Question

The handoff shift report includes: Mrs. T, 56 years old, was admitted around midnight from the ER after experiencing
some chest pain. She has coronary artery disease and smokes one pack of cigarettes a day. Her father
died of heart disease and she has a brother with hypertension. Her VS are T 98° F, P 90, R 26, BP 164/100,
pain level 0, pulse ox 97%. Mrs. T has been taking verapamil, nifedipine, and atenolol. Mrs. T will continue
with her usual cardiac and blood pressure medications and is also started on aspirin 81 mg, docusate sodium,
and lovastatin. Nitroglycerin tablets 0.4 mg SL are ordered prn chest pain and has Mylanta 30 mL q2h prn.
She has bathroom privileges with assistance, a saline lock, and oxygen at 3 L/min/nasal cannula to keep the
oxygen saturation greater than 96%. Mrs. T is upset about not being able to get up and smoke. Mrs. T is
requesting to use the commode as you start your shift.

What is the priority?

• Take the vital signs and assess
• Assist to commode
• Perform a body systems
• Check oxygen saturation level

• Talk with Mrs. T

Answer 1

The five nursing interventions can be prioritised as follows :

1. Take vital signs and assess the pain level

Rationale : it is important to assess the vital signs before any other intervention to know the physical status of the patient. Vital signs will help the nurse to the health status and improvements in patient condition. It will also help decide whether to mobilise the patient for commode or not. Assessment of pain level will determine whether the patient can walk to use the commode or requires assistance.
2. Check oxygen saturation level

Rationale : oxygen saturation level will also help determine the health and cardiovascular status of the patient. If oxygen saturation levels is low the patient cannot walk to use the commode and requires assistance.
3. Assist to commode

Rationale : after assessing the vital signs and oxygen saturation, the nurse can help the patient to use commode as the patient has the urge to use the commode.
4. Talk to Mrs T

Rationale : while assisting the patient for commode the nurse can talk to Mrs T about how is she feeling

5. perform body system assessment

Rationale : as the patient becomes comfortable and relaxed after using commode, nurse can perform the body system assessment.