Question

Situation/Transition:

Upon nurse entering room, the patient is lying supine in bed with the head of bed at 30 degrees. His personal appearance is disheveled and his room is a mess. He is experiencing alcohol withdrawal manifested by anxiety, agitation, tremors, disorientation, and sweats.

Physiologic State

Temp = 99.5 F (37.5 C)

Blood Pressure = 162/100

Pulse = 122

Respiratory Rate = 24 •

Heart sounds: Regular •

Lung sounds: Clear bilaterally, diminished in bases •

Bowel sounds: Hypoactive •

Pulses: 2+ throughout •

Pain: 4/10 •

Patient states, "I feel terrible right now. My hands are shaking when I put them out at my sides!"

Questions:

1.What are abnormal findings?

2. What are the nurse’s priority interventions?

Answer 1

Answer 1: The abnormal findings includes :

• The abnormal blood pressure. The 162/100 shows increase blood pressure.
• The increased pulse rate that is 122. The normal pulse rate should be 60- 100 beats per minute.
• The respiratory rate should be in between 12- 16. But here it is 24, which shows the abnormalities.
• Lungs sound diminish at the bases. This indicate the presence of the fluid at the base.

Nursing intervention:

• The nurse should intervene about the respiratory rate of the patient.
• The nurse should ask for the diagnostic test and x- ray of the chest of patient.
• The nurse need to take blood samples for the culture.
• The nurse should intervene about the the breathing patterns.
• The nurse need to provide oxygen ( ventilation) to the patient.