Question

Pain Assessments and Interventions:

Assessment: The patient was alert and orientated X 3/ X 2 and reported left hand pain at the IV site as a 5 on a scale from 0-10 at 0900 d/t potassium infusion; heat pack was placed at the site and IV rate was lowered, reassessment at 0930 was a 0. The patient demonstrated facial grimacing during movement and appeared to be discomfort through out clinical shift. She stated pain level as 0 at 0730 and 1430 when vitals were recorded.

Interventions:

Neurosensory Assessments and Interventions:

Assessment: Patient is alert and orientated X3, sometimes X2. Easily arousal. PEERLA present. No use of corrective lenses/glasses. Patient has slowed, comprehendible speech. Verbal and able to follow two-step commands. Purposeful responses and purposeful movements. Generalized muscle weakness and fatigue.

Interventions:

Respiratory Assessment and Intervention:

Assessment: Patient on room air. Frequent, nonproductive, dry cough noted after an increase in activity. Patient appears to be in no distress. Barrel chest. Normal lung sounds auscultated in all lung fields. HOB is elevated to 30 degrees. No use of axillary muscles. No signs of pallor or air hunger.

Interventions:

Cardiovascular Assessments and Interventions:

Assessment: Patient’s HR 75 at 0730 and 79 at 1130. BP 108/60 at 0730 and 107/52. Patient is placed on remote telemetry. S1 and S2 sounds present. All four extremities are warm and dry. Skin turgor immediate recoil. No signs of clubbing/splitting. Dorsalis Pedi +1 weak pulses. Radial pulses +1 weak. Capillary refill less then 3 seconds. Patient’s color is WNL. No peripheral edema. Abdominal ascites present. SCD’s present. Patient has a hx of HTN, coagulopathy and anemia.

Interventions:

Musculoskeletal Assessments and Interventions: (include activity)

Assessment: Patient has limited ROM in all four extremities and needs partial assistance with ADL’s. Decreased ROM in all four extremities: RUE-mild LUE- mild, RLE- moderate, LLE- moderate. Decreased tone in all four extremities. No muscle contractures present. No peripheral edema or tenderness present. No traction or casts present. No abdominal binder. Able to transfer to bedside commode with one assist. Patient is on high fall risk and a bed alarm is set.

Interventions:

Answer 1

Answer

pain assessment and intervention

• Assess the level of pain by using pain scale reading
• Assess the iv site for sign of infection or inflammation
• To stop the infusion and remove the device.
• To elevate the limb to increase patient comfort; a warm compress may be applied.
• To check the patient's pulse and capillary refill time.
• Perform venipuncture in a different location and restart the infusion, as ordered.
• Check the site frequently.
• Document your findings and interventions performed.

Neurosensory assessment and interventions

• Assess the level of consciousness by gcs
• To check PEERLA
• To check the orientation and alertness
• Check monumental status and neurofuctioning
• Instruct the patient to limit activity

Respiratory assessment and interventions

• To assess the the respiratory status
• Assess patient’s exposure to risk factors.
• Assess the patient’s past and present medical history.
• Assess the signs and symptoms its severity.
• Assess the patient’s knowledge of the disease.
• Assess the patient’s vital signs.
• Assess breath sounds and pattern.
• Administer o2by face mask
• Teach coughing and breathing exercises
• Administer bbronchodilators

Cardiovascular assessment and interventions

• Assess the cardiovascular function
• Check pulses especially apical and peripheral pulses
• Assess the level of edema by grading
• Elevate the affected extremities
• Check the blood pressure
• Assess the ascities
• Assist abdominal paracentesis
• Administer antihypertensive
• Administer iro and folic acid

Musculoskeletal assessment and interventions

• Assess the level of activity
• Assess the high risk fall
• Assess the general musculoskeletal history
• Check the range of motion
• Assist the patient to perform activities of daily living
• To check tenderness and pain on the area
• Administer opoiod analgesics
• Encourage to do small exercise.