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:

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:

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:

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:

Gastrointestinal Assessment and Intervention: (include ordered diet)

Assessment: Patient is on a general diet. Patient did not eat her breakfast; she ate 25% of lunch and 25% of her dinner. Patient’s abdomen was distended and ascites was present. Hypoactive bowel sounds present in all 4 quadrants. Patient given protonix for gastric mobility at 0900. Patient had loose brown/yellow bowel movements 4 X in the commode. Patient was on lactulose, which was discontinued in the AM.

Interventions:

Endocrine Assessment and Intervention:

Assessment: Patient has a hx of DM II. Accuchecks every 6 hours and on a sliding scale. Patient’s glucose was 170 at 1200 and was given Insulin aspart 3 units at 1200. Patient has a history hypothyroidism; synthroid 50 mcg was given on an empty stomach at 0900. Patient does not exhibit diaphoresis, nervousness, or change in skin color. No signs of heat or cold intolerances.

Interventions:

Reproductive Assessment and Intervention:

Assessment: Patient had two children 36 and 40 years ago.

Interventions:

Vascular Access Assessment and intervention:

Assessment: Patient has an IV in her left hand and another IV in her right brachial. Dressing dry and intact. No continuous IV fluids running at this time. No signs of infiltration, redness or phlebitis at either IV site. Patient stated burning at left hand IV site during potassium chloride infusion, infusion lowered and heat pack given.

Interventions:

Safety Assessment and Intervention:

Assessment: Patient is at a high risk for falls. Three-side rails are up and the bed is in the lowest position. Bed alarm is on. Call light is with in reach. Turn patient every two hours to prevent skin break down. Ensure HOB is 30-45 degrees.

Interventions:

Psychosocial Assessment and Interventions:

Assessment: The patient lives in a house in Chicago with her son Tommy. She has two grandchildren that came to visit her at the bedside. She was a former smoker and alcoholic. She stated that she currently drinks one mixed drink of vodka each day. Her husband passed away 15 years ago and that’s when her drinking got bad. She stated, “I’m not as bad of a drinker as my father was.” She stated that she enjoys cooking because it makes her feel happy, however has not been able to cook as much because of her limited mobility and pain.

Interventions:

Answer 1

#1.The intravenous infusion with potassium chloride is usually irritating to the skin because if its concentration. Though the patient verbalises a pain score of zero, the facial grimace still shows the discomfort .In order to improve the comfort level of the patient

• Reassess the IV site for any redness, swelling ,tenderness , extravasation ,phlebitis .
• Ice application can be provided after the infusion
• In case the IV cannot be disconnected ,ensure to infuse it through a new peripheral line in order to reduce discomfort .This is applicable if the previous IV line is not patent or causing any trouble to the patient .
• According to recent research practice it is advised to add lidocaine in the IV drip to reduce the pain (This is strictly applicable only if the provider writes an order)
• Reassure the patient and encourage the patient to engage in conversation .This can help to identify the root cause for discomfort and provide appropriate care

#2.The intervention required for a patient who has frequent non productive cough are

• Provide luke warm water to sip or drink .This can ease the throat and reduce antidote throat
• Administer lozenges and cough suppressant as per order to relieve cough
• Encourage the patient to gargle with salt water in order to relieve sore throat due to cough
• Humidify the air in the room to reduce the cough

#3.The neurosensory assessment intervention for the patient are

• Monitor GCS ,neurological assessment periodically in order to observe  and plan for care
• Provide physiotherapy in order to improve the muscle functioning and reducing its weakness
• Encourage to do range of motion exercise .This can improve the muscle function and enhance mobility
• Speech therapy can be provided
• Ensure to provide speech therapy in order to improve it

#4.The cardiovascular interventions for this patient are

• Encourage the client to increase the fluid intake as the blood pressure is low .
• Administer IV fluid to elevate the blood pressure
• The patient can be encouraged to be in reverse trendlenburg position in order to improve blood circulation to heart by increasing the diastolic pressure
• Prepare the patient for ascitic taping if ordered
• Encourage to place patient in semi Fowler position to prevent dyspnea due to ascities
• Withhold antihypertensive drugs as the blood pressure is already low
• Support the client to increase the hemoglobin levels through diet and medication