructor wanted.. I gave her some IDEAS.

They obviously eat the old .. too!

[hiddencatRN, BSN, RN]

man, if there ever was an answer to "do nurses eat ther young" ... here it is!She needed guidance, those crazy nursing process papers made it very difficult to find what the instructor wanted.. I gave her some IDEAS.

They obviously eat the old .. too!

I think you are maybe not clear on where the wide boundary between guidance and "giving someone the answer" lies. We're not withholding the answer to be mean, we're not giving it to her because it doesn't benefit her in the long run to have answers handed to her.

[MunoRN, RN]

Easy now, first of all there is no real "answer" to this question, just things to think about and other questions to ask, this is homework, not a test. The OP was completely appropriate in saying 'here is what I came up with but now I am stuck, how would others approach this question?'

If the question had more information, then it might be possible to have a single answer, but it doesn't address: What is the patient's true baseline BP (a BP in pre-op holding is not a true BP and is most likely elevated above baseline, 95/58 may be his normal BP). What are his labs? Assessment info? ABG's? What meds has he been given and how much? What PRN's are available? Fluid balance? LOC? Pt Hx?, etc. I applaud the OP for knowing her resources and using them.

The only potential for learning this question provides is in a discussion with others, preferably those with experience, about what to consider and assess, that's not "giving away the answer", it's mentoring.

[beauty_132]

been ther done that and muno RN, you are the kind of nurses i would like to shadow. i am in a two year RN program and goin into my second year. the one thing students hate and you should all know this is a instructor or a primary that is not willing to help you find the answers. it almost like do or die. but this is the time for us to learn and to have guidance. and the best way to do that is from you guys because personally the books dont really due much except for give you a general knowledge. we learn how to think like nurses from our fellow peers and expiernce in the end and any sort of guidance is welcome. not the brain teasers because there is really not one answer.

I had a pt just like this, and after assessing labs and checking meds it turned out that the pt had a low pain tolerance and was hitting the PCA like there was no tommorrow. we took the pca pump away for awhile had doc order a nonn opiod analgesic elevated the head of the bed and his vitals stabilized after 30 mins.

There is simple answers some times and haveing guidance is what gets you to the point of being able to decide what could be happening..... everyone here were students once you know how hard it is so take an easy on us when we ask for guidance......:)