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Medical-Surgical Nursing

Chapter 33

Medical-Surgical NursingChapter 33

Read the Electronic Health Record

1.
Sample answer: Low BP, skin cool to touch, tachycardic heart rate.
2.
Sample answer: Perform a more thorough peripheral vascular assessment, look for capillary refill in the limb with the surgical intervention, check for edema, pulse quality.
3.
Sample answer: The patient may go into early compartment syndrome from the trauma and surgical intervention; if there is a pulse deficit, this is a medical emergency and warrants a call to the provider. An ECG may be done as hyperkalemia can be driving the tachycardia, which is a sign of compartment syndrome/crush injury.
4.
Answer may include rhabdomyolysis and the patient may need an emergent intervention.
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