I am having a tough time figuring out who to assess first in this assignment and am wondering if one of you kind sols wouldn't mind helping me figure this out. Honestly, I don't know how you manage the pressure when so many are in need of your help. It's truly amazing. I've changed the order so many times already and have to figure this out ASAP. Any help is greatly appreciated!! Even if it's just the order. I'm feeling quite lost. Please Forgive me, I know this is long...
You have been assigned the following patients for the night.
Ms. Smith: Hospital day 1 (HD1): 16 year old woman admitted last night for PIH at 32 weeks gestation to stabilize BP. Is on q8 hr IV Labetalol doing a 24 hour creating urine collection. Last BP 200/101. Her BP on admission was 230/110.
Ms. Ortiz: Day of surgery (DOS): 50 year old woman 2 hours post-op abdominal hysterectomy for menorrhagia and fibroids on a morphine Patient Controlled Analgesia (PCA), pulse oximeter, and 2L non-humidified oxygen via nasal canula.
Ms. Linden: HD 2, 32 year old woman who is not pregnant. Hospitalized on IV antibiotics for PID. Last temp 2 hours ago was 38.7C.
Ms. Douglas: HD4, 30 year old woman hospitalized with preterm premature rupture of membranes (PPROM) at 28 weeks. Last temp 2 hours ago was 36.7C.
1)Which patient would you assess first, second, third, and fourth? What was your rationale for this order?
2)List the 5 priority assessments you would make for each patient when in the patient's room. These assessments should reflect knowledge of the underlying problem.
This is what I'm thinking, but it's a tough call -both ms smith & ms ortiz/ms douglas seem to be most unstable. I don't know anymore...
#1 Ms Smith- Pregnancy Induced Hypertension, Severe preelampsia?( if proteinuria >/= 2 g), at risk for seizures, CVA, DIC, renal failure, hepatic rupture.
If no proteinuria, she's still at risk for HELLP syndrome; risk for hemorrhage, pulmonary edema, hepatic rupture.
High risk pt! Frequent assessment q 15 min for headache, blurred vision, R epigastric pain, blood pressres, may need to deliver--> fetal distress
PRIORITY DX: Risk for injury, Deficient fluid Volume?, Anxiety
Top complications= Seizures, HELLP syndrome ???
#3 Ms Douglas- PRROM
Risk for infection r/t loss of protective barrier. Highly susceptible to infection!
Monitor for signs of Chorioamnionitis.
Mother- Risk for injury
28wk fetus- risk for injury: prolapsed cord
May need to induce labor
#4 Ms Linden
#2 Ms Ortiz?
Only 2h post op.
Mjr complication:
Ahhh! I'm not sure. I've changed the order so many times. This is not a good sign for me. Please help.
* 50 yr old woman, 4 hours post-op abdominal hysterectomy for menorrhagia and fibroids. She has orders to ambulate in 2 hours (6h post-op)
* You enter her room & find her sleeping. When you wake her, she lifts her head off the bed, looks at you, mumbles about her pain and falls right back to sleep.
* Her PCA is set at 1mg Morphine q 6 minutes on demand.
* She has made 10 demands for morphine in the last 12 minutes.
* O2 sat 96% on 2L non-humidified oxygen by NC.
* Respiratory rate = 14
* Complains of severe dry mouth
* Lips cracked and dry, family member wetting them with wash cloth.
* She has on bilateral sequential compression devices (SCDs).
Based on this info, what is the priority nursing diagnosis?
Priority nursing interventions?
What do you do about the order to ambulate?
I'm thinking...
PCA 1mg Morphine q 6min on demand (Morphine - risk for respiratory depression)
(don't know what other meds she's on) Dosing is at standard level.
o Recent spike in pain--- what is the cause????
Increase dose?
RR= 14 norm= 12-20
O2Sat = 96% on 2L by NC (low end, not good)
SCD's to prevent dvt
Sleeping/Mumblingà Sedation/Decreased level of consciousness? Many possible causes.
No other information given!!
Need to assess her from head to toe. Priority= Pain assessment, inscision site, vitals, nuero,
POSSIBLE DX
Acute pain r/t incision site
Risk for Insufficient Fluid Volume and Imbalanced Electrolytes
Dry cracked lips, severe dry mouth,
Risk for Hemorrhage r/t ineffective vascular closure or alterations in coagulation
-need to check for bleeding
Risk for Infection
Risk for thromboembolism r/t immobility, vascular manipulation, surgery ??
sblivefree
16 Posts
This assignment is really kickin my butt!
Scenario:Mrs. O
* 50 yr old woman, 4 hours post-op abdominal hysterectomy for menorrhagia and fibroids. She has orders to ambulate in 2 hours (6h post-op)
* You enter her room & find her sleeping. When you wake her, she lifts her head off the bed, looks at you, mumbles about her pain and falls right back to sleep.
* Her PCA is set at 1mg Morphine q 6 minutes on demand.
* She has made 10 demands for morphine in the last 12 minutes.
* O2 sat 96% on 2L non-humidified oxygen by NC.
* Respiratory rate = 14
* Complains of severe dry mouth
* Lips cracked and dry, family member wetting them with wash cloth.
* She has on bilateral sequential compression devices (SCDs).
Based on this info, what is the priority nursing diagnosis?
Priority nursing interventions?
What do you do about the order to ambulate?
I'm thinking...
PCA 1mg Morphine q 6min on demand (Morphine - risk for respiratory depression)
(don't know what other meds she's on) Dosing is at standard level.
o Recent spike in pain--- what is the cause????
Increase dose?
RR= 14 norm= 12-20
O2Sat = 96% on 2L by NC (low end, not good)
SCD's to prevent dvt
Sleeping/Mumblingà Sedation/Decreased level of consciousness? Many possible causes.
No other information given!!
Need to assess her from head to toe. Priority= Pain assessment, inscision site, vitals, nuero,
POSSIBLE DX
Acute pain r/t incision site
Risk for Insufficient Fluid Volume and Imbalanced Electrolytes
Dry cracked lips, severe dry mouth,
Risk for Hemorrhage r/t ineffective vascular closure or alterations in coagulation
-need to check for bleeding
Risk for Infection
Risk for thromboembolism r/t immobility, vascular manipulation, surgery ??
Any advice??