Question

Case Study: A female is admitted for a total abdominal hysterectomy (TAH) this morning. She is 52 years old and is obese. Her past medical history indicates that she stopped smoking 5 years ago. Both parents are deceased. Mother died at the age of 88 and father died from a heart attack at the age of 62. The client’s vital signs are: T; 97.8, P: 76. R: 18, BP:164/72. The following laboratory studies were done: CBC, PT, serum electrolytes of K+, Na+, serum FBG(fasting blood glucose), BUN, and creatinine. The UA, chest x-ray report, and ECG report are in the chart.

Follow-up case study: The patient returns from the post anesthesia room, sleepy but easily arousable. The physician writes the following postoperative orders:

• NPO-May have sips of water in the AM • IV-Dextrose 5/0.9% Normal Saline infused at 100mL/hr • Ambulate this evening • VS q30 min for first hour, then q1hr x 2hr, then q4h • Incentive spirometer q1h while awake • PCA-Morphine sulfate aet at 1mg/6min per patient demand (not to exceed 30mg/4hr) • Antiembolic stockings and pneumatic compression device to legs continuously • Indwelling urinary catheter to gravity-remove in AM Instructions

Use the follow-up case study to (1) identify which medical order the nurse would do first and (2) list the priority nursing interventions the nurse would independently perform and provide a rationale for each intervention.

Answer 1

1,.First nurse should take the vital signs-checking vital signs will help to understand the patient is stable or not .if any variation in vitals indicates patient has some complications after surgery.so first check the vitals when receive the patient.

2.1.iv infusion of 5% dextrose should be started at the early as patient is nil per mouth.

2.vital signs should be monitored as per the order to find out any complications .

3.sips of water can be given.

4.incentive spurometry to improve breathing status of patient after surgery especially after general anaesthesia.

5.mprphine sulphate if patient has pain.

6.ambulate the patient to improve circulation.

7.provide stockings to prevent DVT after abdominal surgery.

answered by: anonymous