Mrs. Lu complains of being short of breath. Three hours after she was admitted to her room Jim assesses her temperature and it is 101.2° F orally. Jim takes her other vital signs: blood pressure is 100/70 mm Hg, pulse is 112 beats/min, and respirations are 30 breaths/min. Her pulse oximetry is 88%. What two priority nursing interventions should Jim initiate to treat these changes in Mrs. Lu’s condition? What are the rationales for choosing these interventions?
Ans:- Nursing interventions to treat the changes in Mrs. Lu's condition are as follows:-
1. Fluid therapy,
2. Oxygen therapy.
Rationale of these interventions are as follows:-
1. Fluid therapy:- she we start to give the fluids mainly isotonic to the patient as fluids will increase the circulatory blood volume and hypovolemia will be Normal and if hypovolemia will be Normal then heart rate will automatically will be Normal because heart rate increases due to the hypovolemia.
In hypovolemia circulatory blood volume becomes lower and it leads to lower venous return irrespective of its causes, and when hypovolemia is sufficiently severe , arterial hypotension. Compensatory system release of catacholemines , promotes peripheral vasoconstriction, increased cardiac contractility and tachycardia.
That's why we will give fluids therapy.
2. Oxygen therapy:- As saturation of mrs. Lu is 88% and it's a very critical situation and in this situation first step should be to start oxygen therapy to restore the normal saturation.
After that we can give medication as per doctors order and these medications are given through an inhaler that enables patient to breathe the medicine into lungs. So that patient's saturation level becomes normal faster.
Mrs. Lu complains of being short of breath. Three hours after she was admitted to her room Jim assesses her temperature...
Mrs. Lu complains of being short of breath. Three hours after she was admitted to her room Jim assesses her temperature and it is 101.2° F orally. Jim takes her other vital signs: blood pressure is 100/70 mm Hg, pulse is 112 beats/min, and respirations are 30 breaths/min. Her pulse oximetry is 88%. Jim is listening to Mrs. Lu’s lung through the stethoscope, he hears a high-pitched musical sound. What is this lung sound and what does this indicate??
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