Mrs. A. D., the 50-year-old school nurse who went to primary healthcare center, complaining of feeling dizzy and nauseated. The nurse immediately noted that she looks to be having some difficulty catching her breath during coughing. A new graduate nurse takes Mrs. A.D admitting vital signs as:pulse 122, RR 14, BP 88/50 mmHg, tympanic temperature 39 degrees Celsius, SpO2 92%. As the nurse enters Mrs. A.D.'s room she noticed that Mrs. A.D. turned on her right side, and her eyes are closed. Mrs. A. D’s respirations appear labored and forceful. While the nurse is inside the patient’s room the electronic BP machine alarm is sounding. The nurse noticed that the electronic machine is flashing "72 systolic" with no diastolic reading. Mrs. A.D.
Answer the following questions:
1. List in order of priority your first three nursing interventions.
2. Which vital signs should you reassess and which methods should you use? (5 points)
3. Which hourly vital signs should you delegate to a UAP?
I thought that my first intervention is to change her position and put ventilator
then reducing her fever
and I will reassess her BP because it may have false reading
and I will let the UAP to check her temp and pulse and spo2
is my solve to this case study logical or not?