I1. You walk into Anna’s room and on initial assessment you found Anna is restless. The patient care tech just finished doing the vital signs on Anna and handed over it to you; BP: 170/84 mm Hg
Pulse: 122 beats/minute
Respirations: 40/minute
Pulse Oximetry: 96% on the BiPAP
Oral Temperature: 98.6F (Her last ABG done 30 minutes before shows pH of 7.38, Pco2 of 40, Po2 of 110, and HCo3 of 24)
Anna is found restless, pulling on to the mask trying to remove it and the patient care tech is resisting her. She is shouting repeatedly ‘pain’. She appears partially confused. What nursing interventions should be appropriate for her?
The nurse should switch the BiPAP mask to a regular oxymask and should give Anna a break from the BiPAP (ABG shows improvement). The nurse should address her concerns such as dry mouth, by offering a mouth swab and giving Anna some water. The nurse can educate Anna about using the call bell if she starts to experience shortness of breath and can perform frequent …show more content…
The physician has written discharge orders for Anna. Anna’s spouse Steve Starke is also at the bedside, waiting for the nurse to bring the discharge paperwork. Anna’s morning labs are as follows: hemoglobin 10.4 g/dl, hematocrit of 28%, BNP level of 200pg/ml, and white blood count of 9,000 cells/mm3. Her morning chest x-ray results are normal. Her assigned RN checked vital signs before discharge. The vitals are as follows: Temperature: 97.20F, Heart rate: 80 beats per minute, BP: 130/76 mm Hg, respiration: 18 breaths per minute, and pulse oximetry: 98% on room air. Anna is fully alert, oriented, denies any discomfort or pain. The assigned nurse brings the discharge paperwork, educational booklet, and discharge medication reconciliation form. She handed over all the prescriptions, informed Anna to call the pharmacy in the morning to get all her prescriptions refilled. You call volunteer to take Anna down to the main
Pulse: 122 beats/minute
Respirations: 40/minute
Pulse Oximetry: 96% on the BiPAP
Oral Temperature: 98.6F (Her last ABG done 30 minutes before shows pH of 7.38, Pco2 of 40, Po2 of 110, and HCo3 of 24)
Anna is found restless, pulling on to the mask trying to remove it and the patient care tech is resisting her. She is shouting repeatedly ‘pain’. She appears partially confused. What nursing interventions should be appropriate for her?
The nurse should switch the BiPAP mask to a regular oxymask and should give Anna a break from the BiPAP (ABG shows improvement). The nurse should address her concerns such as dry mouth, by offering a mouth swab and giving Anna some water. The nurse can educate Anna about using the call bell if she starts to experience shortness of breath and can perform frequent …show more content…
The physician has written discharge orders for Anna. Anna’s spouse Steve Starke is also at the bedside, waiting for the nurse to bring the discharge paperwork. Anna’s morning labs are as follows: hemoglobin 10.4 g/dl, hematocrit of 28%, BNP level of 200pg/ml, and white blood count of 9,000 cells/mm3. Her morning chest x-ray results are normal. Her assigned RN checked vital signs before discharge. The vitals are as follows: Temperature: 97.20F, Heart rate: 80 beats per minute, BP: 130/76 mm Hg, respiration: 18 breaths per minute, and pulse oximetry: 98% on room air. Anna is fully alert, oriented, denies any discomfort or pain. The assigned nurse brings the discharge paperwork, educational booklet, and discharge medication reconciliation form. She handed over all the prescriptions, informed Anna to call the pharmacy in the morning to get all her prescriptions refilled. You call volunteer to take Anna down to the main