At 8:30 AMyou note that Mrs. F is lethargic and very slow to respond to verbal...

At 8:30 AMyou note that Mrs. F is lethargic and very slow to respond to verbal stimuli. Skin is cool with slight cyanosis noted on nail beds. P 110 and irregular, R 14 shallow, pulse ox 92%, BP 90/70, which is lower than her usual of 130/88.

Based on these findings, what nursing interventions would you implement immediately?
What nursing actions can you delegate/assign to the personal support worker?

Solutions

Expert Solution

Patient is very sick and is going in shock so first of all i will inform to the doctor about the vital signs and condition.

1. Send blood for test in the lab as per doctor's order to check ECG, ABG,cbc ,and will arrage crossmatch in advance if the patient requires then we can administer anytime.

2. It is clearly mentioned above that Mrs.F is lethargic and very slow to respond. Her B.P is 90/70 and pulse ox92%. So first of all propped up bed should be provided to her with Oxygen administration 2litre per minute by mask, then regular monitoring of saturation should be done.

3. Her skin is cool and cyanosis is present so we should provide her a warm environment, provide her a blanket, keep the extremities warm, if the air conditioner is on then it should be put off.

4. Her BP is 90/70 i.e,. lower than her usual Bp. So an I.V fluid should be administered to get back the B.P to its normal stage.

5.To administer blood if it reqiures.

6.To get ready with emergency trolley, because the patient is sick and anything can happen at any time so we have to closely monitor the vital signs, if it is not improving then the condition of the patient may deteriorate and we may have intubate the patient also.

6.Take risk consents from the relative after explaining her serious condition.

7.Talk to ICU nurse to book the ventilator, in case of emergency if we have to shift the patient to ICU.

Personal support worker should be assigned to look after the patient properly.

She should be with the patient at all times.

Advise to provide the patient a comfrtable environment.

Inform to the nursing staff immediately if she notices any unusual thing.

To provide emotional support.

To look after the nutritional need of the patient.

To maintain personal hygiene of the patient

Nightingale answered 1 year ago

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