Answered: PERRLA • Motor and sensory function…

An Illustrated Guide To Vet Med Term

4th Edition

ISBN:9781305465763

Author:ROMICH

Publisher:ROMICH

Chapter17: Drugs And Dissection

Section: Chapter Questions

Problem 1.2CS

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Question

Kngwarreye is a 60 yr old Anmatyerre woman from Urpuntia in
Central Australia. She has been referred and admitted to hospital for
exacerbation of her COPD. She is currently receiving increased regular
salbutamol, oral steroids in addition to her regular medications and
intensive respiratory physiotherapy rehabilitation before returning to her
community in the next week.
 Hx COPD, cor pulmonale
 It is 0800 and you attend to undertake her observations. She looks at
you vaguely and asks where she is. However, after a moment she
seems fine. She seems a bit agitated and says she doesn’t want
breakfast because she feels like she needs to vomit.

P: Provoking Factors: coughing and taking a deep breath
Palliative Factors: Nothing makes me feel better
Q: aching
R: Everywhere
S: “not too severe, I just don’t
feel right”.
T: “I woke up during the night
feeling hot all over”.

BP: 104/68 mmHg
• HR: 112bpm
• RR: 26 bpm
• Temp: 38.1°C
• Sp02: 87% on RA

Cardiac
Assessment
findings
 Pulse – Regular, rapid and
palpable
 JVP - not visible
 Peripheries are warm
 Pale
 CXR - Nil evidence of enlarged
cardiac shadow or lung changes pre-
operatively.
 ECG – Sinus Tachycardia

Respiratory
Assessment
• Dyspnoeic
• Increased Work of
breathing
• Generalised Bilateral
crackles
• Decreased lung sounds L
side
• Chest Xray – Extensive L
sided chest consolidation all
fields.

Neurological assessment
• LOC: A&O x3
• PERRLA
• Motor and sensory function
intact
GCS: 15- but slow to respond

BGL: 4.1 mmol/L

UA: negative

Her fluid intake is 700 ml since last 7 hours out of which 700 ml completed and commenced another 1000ml commenced at 7am in morning urine out put is 180 ml in last 7 hours

Question: Nursing diagnosis 2 GOALS, ACTIONS, RATIONALE and EVALUATION( words 300)

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