What are you on alert for with this patient? (Signs & Symptoms)
1. Sudden, significant increase in blood pressure. Also, exertional dyspnea, shortness
... [Show More] of breath, excessive increase in respiratory rate
2. Insufficient venous return/ Development of DVT; swelling of the legs, thickening of the skin, hyperpigmentation on the skin of the lower extremities
3. Infections caused by inappropriate catheterization: cloudy urine, blood in the urine; strong urine odor; pressure, pain or discomfort when voiding, fever
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)
1. Basic assessment such as vital sign to monitor patient’s blood pressure. Observe patient respiratory rate and perform pulse oximeter
2. Skin assessment to assist patient’s legs. Check for swelling, red, hard, or tender of both legs. Ask patient any pain or tenderness in the leg. Any pain when you breathe, sharp or tightness on the chest which can be emergency issue caused by DVT.
3. Head to toe assessment- inspect patient’s urine output, the color and odor. Urinalysis can detect presence of infection. This test identifies any bacteria or fungal in the urine.
List Complications that may occur related to dx, procedure, comorbidities:
1. Deep vein thrombosis (DVT)
2. Pneumonia from extended bed rest
3. Pressure Ulcer
What nursing or medical interventions may prevent the above Alert or complications?
Management of Care: What needs to be done for this Patient Today?
1. Perform basic assessment such as vital sign, temperature, pulse oximeter, check the radial pulse.
2. Physical therapist is scheduled
3. Reposition patient every 2 hours prevent develops of pressure ulcer
4. Performed urinary catheterization
5. Educate patient about bladder management
6. Educate patient about intake and output
7. Perform skin assessment for ulcer and prevent impaired skin outbreak
Priorities for Managing the Patient’s Care Today
1. Performed urinary catheterization
2. Educate patient about bladder management
3. Physical therapist is scheduled, with progressive mobilization
4. Assis assessment of vital signs
What aspects of the patient care can be Delegated and who can do it?
Assist patient to get out of bed to wheelchair, bathing, eating. Vital signs, repositioning the patient to improve blood flow and prevent pressure ulcer can be done by PCA
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