Question

N125 Case Study Three Scenario: A 78 year old female patient is transferred from the emergency department to the medical surgical unit. The nurse prepares to complete the initial assessment and notes the following: Blood pressure of 88/48 mm Hg Pulse of 112 beats/minute Respirations of 24 breaths/minute Temperature of 99.6 F Oriented X 1 Skin dry, cracked lips, hand grasps very weak bilaterally. Laboratory values reveal: Na+ 146 mEq/L K+ 2.7 mEq/L Cl-98 mEq/L Ca+ 10.0 mg/L Hgb 8.7 dl/L Hct 54.0 dl/L patient. List 3 priority interventions for this patient. Your interventions can include more labs, X-rays, infusion therapy or whatever you think is necessary. The nurse is waiting on the HCP's orders and anticipates what plan of treatment for this 1. 2. 3. Please explain your rationale for your answers you listed above.

Answer 1

Answer: The three nursing interventions and rationales for this patient are:

• Nurse should monitor the blood pressure of the patient as the results shows low blood pressure. ( This will enable the nurse to understand the reason of low blood pressure, might be due to cardiovascular disease.)
• Nurse should intervene about the fluid intake. ( As due to dehydration, the skin integrity becomes low, weakness occurs)
• Monitor the pulse rate. ( This will reveals about the functioning of the heart.)