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In: Nursing

Jeff Jones, a 45-year-old male patient has arrived to the ER status after being ejected from...

Jeff Jones, a 45-year-old male patient has arrived to the ER status after being ejected from an automobile.  He has a backboard with a cervical collar in place.  Upon assessment, the patient has sustained a C6 spinal cord injury, a right femur fracture, a right tib/fib fracture, and numerous cuts and abrasions from glass and metal fragments.

VS on arrival to ER: Temp:97.5 Pulse: 40 RR: 16 BP: 88/44 o2:95% on 100% non-rebreather mask.

What is the priority nursing assessments?

What is the priority lab tests/diagnostic test?

What is the priority intervention?

What is the priority Potential & Actual Complications

What is the priority Nursing Implications?

What are the priority Medications?

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ANSWER

The patient had aa accident and the vital shows especially HR and BP is low, so there is a chance of hypovolemia. The late symptoms of hypovolemia are bradycardia and low BP. So the vital signs of the patient should be checked closely especially circulatory parameters like HR and BP.

Complete blood count, especially Hb should be checked. Blood loss can results in anemia. At the same electrolytes like sodium, potassium should be checked.

Fluid resusitation to replace the lost fluid from the body and anemia can be corrected by blood transfusion.

The complications will be hypovolemic shock and anemia.

The role of the nurse is to close monitoring of neurologic, cardiovascular and respiratory status. Trendelenburg position can be given. The patient ECG can be monitored to detect arrytmias related to electrolyte imbalance.Skin turgour can be checked.

Crystalloids like .9%NaCl, RL, 3% saline can be given.

Nightingale answered 2 years ago
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