Situation question help...

[studentnurserachel]

I have to give a really complete set of nursing actions and rationale for the following open-ended situation question, and I would appreciate input for additional ideas people might have, here goes:

MD ordered IV D5W at 20cc/hr for pt with hx of CHF. When you enter pt room on morning rounds, you see IV bag is NS at 100cc/hr with only 100 cc left in the bag. In speaking with the patient, you notice that she appears anxious as she tells you in short phrases that she had a fairly good morning. What nursing actions would you take based on above information and why?

What I've got so far:

Stop IV pump

Raise head of bed

auscultate lungs

call physician and report situation and assessment findings

anticipate order for diuretics, foley

[Daytonite, BSN, RN]

This patient may be going into pulmonary edema.

Get that IV turned down to 20cc per hour first and get the bag of D5W up ASAP, but maintain the IV access, because you are going to need it. 20cc an hour is a KVO rate.

Get the patient into a comfortable position with the head of the bed up.

You should also be checking the patients blood pressure--now, checking for productive cough and noting the color of the nail beds. Note the pulse rate and listen for heart tones. Ausculate the lungs.

After assessing lungs and heart, then, call the doctor.

Anticipate that diuretics, oxygen, ABGs and labwork are going to be ordered.

[liljsmom02]

i agree with daytonite but also check your pt's output for the last 8 hours.

[studentnurserachel]

Thanks! Great suggestions!