Question

II. Nurse Collected Clinical Data: Current VS: T: 100.5 (oral) P: 110 (regular WILDA Pain Assessment (s" vs) Words: Intensity: 610 Location: RUQepigastric Duration: Continuous Ache BP: 12888 0 2 sat: 95% RA | Aggravate: Nothing Alleviate: Nothing Orthostatic BP's: Position: HR: BP: Standing What VS data is RELEVANT that must be recognized as clinically significant? 110 128/88 132 124/80 RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL Appears uncomfortable APPEARANCE: Breath sounds clear with equal acration bilaterally, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks CARDIAC and s GE Abdomen large-rounded-firm to touch, bowel sounds audible per auscultation in all 4 uadrants Voiding without difficulty, urine clear/light orange Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry GU SKIN: What assessment data is RELEVANT that must be recognized as clinically significant? RELEVANT Assessment Data: Clinical Significance: 2014 Keith Rischer/www. KeithRN.com

Answer 1

1. Relevant vital sign data are -temperature of 100.5 °F , heart rate of 110 beats per min and ache in the right upper quadrant with a score of 6 out of 10 .

The clinical significance of these vital sign - indicates the presence of infection which is causing the fluctuations in the vital signs and causing pain in the abdomen

2. Relevant data is that the patient is uncomfortable and he is slightly dehydrated as indicated by tacky dry lips and oral mucosa , his sclera is slightly yellow and urine is light orange in colour. The clinical significance is that the patient has biliary obstruction and accumulation of bilirubin due to infection (mostly viral)

3. Alanine transaminase (ALT). ALT is an enzyme found in the liver that helps your body metabolize protein. When the liver is damaged, ALT is released into the bloodstream and levels increase. It's normal range is 7 to 55 units per liter . Its critical level.is when it crosses the normal range . 128 U/L is a critical level. Nursing intervention for increased ALT are :-

- assess the vital signs of the patient

- assist with the medical treatment

- advice to avoid fatty foods

- encourage to increase intake of proteins and vitamins

- help the patient to maintain compliance to drug by explaining the importance of medication and the correct to.e to have it

- advice to drink more water , avoiding raw foods and emphasise on maintenance of hygiene .

- check the therapeutic levels of the enzymes and notify physician if there is any variation .

4. Albumin and total protein. Albumin is one of several proteins made in the liver. Your body needs these proteins to fight infections and to perform other functions. Lower-than-normal levels of albumin and total protein might indicate liver damage or disease. Its normal range is 3.5 to 5gms/ dl . It's critical value is when it becomes less than 3.5gm /dl. 2.5 gm/ dl.is a critical value .

Nursing intervention for decreased albumin levels are :-

- assess the vital signs of the patient

- administer albumin as per the order of physician and give it by infusion method .

- encouraging to eat more protein and vitamins

- assessing the therapeutic levels of albumin

- providing g psychological and emotionally all support to the patient and family

- weight monitoring daily to see the effect of albumin ,because decreased albumin causes edema

- monitor the intput and output