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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

The nurse on an intensive care unit is caring for an 83-year-old female admitted for a urinary tract infection and sepsis. The patient has been in a nursing home following a cerebrovascular accident resulting in right-sided weakness and paresthesia. The patient appears to be malnourished with sunken skin over bony prominences. During the shift assessment, the nurse notes a reddened area of intact, nonblanchable skin on the sacral areas. The head of the bed is elevated because the patient is at risk of aspiration with feedings.
1 .
How should the nurse assess the skin?
2 .
What factors increase this patient’s risk of skin breakdown?
3 .
What things can the nurse do to prevent further damage and promote healing?
4 .
You are caring for a patient who is recovering from a laparotomy surgery. The patient has been coughing all morning. The patient states that it “feels like something has come undone.” Upon examination you see that a section of the surgical incision has come apart. What should you do?
A patient is brought to the emergency department by ambulance at 7 p.m., approximately an hour after a house fire. The patient has second- and third-degree burns on their left side, including the left side of their head, their left arm and leg, and left torso and back. The nurse and receiving physician agree that the TBSA of the patient’s burn is 49.5 percent. The patient received 1,000 mL of lactated Ringer’s in the ambulance. The patient weighs 141 lb (64 kg). Using the Parkland burn formula, answer the following question about what the nurse should do.
5 .
How much fluid and what type of fluid should the nurse give the patient in the first twenty-four hours?
6 .
How much more fluid and at what rate should the nurse give the patient over the next seven hours?

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