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 1000 ml since last night out of which 700 ml completed and urine out put is 180 ml. Question what would be nursing GOALS?
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 1000 ml since last night out of which 700 ml completed and urine out put is 180 ml. Question what would be nursing GOALS?
Chapter17: Drugs And Dissection
Section: Chapter Questions
Problem 1.2CS
Related questions
Question
ngarla 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.
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”.
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
• 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
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.
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
• 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 1000 ml since last night out of which 700 ml completed and urine out put is 180 ml.
Question what would be nursing GOALS?
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