prioritize the following five recommended nursing interventions asyou, the nurse would do them to initially take care of Mr. T. I ama number in the box identify the order of your interventions andstate a rationale for each intervention.
The interventions are:
assess for bed alarm and safety features
administer a see the element in 500 mg tabs
gather urinary output data
assess mental status
perform a body systems physical assessment
Transcribed Image Text from this Question
2-17 THE PATIENT WITH UROSEPSIS 163 2-17 THE PATIENT WITH UROSEPSIS 1500 Handoff Report s Mr. TD.79 years old. was admitted today to the hospital with the diagnosis of resepsis. He has an IV of lactated Ringer’s infusing at 100 ml/ht . Ceftriaxone IIVPB GAM is ordered. He is on 1 & 048h. soft diet, bathroom privileges with assistance, and acetaminophen 500 mg tabs i po gth for temperature greater than 38°C. His 2:00 PM VS wete T38CP 78, R22. BP 146/88, pulse on 96. He has been more restless this afternoon, trying to get out of bed and disoriented to time and place. His urine kadark yellow and cloudy. He was mowed closer to the nurse’s station to assist with frequent monitoring Mr. TD lives alone. His daughter took him to the doctoe when she visited him and found that he had a fever and he complained of frequent urination and incontinence. His oral intake has been minimal The certified nurse autant reports to you the change of shifi VS of T38.8°C. P 88, R 24, BP 164/80, The following nursing interventions are recommended initially 2 Priority Setting and Decision Making pole or 97% Prioritize the following five recommended nursing interventions as you. the nurse, would do them to initially sale care of Mt. TD. Write a number in the box to identify the order of your interventions (#1 – first interven tur + second intervention, etc.), and state rationale for each intervention Interventions Rationale Priority # * Alles for bed alarm/safety features * Administer acetaminophen 500 mg tabs i Gatherinary output data • Aumental status Perform a body system physical KEY POINTS TO CONSIDER Ellac. All reserved 164 SECTION TWO. My Sand DeMag You perform a followment ar 700 PM and the following 1. VST385C 198 R22 RP 1207.be 3. He is sleepy, lethargic He winnt of a sant mont of urine Collaborative Learning Activity: What do the following: (1) select the one nursing diagnosis that is a pelety at this time. (2) provide a nationale for your selection, and (3) list the ing and Design Making 2 Pricity interventions that you to meet the needs of the patient All of the following using diagnoses may apply to Mr. T. Ride for impaired skin integrity. Impaired urinary elimination, Risk for injury, Acute confusion. Hyper- thermie. Deficient huid volume, and attitor less than body requiremenes, Risk for shock, Ine. fective breathing pattern, Futiget Nursing Interventions Rationale Nursing Diagnosis As you take his 8:00 PM vital signs, you ases the following tips and symptome: Lethargic, skin very warm and flushed. VS. T 39.1°C. P 130, R 28. BP 90/54, polic ox 88% Based on the situation at 8:00 PM, identify and write the priority problem in the box below. Then, starring with the wall box labeled 1, prioritize the nursing interventions for this situation and identify your follow up action plan for Me TD NURSING INTERVENTIONS DECISION-MAKING DIAGRAM A. Check pulse ox B. Prepare to start New Action Plan C. Prepare to Insert Indwelling urinary catheter D. Take vital signs 45min E. Record findings E Notify physician NOTES Priority Problem Caro 2015 Elsevier Inc. All
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