Answer Happy

Post op day 5 Mary had a fall today with a head strike while in the shower. She is responsive. What is your plan of action? (Be specific-think practical) What observations will you be doing and why? On the third lot of vital signs, you do you find the following: Mary is talking a lot, telling you she is missing her mom, and that she wants to take her out to do some wine tasting. She is speaking very fast, and you find it difficult to understand what Mary is saying. She is not keeping her arm still for you to do the blood pressure. Her pulse is faster than before, and her pupils are responding slower than the previous observation. You also note that there is a fair amount of brownish blood seeping through the bandage on her knee, it smells foul. What is your plan of action and what is happening to her wound? Vital signs: BP 90/50, Pulse 102BPM, Respiration 28, O2Sats 92%, Temp 38.5°C, BGL 3mmol. Pupil size 2- sluggish. What does this tell you?