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Jane Smith, a 21-year-old client, is admitted with infective endocarditis. The client has a history of...

Jane Smith, a 21-year-old client, is admitted with infective endocarditis. The client has a history of mitral valve prolapse and a recent strep throat infection, which she stated when she felt better, she stopped taking the antibiotic. She presents to the telemetry unit with Osler nodes present on the pads of her fingers and toes, and Janeway lesions on the palms of her hands and soles of her feet. She has splinter hemorrhages present on her fingernails. The nurse notes that the spleen is enlarged and tender during palpation. The client is lethargic and stated that she has no appetite and has lost 5 lb this past week and 10 lb in 2 weeks because she has no appetite. She complains of muscle aches in her lower back and thighs and joint pain everywhere. The vital signs are T, 102 ° F; BP, 90/50 mm Hg; HR, 110 beats/minute; RR, 28 breaths/minute. She has a midsystolic click, followed by a late systolic murmur present. The LPN/LVN reviews the following orders on the chart and decides on nursing management needed for the client.

Admit to medical-surgical unit, infective endocarditis; keep on bed rest. No known allergies. Monitor via telemetry.

Blood cultures × 3, 1 hour apart and separate sites.

Obtain CBC with differential, renal profile, liver profile and send to lab.

D51/2 NS at 100 mL/hr per one IV site and the other IV site keep as saline lock for IVPB medication; NPO; transesophageal echocardiography (TEE) in 1 hour. More orders to follow after procedure is completed.

What nursing management is needed for the client? (Bullet your detailed responses.)

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Answer #1

The following nursing management is needed for the client are

  • Monitor vitals ,to keep on observations and helpful in assess the progress and status of the patient
  • Insert IV cannula and start the IV fluid to normalize the blood pressure
  • Send blood sample for culture ,for early detection and identification of causative organisms to initiate antibiotic
  • Provide tapid sponge to bring down the fever
  • Prepare the patient for TEE
  • Get ready for the consent of the procedure
  • Assess the patients heart sound for any murmur.
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