The Nurse Reviews Ms Jacksons Preoperative Lab Test Results Drawn Earlier in the Week
Applied Nursing Process for the case written report. Give at least one...
Image transcription text
ICase Study Helen Jackson, a 63—year—erstwhile Caucasian female, anives at the surgery eye for her preoperative appointment. She is scheduled to undergo left hip replaceth surgery in 1 week The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. 1. Which vital sign requires follow—up past the nurse? — BF of lfiflfES. This blood pressure is elevated and requires further action by the nurse. The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications, hydrochlorothiazide fl-Iydrodiuril), a diuretic, and warfarin [Coumadin}, an anticoagulant, every day for over a year. 2. What nursing activity is almost important?' — Explicate the need to hold the warfarin priorto surgery. The nurse so reviews Ms. Jackson'due south preoperative lab test results, drawn before in the calendar week. 3. Which serum lab value requires follow—up by the nurse? —W'EC of 14,00flimm3. The nurse talks with Ms. Jackson well-nigh what to expect the twenty-four hour period of surgery and during the immediate postoperative flow. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in through her mouth deeply and exhaling through pursed lips forcefully and chop-chop. 4. What action should the nurse implement? — Demonstrate the deep breathing and cough technique again. When the nurse begins pedagogy about the benefits of early mobilization following surgery, Ms. Jackson states, "011,1 know ifI stay inbed very long I will getbedsores."r 5. How should the nurse reply? — "Bedsores are ane of many problems that can occur from prolonged bedrest." The nurse discusses postoperative pain management with Ms. Jackson and explains the use of a patient— controlled analgesia {PEA} pump. Ms. Jackson expresses fright that she might accidentally overdose herself, since she volition exist sleepy after surgery. 6. How should the nurse respond? — I"The pump has a control device that prevents yous from taking also much medicine." While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes that Ms. Jackson begins to cry. 7. What activity should the nurse take? — Quietly sit with the client. Afterward Ms. Jackson stops crying, she states, I"My male parent was in so much hurting before he died. Talking about pain brings back so many memories." 3. How should the nurse answer? — "It sounds as if you went through a difficult time when your father died."r
Image transcription text
The next week, Ms. Jackson arrives at the surgery center iii hours before her scheduled surgery. 9. Which question is about important for the nurse to ask Ms. Jackson during the admission interview"? — "Have you had anything to eat or beverage since midnight?" After completing the admission interview, the nurse reviews Ms. Jackson'due south medical record and notes that the surgical consent form is filled out but is non signed by the client. Hi. What action should the nurse take? —Ask Ms. Jackson if she has received sufficient information to sign the consent form. The nurse observes that the word, I"Yes"r has been marked on Ms. Jackson'due south left hip, and the discussion, "No" has been written on her right hip. xi. What activeness should the nurse implement? -Confirm that the left hip is the site of the scheduled surgery. Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the DR. table. Afterward full general anesthesia is induced, the nurse positions Ms. Jackson for surgery. 12. Which nursing diagnosis has the highest priority at this fourth dimension? - Risk for asdvasratissmsiticatva injury- lIZl'ncae the DR team has assembled in the room, the circulating nurse calls for a time out. 13. What action should the nurse take during the time out'lll —Review the scheduled procedure, site, and client. Following surgery, Ms. Jackson is admitted to the Mail service Anesthesia Care Unit. The operative written report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 916'" F, P 33, R. 14, and HP lflflf'fifty'fl. 14. What action should the nurse implement first? — Position the client on her side. While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. 15. How should the nurse certificate this finding? — Left hip dressing make clean, dry, and intact. The nurse continues the postoperative assessment. 16. To assess for atelectasis, what action should the nurse take? —Auscultate the client's breath sounds. The nurse determines that Ms. Jackson's bowel sounds are hypoactive. 1?. What action should the nurse implement in response to this finding? —Document the assessment finding in the chart.
Image transcription text
During the postoperative assessment, the nurse observes Ms. Jackson'southward surgical site. The left hip dressing has a moderate amount of sanguineous drainage. 13. What action should the nurse implement? [select all that apply] - Marker the corporeality ofdrainage on the dressing. — Observe the linens under the hip. The erse observes that the Hammer; drain is full of sanguineous drainage. xix. What action should the nurse implement first? — Empty the drain and measure the amount. The erse notifies the surgeon of the wound drainage. 2D. What lab data is important for the nurse to study to the surgeon?— — Hemoglobin and hematocrit. Based on the lab data provided by the nurse, the healtheare provider prescnbes the transfusion oftwo units of packed red blood cells as soon equally possible. In one case the first unit of packed red claret cells is ready, the nurse obtains the claret from the claret bank. When the erse enters Ms. Jackson's room to begin the transfusion, the UHF is giving Ms. Jackson a partial bath. 21. What action should the nurse take? —Hang the transfusion of packed cells while the HAP continues to consummate the client'due south personal care. Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of TS mlfhour. 22. in transfusing the 251] ml unit ofpacked scarlet claret cells, what activity should the nurse implement? —Cease the N solution and transfuse the packed cells at 125 mhhour via tubing connected to a bag of saline solution. The ii units of packed RBCs are transfiised without complexity. The drainage begins to decrease, and Ms. Jackson's hemoglobin and hematoerit remain stable. The erse is assisting Ms. Jackson to the bedside commode on the second postoperative twenty-four hour period. Ms. Jackson states, "I have never had to depend on anyone before. I similar to take intendance of myself. I experience so helpless."r 23. In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? — Situational low cocky—esteem. The erse teaches Ms. Jackson safe transfer techniques and consults with the concrete therapist to begin ambulation activities as soon every bit possible. 24. What is the rationale for the inclusion of these actions in Ms. Jackson's plan of intendance? increased mobility volition promote an improved sense of command. Later Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. 25. Atwhat step inthe procedure should the nurse don sterile gloves? — Earlier cleansing the client'south hip incision.
Image transcription text
While cleansing the incision, the nurse observes that the staples are intact, just a 2 cm gap has opened at the lesser ofthe incision. as. How should the nurse document this finding?I —Srnall surface area of dehiscence at bottom of incision. Case Effect Ms. I ackson's surgical wound continues to heal slowly and she is discharged fi'oni the inpatient surgery center. She continues to receive physical therapy until she is once again completely independent.
- Practical Nursing Process for the case study. Give at to the lowest degree one example for each function of the nursing procedure
Answer & Explanation
Solved by verified proficient
<p>molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Na</p> Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet
Unlock full access to Course Hero
Explore over 16 million pace-by-pace answers from our library
Subscribe to view respond
l laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit down amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices air conditioning magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolo
, dictumor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odi
, dictum
s a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit down amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices air-conditioning magna. Fusce dui lectus, congue vel laoreet air conditioning, dictum vitae odio. Donec ali
, dictum
cing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus dues, dapibus a molestie consequat, ultrices air conditioning magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem
ongue vel laoreet a
sum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectu
, dictum
rem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui l
ctum vitae odi
sque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices air conditioning magna. Fusce dui lectus, congue vel laoreet air-conditioning, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus dues, dapibus a molestie consequat, ultrices ac magna. Fusce dui l
, dictum
e vel laoreet air conditioning, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus dues, dapibus a molestie consequat, ultrices air-conditioning magna. Fusce dui lectus, congue vel laoreet
congue ve
m risus ante, dapibus a molestie consequat, ultrices air-conditioning magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit down amet, consectetur adipiscing elit. Nam lacinia pul
, dictum
dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet air conditioning, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet,
Source: https://www.coursehero.com/tutors-problems/Nursing/27525123-Applied-Nursing-Process-for-the-case-study-Give-at-least-one-example/
Post a Comment for "The Nurse Reviews Ms Jacksons Preoperative Lab Test Results Drawn Earlier in the Week"