Answer Happy

2-6 THE PATIENT WITH TOTAL PARENTERAL NUTRITION 0800 Handoff Report 2 Priority Setting and Decision Sin the handoff report you learn that your patient, Mrs. FJM. is improving. She had only 1 watery stool during the night shife. The 0600 vital signs are: T 98.8-7. P 76, R15, BP 140/94. pulse ex 95%. At 0600, she complained of pain in her right lower leg at a pain level of 3. the patient said it feels like an achy doll feeling that was present when she awoke. No edema noted. pedal pulse is present. Blood glucose was done The following patient care plan information is available VS every 4 hours R) subclavian central line inserted M16 Dict: NPO 1&OW Weich every AM Parenteral nutrition (PN) per IV pump @ Routine med: 83 mL/hr BRP with assist pm Vit. K 10 mg subcut every Mon Lipids 10% (M-W-F) infuse over 12 hours Regular insulin 2 units BG fingersties every urs (6-12-6-12) if BG - 180-200 mg/dL. Admit date: 3/16 De Dehydration/Diarrhea Name: FJM Age: 55 Hx of Crohn's disease with acute cacerbation, Call MD if BG more than 200 mg/dl. atrial fibrillation, smoker, 1 pack per week Prioritize the following five recommended nursing interventions as you would do them to take care of Mrs. FJM. Write a number in the box to identify the order of your interventions (el - first intervention, +2 = second intervention, etc.), and state a rationale for each intervention INTERVENTIONS PRIORITY # RATIONALE • Perform a body systems physical assessment • Assess right leg • Assess central line for parency and central line dressing • Ger 0600 blood glucose results • Assess right arm and neck for distention KEY POINTS TO CONSIDER All rights reserved.
128 SECTION TO Priority Setting and Decision Making Mr. FJM was taken to xray 1 hour apa. On her return to the unit, the IV pump is beping and you are informed that the machine has been beeping for a long time. You are the following 1. PN not Infusing 2. Skin warm, diaphoretic. complains of nerves and mapid heartbeat 3. VST 986 PUIS R 26, BP 136/90, pulse ox 96%, right lower les pain level 4. dull achy pain o nursing diagnosis that is a priority at this time. (2) provide a rationale for your selection, and 3) lische interventions that assist you to meet the needs of the patient. All of the following nursing diagnoses may apply to Mrs. FJM: Anxiety Risk for infection. Risk for decreased activity tolerance. Risk for imbalanced fluid volume, Impaired the integrity, Ineffective peripheral tiste perfusion Imbalanced nutrition: less than body requiremen. Risk for unstable blood glucose level, Deficient knowledge 2 NURSING INTERVENTIONS RATIONALE NURSING DIAGNOSIS Three hours later, Mrs. FjM's family comes to the nursing station to say that Mrs. FJM is having difficulty breathing You go into Mrs. FJM's room and assess the following complaints of chest pain, R 36, P 134, BP 108/88, polse ox 90%, coughing, dyspnea, anxiousness On the basis of the situation 3 hours later, identify and write the priority problem in the box below. Then, starting with the small box labeled 1, prioritize the nursing interventions for this situation and identify you follow-up action plan for Mrs. FJM. DECISION-MAKING DIAGRAM NURSING INTERVENTIONS A. Say with Mrs. FJM B. Raise head of bed New Action Plan #2 4 #6 C. Take P. R. BP, assess pain level D. Monitor oxygen sinuration level E Notify MD @ @ @ @ @ Administer oxygen NOTES Priority Problem