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Rotator Cuff
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- Joined: May 2007
- Location: Brisbane
- Posts: 85
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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
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adelleg
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- Joined: Dec 2007
- Location: Brisbane
- Posts: 2
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Dec 04, 2007, 02:57 pm
I hope the patient is ok!!
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Rotator Cuff
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- Joined: May 2007
- Location: Brisbane
- Posts: 85
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Dec 04, 2007, 03:06 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.
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adelleg
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- Joined: Dec 2007
- Location: Brisbane
- Posts: 2
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Dec 04, 2007, 03:16 pm
oh, I see - thought it was a "real" patient with those sort of stats, he is probably in shock...
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Rotator Cuff
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- Joined: May 2007
- Location: Brisbane
- Posts: 85
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Dec 04, 2007, 03:41 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
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Ronnie
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- Joined: Oct 2006
- Location: XXXXville
- Posts: 34
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Dec 05, 2007, 12:25 am
Last edited Dec 05, 2007, 12:25 am
update #1
If conscious ask if he is diabetic maybe having a hypo. Do a stat BSL. <3.5mmol indicates a hypo.
modified: Wednesday 05 December 2007 12:27:14 am - Ronnie
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lauz
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- Joined: Oct 2007
- Location:
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Dec 05, 2007, 10:53 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.
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Rotator Cuff
(offline)
- Joined: May 2007
- Location: Brisbane
- Posts: 85
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Dec 05, 2007, 11:03 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
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