You are a nurse in the medical ICU and take the following report from the ER department ED nurse; "We
have
a patient for you, RL is an 89-year-old frail woman who has been in a nursing home. Her admitting
diagnosis is
sepsis, pneumonia, and dehydration, and she has a known stage 111 right hip pressure ulcer. past
medical;
includes remote cerebrovascular accident with residual right-sided weakness and paresthesia, remote
myocardial infarction, and peripheral vascular diseasea. her vital signs are 98/62, 88 and regular, 38 and
labored, 100.4 F . lab work is pending; she has oxygen at 10L via face mask, an IV of D5. 45NS at 100ml/hr
and an indwelling foley. The infectious disease doctor has been notified and respiratory therapy is with the
patient. They are just leaving the ED and should arrive shortly.
Review the scenario provided.
- Identify the abnormal vital signs in the scenario.
- Identify the abnormal assessment findings in the scenario.
- Identify 3 client-specific risk factors that impact skin integrity.
- Identify two priority (physical) nursing diagnoses for the client: one that addresses skin/tissue integrity
and
one for oxygenation.
- Identify a goal for each nursing diagnosis.
- Identify 2 SMART outcomes for each goal.
Respond with another; where you; Identify 5 client-specific nursing interventions (2 assess, 2 do and 1
teach)
for the skin/tissue integrity nursing diagnosis. Identify 4 client specific nursing interventions (2 assess and
2 do)
for the oxygenation nursing diagnosis.