Question

What priority nursing actions apply to the case study (Saunders document along with page number)

Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with minimal assistance. Family at beside. Dr. Sangerstien

Answer 1

Answer:

From the given scenario, patient is having post operative hyperthermia.Nursing interventions are,

1.Apply cooling measures( tepid bath,cold packs, cooling blanket).

This measure helps to promote coolinglower the core temperature.

2.Administer antipyretics.

Antipyretics lower the body temperature by blocking the synthesis of prostaglandin that acts is hypothalamus.

3.Monitor intake and output.

To determine the need of fluid resuscitation if he is dehydrated.

4. Eliminate excessive clothing.

Exposing skin too room air reduces warmth and increases evaporative cooling.

5.Keep ready the oxygen therapy.

Hyperthermia increases the metabolic demand of oxygen.

6. Educate the patient and family regarding his condition , and management.

To relieve anxiety.

7. Recheck the vital signs.

To evaluate the outcome.