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Medical-Surgical Nursing

What Should the Nurse Do?

Medical-Surgical NursingWhat Should the Nurse Do?

What Should the Nurse Do?

The nurse is caring for a patient who presented to the ED with abdominal pain and fatigue for the past several hours. The patient reports a history of hypertension, PUD, and chronic obstructive pulmonary disorder. Laboratory values obtained include a hemoglobin of 7.8 g/dL and hematocrit of 24%.
1 .
Based on the patient’s medical history and laboratory values, what condition should the nurse suspect?
2 .
Upon ambulating to the bathroom, the patient reports feeling lightheaded. The ED nurse takes the patient’s vital signs, which reveal a blood pressure of 95/55 mm Hg and a heart rate of 117 beats/min. The patient is able to sit on the commode; after wiping, they notice the presence of bright red blood in the stool. What actions are appropriate by the nurse at this point?
Sarah, a 55-year-old female, has been admitted to the ICU after a severe car accident resulting in multiple injuries, including fractures and internal bleeding. She presents with oliguria, indicating decreased urine output, and complains of generalized edema and discomfort in her lower back. Sarah has a medical history of hypertension and type 2 diabetes mellitus, both poorly controlled. On assessment, her blood pressure is 160/100 mm Hg, heart rate is 110 beats/min, respiratory rate is 22 breaths/min, and temperature is 37.8 °C (100.04 °F). Laboratory results reveal elevated serum creatinine and BUN levels, suggestive of AKI. Nurses prioritize assessing her fluid balance, monitoring electrolytes, and implementing measures to optimize renal perfusion.
3 .
What signs and symptoms indicate potential renal dysfunction in Sarah's presentation?
4 .
Considering Sarah's presentation and medical history, what are the primary hypotheses for the cause of her AKI? Consider prerenal, intrarenal, and postrenal causes.
Nikki, a 65-year-old female, is admitted to the ICU after a severe motor vehicle accident. She presents with multiple fractures, including a femoral fracture, and is intubated due to respiratory distress. Nikki reports severe pain in her left thigh and limited mobility. Her medical history includes hypertension and osteoporosis. Upon assessment, her vital signs reveal a blood pressure of 140/90 mm Hg, heart rate of 110 beats/min, respiratory rate of 24 breaths/min, and oxygen saturation of 92% with supplemental oxygen. Additionally, she exhibits signs of muscle wasting and decreased range of motion in her affected limb.
5 .
What physical examination findings might indicate potential musculoskeletal complications in a critically ill patient like Nikki?
6 .
What interventions would you implement to address Nikki's pain and limited mobility while minimizing the risk of further musculoskeletal complications in the ICU?
7 .
What would the nurse advocate for regarding nutritional support?
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