Posted: November 1st, 2022

A 70-year-old female

Medical

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A 70-year-old female has been admitted to the hospital. The consumer has had nausea and vomiting for the previous three days. Upon admission the consumer is barely confused and weak. Her important indicators are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her ache stage is an “eight”on a scale of Zero-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the correct and left decrease quadrants and within the left higher quadrant. Stomach is difficult and distended. When questioned as to her final bowel motion, the consumer responds, “I’ve not moved my bowels in over one week.” Mucous membranes dry; pores and skin turgor poor. The stomach is difficult and swollen. When requested when she had her final bowel motion, the consumer says, “I have not moved my bowels in over every week.” Mucous membranes are dry, and pores and skin turgor is low.
The well being care supplier (HCP) orders the next:
IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When accomplished infuse LR at 100 mL/h
Insert indwelling urinary catheter to straight drainage
Get hold of urine Assessment (UA) and urine tradition and sensitivity (C& S)
Insert nasogastric (NG) tube to intermittent suction
Food plan: NPO
Vitals indicators each four hours
Labs: CBC and electrolytes stat
Monitor I & O each shift
Questions:
The HCP ordered 1 Liter of LR to infuse over 6 hours. Calculate the move price you’ll program the infusion pump. _____________________mL/h (spherical to the closest entire quantity).
The consumer states she has ache to her left forearm 4 (four) hours after the beginning of the infusion. Upon inspection and palpation of her forearm, the nurse notes redness and swelling on the IV website and the forearm is heat to the touch. What’s the preliminary motion the nurse ought to take?
What are the really useful nursing interventions when an IV turns into infiltrated? What are the really useful nursing interventions when phlebitis is famous?
A urine tradition C& S is ordered. How would the nurse receive a urine C& S from a indwelling urinary catheter?
To whom can the nurse delegate the duty of taking the urine pattern to the labatory? How ought to the specimen be transported?
After an X-ray has confirmed placement of the NG tube, how would the nurse verify for placement previous to the administration of medicine(s) and/or feeding(s) by means of the NG tube?
The nurse is checking placement of the NG tube, what would a gastric pH of four or decrease point out? What would a pH of 6 or increased point out?
Identify two issues that may happen with an NG tube? Record nursing actions to stop these issues.
The consumer asks the nurse if she might have a glass of water as a result of she is extraordinarily thirsty. What’s the greatest response for the nurse to make?
The consumer’s lab outcomes have returned. What findings (urine and serum) would point out dehydration?
What can be a precedence nursing analysis for this consumer? Record one short-term purpose. Record three interventions in your precedence nursing analysis.

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