Author Question: At 1530, the nursing assistive personnel (NAP) reports the following: Vital Signs Blood pressure ... (Read 92 times)

LCritchfi · **on:** Jun 25, 2018

At 1530, the nursing assistive personnel (NAP) reports the following:

Vital Signs
Blood pressure 148/82 mm Hg
Heart rate 118 beats/min
Respiratory rate 24 breaths/min
Temperature 101 F (38.3 C)
Spo2 92

Based solely on her vital signs, what could be happening with M.N., and why?

You go to assess M. N. What do you need to include in your assessment at this time?

Question 2

It is 1130 and M.N., age 65, is being admitted to your surgical floor after having undergone an open cholecystectomy for acute cholecystitis. She has a nasogastric tube to continuous low wall suction, one peripheral intravenous (IV) line, and a large abdo

Physician's Orders
Clear liquid diet; progress low-fat diet as tolerated
D5 NS with 40 mEq KCl at 125 mL/hr
Turn, cough, and deep breathe q2h
Incentive spirometer q2h while awake
Oxygen per protocol to maintain Spo2 at 95
Dangle in am
Morphine sulfate 10 mg IM q4h prn for pain
Ampicillin (Omnipen) 2 g IVPB q6h
Chest x-ray in am

Are these orders appropriate for M.N.? State your rationale.

djpooyouma · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Her blood pressure, pulse, and respirations are high, perhaps because of incisional pain, fever
(inflammatory process), or hypoxemia.
Temperature is elevated; this might be because of an inflammatory response from having infection
(cholecystitis on admission) or a normal postoperative reaction.
Her oxygen saturation is low. Incisional pain might cause splinting and shallow respirations, resulting
in atelectasis and/or hypoxemia. She might also be developing pneumonia or an embolus.

Observe her general status. Is she restless or agitated? Is she alert and oriented in all spheres?
Observe the color of her skin. Is it pale, flushed, cyanotic? Is she diaphoretic? Cool? Are respirations
labored? Is she using accessory muscles? Can you see her chest significantly rising and falling? Ask
her how she feels as she is breathingdoes she feel short of breath?
Auscultate and percuss her lung fields. Check her capillary refill time.

Answer to Question 2

M.N. should remain on nothing-by-mouth (NPO) status and not receive a diet order until she
resumes bowel sounds and passes flatus. It usually takes 48 to 72 hours for the bowels to resume
peristalsis after abdominal surgery. Then the nasogastric tube will be removed and M.N. can start
eating.
You need to know M.N.'s potassium level before administering an infusion containing this level of
potassium.
Morphine sulfate should be given intravenously in small doses (1 to 2 mg) at more frequent
intervals (q1- 2h as needed). IM (intramuscular) injections are both painful and unnecessary.
M.N should dangle the evening of surgery and be out of bed to a chair and progressively
ambulating beginning the next day.