Question

Clinical Simulation Mrs. Julia Davis is a 76 year old woman with a history of CAD and frequent UTIs. She is admited to the medical- surgical unit from the ER with SOB, lower abdominal pain, chest pain lasting less than S minuties and relieved with nitroglycerine. Her vital signs are: BP 17090, AR 106, R 28, T 102.3 Provider's orders: Bedrest 02/2L via nasal cannula Vital signs every hour for first 4 hrs, then every 4 170-90, Temp 102 peripheral IVNS 1000 mil at 50 ml hr hrs Call MD for BP Start 1 &O 2 gm sodium diet CXR soday Insert Foley catheter W16 French Collect urine for culture and sensitivity Digoxin 0.125 mg daily, hold for HR60 Tylenol 650 mg every 4 hrs pm Temp 101 Lasix 20 mg IVP ow Ampicillin 250 mg IVPB every hrs On insertion of the catheter, the balloon cannot be inflated and the client complains of pain. BP is 190/100 after one hour. Client complains of chest pain. No urine output for one hour. Questions: What assessments need to be made by the murse What is the priority for the murse when the client arrives in the room? What information does the nurse nood to know to dilute ampicillin if it is supplied in a vial as a powder? How fast can it be infused? Over what period of time should the Lasix be administered Can any of the tasks be delegated to UAPs List nursing diagnoses applicable to this client Construct a concept map for this client Write a plan of care and interventions nocessary for this patient?

Answer 1

Asessment by the nurse

1. vital signs

2. intake and out put chart

3. Assess the pain and the nature of the pain

4. asess the blood pressure

Any other difficulties by the patient to be assessed

the priority can be airway breathing and cerculation, and vital monitering along with bp and administration of the docter and also carry out the orders as per the regulation.

The nurse should know the mg of ampicilline in the vial and how much ml of water is adding to the vial in order to dilute the same. The speed of injection as per the normal standards not too much slow or not much fast, can be infused with a medium speed.

Lasix can be given at normal speed not having too much slow or too fast.

Oxygen connecting and intake out put charting and transfering for X ray can be delegated to UAP's

nursing diagnosis

1. chest pain related to inadequate suply of blood to the heart

2. breathing difficulty related to inability to take breaths

3. decreased urine out put rellated to inadequate fluid intake

4. high risk for infection related to urinary catheter insertion

concept map

diagnosed with CAD and UTI

Vital temp 102.3

BP 170/90 increased to 190/100

has provided with IV NS 1000ml at 50ml per hour

plan of care for the patient

complete monitering of the vitals, intake out put chart and chest pain his nature intensity,

for the uti ampicillin injection along with that adequate amount of water should be provided.

lasix has been given to the patient along with 50ml per hour of normal saline, so the out put is a must and signs of edema has to assessed