Question

Time Evaluation and Priority Setting Lisa Jones, 8 year old, was admitted to the unit from surgery yesterday, after having a cardiac catherization with PCI. Lisa's history includes chronic atrial flutter, urinary incontinence and diabetes mellitus. During the night, she pulled her urinary catheter and IV catheter out. The night nurse reported to you that the IV catheter and Foley catheter would need to be replaced. The nurse explains that there was a cardiac emergency on the unit which has delayed the Foley and IV being replaced. The patient complaints that she has pain/discomfort in the rectum and is ver upset at the night staff because they don't care about patient's and are rude. After she stops yelling and has calmed down, she informed you that she has pain in her left call. During assessment, the nurse notes that the area is warm, reddened and tender to touch. Doctors Order: 1. Baseline Partial Thromboplastin time, International Normalized Ration, Platelet co Hemoglobin and hematocrit 2. Repeat PTT per heparin protocol (every 6 hours at first) 3. Chest radiograph 4. Intravenous heparin per protocol 5. Elevate and apply heat to affected extremity irections: 1. What are the focus areas of assessments? 2. Determine the priority after performing the assessment. - Use the Time log provided to plan your activities in order of priority.

Answer 1

1.The important focus area to be assessed are

• Surgical site for infection,bleeding,bluish discoloration
• Vital signs to get the baseline data (Blood pressure ,heart rate and spo2,Respiratory rate)
• Assessing for post op cardiac cath operation (DVT can resuit in warm, tender,reddenedcalf muscles)
• Checking for pedal pulse in the operated leg to know about the circulation
• Assess the skin tone for integrity due to incontinence
• Check when the heparin infusion as stopped due to the absence of IF catheter

2.The priority after assessment are

• Monitor vital signs
• Check for complications
• Insert an intravenous line for medication administration
• If patient is quite stable ,foley's catheterise the patient
• Provide skin care to maintain intact skin and a good integrity.
• Meanwhile inform the concerned physician or the on duty doctor to assess the patient for calf pain
• Documentation

3.The activity can be planned the following way

• Monitoring vital signs and elevate the lower limb and apply heat to improve circulation and prevent any clot.
• start the heparin infusion after inserting the IV line and prior to starting collect the blood sample for PTT,INR,platelet,haemoglobin and Hct.
• Do a chest X Ray to assess for pulmonary embolism.
• Monitor patients other parameters like blood glucose levels ,urinary output
• Maintain an intake and output chart to carefully monitor and prevent any complications.