It is 11.00 am and you are working the Surgical Tele floor. Youare taking care of Ms. J.S. who is a 35 y.o. female AfricanAmerican patient with a history of hypertension and high bloodsugar due to the Cushing’s disease and Adrenal tumor she has.She isscheduled for tomorrow morning for a laparoscopic adernalectomy ofpheochromocytoma. She has a PIV access which is running 0.9% NS at100 ml/hr. Patient received her 09.00 am scheduled medicationsincluding pypertension PO meds, but she has a couple of IV/PO PRNmeds for Hypertension in her MAR. The patient is calling you andcomplains of Severe headache, chest discomfort, dizziness, nausea,and being anxious. You are checking the patient’s vital signs andsee that the BP is 240/120, HR is 124 ST on tele, RR is 30, Sp02 is95% RA, and temp is 100.0 F.
1. What is your highest priority nursing interventionfor this patient and why?
2. What would you like to recommend as your ISBARprocess?
