Question

After 8 hours on your unit, Ms. Schmidt is attempting to get out of bed and speaking about random things with an inability to focus on your questions. Her skin is hot, RR is 32, pulse is 102 and her BP is 140/78. The pulse ox alarm is going off and reads 89%. She keeps trying to take off her oxygen and the pulse ox probe. Her lungs have crackles bibasilar and in the right middle lobe. She has a nonproductive cough. She is not able to give a subjective pain level. Urine output is sufficient and her IV is intact. What is your next nursing intervention and what MD orders do you anticipate

Answer 1

Ans) Postoperative delirium – This is a temporary condition that causes the patient to be confused, disoriented, unaware of their surroundings, and have problems with memory and paying attention. It may not start until a few days after surgery, comes and goes, and usually disappears after about a week.

Nursing Interventions:

- Orient the patient, try to stabilize.

- Keep one relative/ care taker with the patient so that unnecessary behaviour of patient is btought to the notice of the health care provider at once.

- Monitoring the patient every hourly.

- Notify any deviations to the physician.

- Carry out all due orders of the physician as prescribed.