Concept explainers
To determine:
Listing the priority order of first five interventions?
Case summary:
A 56-year-old school teacher named Mr.Coburn walk-in the health center with hyperthermia, dizziness, and nausea. He is having breathing difficulty while coughing. He was admitted to the hospital with vital signs of RR 22 and easy, pulse 122 and regular, BP 88/50 RA, tympanic temperature 380C (100.4oF), SpO2 92%. A nurse entering his room monitored electronic blood pressure machine is alarmed with a cuff on right arm showing 72 systolic and no diastolic reading. Mr.Coburn turned on his right side and his respirations are labored.
Explanation of Solution
Since Mr.Coburn diastolic blood pressure is null and he is having a high temperature, the nurse should immediately do the following interventions to aid him.
The first five interventions should be the following.
- 1. First, the nurse should call Mr.Coburn’s name or touching him to assess his level of consciousness.
- 2. Next, find Mr.Coburn’s respiratory rate and try to get an assessment of his ventilation effort.
- 3. Move the patient with his head elevated on the bed.
- 4. Obtain a blood pressure of the patient since his vital signs are low.
- 5. Also get an apical pulse to check for dysrhythmias.
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