Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: (oral) 97.4 ℉ P Denies pain...
Patient Care Begins:
|
Current VS: |
P-Q-R-S-T Pain Assessment (5th VS): |
|
|
T: (oral) 97.4 ℉ |
P |
Denies pain |
|
P: 112 (lying down), 120 (sitting), 132 (standing) regular rhythm |
Q |
|
|
R: (regular) 28 |
R |
|
|
BP: 106/72 (Lying down), 92/66 (sitting), 84/60 (standing up) |
S |
|
|
O2 sat: 91% |
T |
|
|
RELEVANT VS Data: |
Clinical Significance: |
|
Current Assessment: |
|
|
GENERAL APPEARANCE: |
Ht 4’11”, Wt 100 |
|
RESP: |
Breath sounds clear and diminished in bases, short of breath. |
|
CARDIAC: |
Tachycardia, regular rhythm, no edema |
|
NEURO: |
Muscle tone generally weak |
|
GI: |
Mucous membranes pale, tongue smooth/shiny, abdomen soft, non-tender, spleen palpable. |
|
GU: |
Patient has not voided yet |
|
SKIN: |
Pale, intact w/o erythema or ecchymosis |
|
RELEVANT Assessment Data: |
Clinical Significance: |
Homework Answers
Simce the patient is pale, tachycardia present, BP fluctuation posturally. The clinical signicance might be
Postural hypotension
Anemia, ?Blood loss
? Bilateral Pleural Effusioin
Add Answer to:
Patient Care Begins:
Current VS:
P-Q-R-S-T Pain Assessment (5th VS):
T: (oral) 97.4 ℉
P
Denies pain...
Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: (oral) 97.4 ℉ P Denies pain...
Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: (oral) 97.4 ℉ P Denies pain P: 112 (lying down), 120 (sitting), 132 (standing) regular rhythm Q R: (regular) 28 R BP: 106/72 (Lying down), 92/66 (sitting), 84/60 (standing up) S O2 sat: 91% T RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Ht 4’11”, Wt 100 RESP: Breath sounds clear and diminished in bases, short of breath. CARDIAC: Tachycardia, regular rhythm, no edema NEURO: Muscle tone generally weak GI: Mucous membranes pale,...
Patient Care Begins: Current VS: T: Coral) 97.4 °F P: 112 (Lying down), 120 sitting), 132...
Patient Care Begins: Current VS: T: Coral) 97.4 °F P: 112 (Lying down), 120 sitting), 132 (standing) regular rhythm R! (regular) 28 BP: 106/72 (Lying down), 92/66 (sitting), 84/60 (standing up) O2 sat: 91% P-O-R-S-T Pain Assessment (5th VS): P Denies pain R S т RELEVANT VS Data: Clinical Significance:
Ht 4'11", Wt 100 Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Breath sounds...
Ht 4'11", Wt 100 Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Breath sounds clear and diminished in bases, short of breath. Tachycardia, regular rhythm, no edema Muscle tone generally weak Mucous membranes pale, tongue smooth/shiny, abdomen soft, non-tender, spleen palpable. Patient has not voided yet Pale, intact w/o erythema or ecchymosis RELEVANT Assessment Data: Clinical Significance:
II. Nurse Collected Clinical Data: Current VS: T: 100.5 (oral) P: 110 (regular WILDA Pain Assessment...
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...
I need help with the clinical significance Current VS: T: 98.6 P: 98 R: 22 COLDSPA...
I need help with the clinical significance
Current VS: T: 98.6 P: 98 R: 22 COLDSPA Pain Assessment (5" VS) Character chest pain feels tight, squeezing Onset I hate to admit it, but I have felt this pain off and on lately Location mid chest area, but I feel it in my back between my shoulder blades BP: 162/98 O2 sat 94% RA Duration: If I rest and sit down it goes away, but I have the pain now Pattern...
Post-op Pain Management: Day of Surgery (1/2) History of Present Problem: Sheila Dalton is a 52-ver-old...
Post-op Pain Management: Day of Surgery (1/2) History of Present Problem: Sheila Dalton is a 52-ver-old woman who has a history of chronic low back pain and COPD. She had a posterior spinal fusion of L4S1 today. She had an estimated blood loss (EBL) 675 ml during surgery and received 2500 mL of Lactated Ringers (LR) Paimis currently controlled at 2 10 and increases with movement. She was started on a hydromorphone patient-controlled analgesia (PCA) with IV bolus dose of...
develop a care plan for a patient that has a Clostridium difficile Colitis. Please use the provided format for building...
develop a care plan for a patient that has a Clostridium difficile Colitis. Please use the provided format for building your care plan. You will need to use your nursing reference materials as you build this care plan. Mindy Perkins is a 48 year old woman who presents to the ED with 10-15 loose, liquid stools daily for the past 2 days. She completed a course of oral Amoxacillin seven days ago for a dental infection. In addition to loose...
FUNDAMENTAL Reasoning: STUDENT Cirrhosis I. Developing Nurse Thinking by Identifying Clinical Relevance/Significance History of Present Problem:...
FUNDAMENTAL Reasoning: STUDENT Cirrhosis I. Developing Nurse Thinking by Identifying Clinical Relevance/Significance History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain, and increasing nausea and vomiting the past 3 days that has not resolved. He is also feeling more fatigued and has had a poor appetite. He denies any ETOH intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds and is...
Please print please 1. What intervention will you initiate based on this priority? Pain management Fever...
Please print please
1. What intervention will you initiate based on this
priority?
Pain management
Fever management
Preparation for surgery to avoid complications
Nursing Interventions
Rationale
Expected Outcome
1.
1.
1.
2.
2.
2.
3.
3.
3.
4.
4.
4.
2. What can you do to engage yourself with this
patient’s experience, and show that they matter to you as a
person?
Rapid Reasoning: Appendicitis Chief Complaint/History of Present Illness: Jennifer Anderson is a 42 year old woman who presents...
Current Assessment: GENERAL APPEARANCE: Appears anxious, body tense, tired (dark circles under his eyes) RESP CARDIAC:...
Current Assessment: GENERAL APPEARANCE: Appears anxious, body tense, tired (dark circles under his eyes) RESP CARDIAC: NEURO: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, Alert & oriented to person, place, time, and situation (x4), flat affect, inability to fall asleep Abdomen softnon-tender, bowel sounds audible per auscultation in all four quadrants Voiding without diffic equal with palpation at radial/pedalpost-tibial landmarks only two...
Patient Care Begins: Current VS: T: Coral) 97.4 °F P: 112 (Lying down), 120 sitting), 132 (standing) regular rhythm R! (regular) 28 BP: 106/72 (Lying down), 92/66 (sitting), 84/60 (standing up) O2 sat: 91% P-O-R-S-T Pain Assessment (5th VS): P Denies pain R S т RELEVANT VS Data: Clinical Significance:
Ht 4'11", Wt 100 Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Breath sounds clear and diminished in bases, short of breath. Tachycardia, regular rhythm, no edema Muscle tone generally weak Mucous membranes pale, tongue smooth/shiny, abdomen soft, non-tender, spleen palpable. Patient has not voided yet Pale, intact w/o erythema or ecchymosis RELEVANT Assessment Data: Clinical Significance:
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...
I need help with the clinical significance
Current VS: T: 98.6 P: 98 R: 22 COLDSPA Pain Assessment (5" VS) Character chest pain feels tight, squeezing Onset I hate to admit it, but I have felt this pain off and on lately Location mid chest area, but I feel it in my back between my shoulder blades BP: 162/98 O2 sat 94% RA Duration: If I rest and sit down it goes away, but I have the pain now Pattern...
Post-op Pain Management: Day of Surgery (1/2) History of Present Problem: Sheila Dalton is a 52-ver-old woman who has a history of chronic low back pain and COPD. She had a posterior spinal fusion of L4S1 today. She had an estimated blood loss (EBL) 675 ml during surgery and received 2500 mL of Lactated Ringers (LR) Paimis currently controlled at 2 10 and increases with movement. She was started on a hydromorphone patient-controlled analgesia (PCA) with IV bolus dose of...
FUNDAMENTAL Reasoning: STUDENT Cirrhosis I. Developing Nurse Thinking by Identifying Clinical Relevance/Significance History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain, and increasing nausea and vomiting the past 3 days that has not resolved. He is also feeling more fatigued and has had a poor appetite. He denies any ETOH intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds and is...
Please print please
1. What intervention will you initiate based on this
priority?
Pain management
Fever management
Preparation for surgery to avoid complications
Nursing Interventions
Rationale
Expected Outcome
1.
1.
1.
2.
2.
2.
3.
3.
3.
4.
4.
4.
2. What can you do to engage yourself with this
patient’s experience, and show that they matter to you as a
person?
Rapid Reasoning: Appendicitis Chief Complaint/History of Present Illness: Jennifer Anderson is a 42 year old woman who presents...
Current Assessment: GENERAL APPEARANCE: Appears anxious, body tense, tired (dark circles under his eyes) RESP CARDIAC: NEURO: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, Alert & oriented to person, place, time, and situation (x4), flat affect, inability to fall asleep Abdomen softnon-tender, bowel sounds audible per auscultation in all four quadrants Voiding without diffic equal with palpation at radial/pedalpost-tibial landmarks only two...
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