Question

Mrs. Space has returned from the short procedure unit as she underwent excision of her tonsils.

Orders are as follows:

Nothing by mouth (NPO) except for ice chips                      

Bathroom Privileges (BRP)

Ancef 1 gram IV every 6 hours         

Intake & Output (I&O) q shift                                                    

D5 ½ NS + 40 mEq KCL @ 125mL

Labs:  

Na =   130 mEq/L (136-145 mEq/L)              Cr = 0.7 mg/dl (0.5-1.1 mg/dl)

K =    5.0 mEq/L (3.5-5.0 mEq/L)                  Glucose = 222 mg/dl

Cl = 100 mEq/L (98-106 mEq/L)                  

BUN = 11 mg/dL (10-20 mg/dL)

Operating Room Report:

Intake: Crystalloid- 2050 mL

Output: Urine- 150 mL, Estimated blood loss (EBL) - 500 mL

A) Based on the information provided, identify physical assessment data needed to plan for her care and information will you share with the provider caring for this patient?

B) Based upon your discussion, what changes to Mrs. Space’s orders should you expect and why?

C) How will you evaluate the effect of your interventions and what do you expect to find?

Answer 1

A) The following physical assessment data that needed plan of care are

• Post operative care (tonsillectomy )
• Administration of medication (IV site care)
• Assisting in mobilisation (early mobilisation)
• Maintaining intake and output chart
• Initiation of oral diet as per order and patient status

B) As the blood glucose level is high Dextrose has to be discontinued (to prevent further hyperglycemia ) .Stop KCL drip as the levels are within normal range (to prevent hyperkalemia)

Half percent NS has to be replaced by 0.9% NS as the patient is having hyponatremia

C) The following evaluation can be done to know the effectiveness of the intervention

• Patient will be on normal mental status (as confusion can occur in hyponatremia)
• The blood glucose level should have returned to normal range