As a nurse, you are caring for the following clients. What would be some of your...

As a nurse, you are caring for the following clients. What would be some of your actions relevant to assessment of vital signs?

1. A 67-year old client who had surgery 8 hours ago to repair a fractured hip and now you cannot palpate a dorsalis pedal pulse. Are there other tools you can use to assess presence of pulses?

2. You have taken your client’s oral temperature and it registered 95.8 degrees Fahrenheit. Is this a concern and what actions will you take?

Expert Solution

1:ans-the other tools to check pulse are temporal, radial, brachial, carotid.But mostly for the patient with CPR we use to check carotid temporal.

For normally we can use radial pulse to put two fingers of other hand om wrist. In the given situation, after her hip surgery we can check radial pulse. If the cannulation done on that site we can also check bracial pulse.

2ans:Normally below 95 degree Fahrenheit,we considered low temperature that means hypothermia. So here 95.8 degree fahrenheit is mild hypothermia. So. Patient general condition we should assess the symptoms of hypothermia like -shivering

-skin wether cold or not

-we should assess for cyanosis

-checking blood pressure should not falls bp

-urine output.

And if the patient is oriented, we can ask that she feeling cool or not. And one more thing we should know while checking temperature, we should not check with swich on fully AC and fans it may happen temperature incorrect value.

If patients feels cold and other above symptoms present then we should firstly make patient comfortable and hot by providing more blanket and warm room temperature and if needed should inform doctor and do neccessary.

Nightingale answered 1 year ago

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