okay, here is the scenario. if anyone can help me with this i would greatly appreciate it or if they could tell me where to look it up, that would help also.
mr jones is a 70 yr old male who underwent colon resection at 8:45am. mr. jones had an extensive colon prep which involved golytly prep and enemas. he has remained npo since midnight last night and does well with his surgery.
post surgery he arrives in the recovery room at 11am, he has a
foley with 90cc clear yellow urine, an ng tube with 150cc of bloody drainage, an iv of lr@125cc per hour. he is drowsy, but
talking.estimated blood loss is 400cc.vs are:bp120/70,heart rate 78, resp18,temp98.2.
one hour after arriving to the floor he is anxious and agitated.
he complains of being cold, his skin is cool with a sluggish capillary refill time of 4 seconds.ng tube now has 200 cc's out since surgery, foley has 110 cc of amber colored urine. vs are:bp 90/55,hr96,thready and weak,resp24,temp99.0.
two hours after returining to the floor, he is confused, he hasn't required any pain meds, his skin is pale, cold and clammy,ng tube with 250cc's of output.vs are:bp74/60, foley has 110cc's, hr132,temmp99.4,resp16.
1.what is most likely wrong with mr. jones?
>2.what is the nurse's immediate response to this situation?
>3.list everything you would do for him, and give a rational why.