Question

patient has developed some complications related to the fall. She has developed an increase in dyspnea and more difficulty ambulating. She also complains of pain when taking a deep breath. She is now on bed rest and requires help with her ADLs. She is also complaining of an increase in pain in her right leg. She states the pain in her right leg is a 6.

VS: BP 160/90, HR 90, RR 26 and labored, pulse oximeter is 90% on RA, and her temp is 38^oC

Lungs sound – crackles heard in the LLL base both A&P

CXR show infiltrates in the LLL

BNP is 528

US of the right leg

New orders: Lasix 40 mg IV now and then daily

K+ 20 meq daily po

Potassium, Sodium, Chloride, Bun and Creatinine in the morning

Oxygen at 3L NC if oxygen saturation is less than 92%

Critical Thinking questions

1-What focused assessments will the nurse now implement and why?

2-What orders will the nurse expect to receive from the physician and why?

3-Why was Lasix changed to IV and oxygen started? Why where electrolytes, BUN and creatinine ordered?

4-What will be the expected outcome and why?

5-What additional nursing interventions would the nurse initiate? Provide rationales for each and prioritize them.

6-How would you evaluate the effectiveness of the nursing interventions?

Answer 1

1. The focused assessment for the patient are

• Cardiovascular system because the level of BNP is very high which is suggestive of heart failure or cardiovascular issue. Also there is elevated blood pressure
• Respiratory system because the patient has pain while breathing in and also has crackles in both left lower lobe which can be a sign of pneumonia.There is also increased breath rate,labored breathing and decreased oxygen saturation
• The patient has elevated body temperature which is because of infection

2. The nurse can expect the following order

• Strict monitoring of vital signs ,as it is the baseline indicator when changes happen
• Oxygen via nasal cannula
• Propped up position to improve lung capacity and breathing
• Antibiotics to treat any infection
• Antipyretics to reduce body temperature
• Analgesic to relieve pain
• ECG,2 D Echo ,cardiac markers to rule out any cardiovascular issue
• Strict intake and output chart

4. The administration of IV Lasix can act faster and provide better action to alleviate patient symptoms like reducing blood pressure

The oxygen was started to prevent any hypoxia and which may lead to hypoxemia and decrease the oxygen supply to heart causing ischemia or infarction

Also it can be helpful to relieved the breathing difficulty

This helps to identify the acid base balance of the patient.It can give an idea of the renal function too.

4. The expected outcome will be

• Reduced blood pressure or normotensive
• Maintaining oxygen saturation
• Decrease in pain
• Able to breath normally