|
 Rotator Cuff
- Joined: May 2007
- Location: Brisbane
- Posts: 85
|
Tue Dec 04, 2007 2:12 pm
afternoon centralites, RC here got a question: 28yr old male clinical obs are B/P 180/110, Pulse 130 irregular, respirations 26, he is diaphoretric and his skin colour is pale. What nursing interventions would you commence. Since this is all the info you are given, I think first intervention would be an assessment/nursing history, cause how do you know what interventions to do if you dont' know what is causing this. I have also thought of oxygen first, but this has to be prescribed by Doctor I think. Anyhow a young dude with this blood pressure reading will probably die if I dont pull my finger out.
RC
|
|
|
|
adelleg
- Joined: Dec 2007
- Location: Brisbane
- Posts: 2
|
Dec 04, 2007, 02:27 pm
I hope the patient is ok!!
|
|
|
|
Rotator Cuff
- Joined: May 2007
- Location: Brisbane
- Posts: 85
|
Dec 04, 2007, 02:36 pm
hi adelleg,
Yeah i think he will die with that sort of blood pressure and pulse, unless it is a typo error in my workbook.
|
|
|
|
adelleg
- Joined: Dec 2007
- Location: Brisbane
- Posts: 2
|
Dec 04, 2007, 02:46 pm
oh, I see - thought it was a "real" patient
with those sort of stats, he is probably in shock...
|
|
|
|
Rotator Cuff
- Joined: May 2007
- Location: Brisbane
- Posts: 85
|
Dec 04, 2007, 03:11 pm
Sorry If you thought it was real patient, I am doing my EEN it was a question in one of my workbook/learning guides. I figure that is why an assessment would be needed first up to ascertain cause of these stats. Like no temperature was given either. You also have to give a rationale for your intervention. It is a bit trickey as to know what you can do and what you can't as an EEN. A strange question I thought. You don't know if you are the only nurse on duty, or whether there is an RN around or a doc. for that matter. Shock sound like as good cause. I am only new to this because i work in aged care and have not done acute placement yet.
RC
|
|
|
|
Ronnie
- Joined: Oct 2006
- Location: XXXXville
- Posts: 25
|
Dec 04, 2007, 11:55 pm
Last edited Dec 04, 2007, 11:55 pm
update #1
If conscious ask if he is diabetic maybe having a hypo. Do a stat BSL. <3.5mmol indicates a hypo.
|
|
|
|
lauz
- Joined: Oct 2007
- Location:
- Posts: 12
|
Dec 05, 2007, 10:23 am
Hi RC
How about doing a respiratory assessment - check O2 sats, respiratory effort - use of accessory muscles etc, wheezing, coughing - productive, non productive etc. Also could do pain assessment - does he have any pain ie chest pain. Recheck obs including temp., ascertain prev history and presenting problem, also assess for anxiety.
|
|
|
|
Rotator Cuff
- Joined: May 2007
- Location: Brisbane
- Posts: 85
|
Dec 05, 2007, 10:33 am
To all who replied
Thanks for your info. In my rationale column for assessment I have pain, anxiety, previous illness history. I also have temp to take and do observations. Hypo and O2 is a good idea. I also thought of doing rechecking BP bilaterial. I guess this questions was to make us think outside the square, cover all possibilities and stop thinking like AIN and start thinking like EEN. Thanks again, I think this dude will survive (PS not a 'real' dude).
RC
|
|
|
You need to be logged in to get access to the forums. You can do so here
