Jeff Jones, a 45-year-old male
Jeff Jones, a 45-year-old male patient has arrived to the ERstatus after being ejected from an automobile. He has abackboard with a cervical collar in place. Uponassessment, the patient has sustained a C6 spinal cord injury, aright femur fracture, a right tib/fib fracture, and numerous cutsand abrasions from glass and metal fragments.
VS on arrival to ER: Temp:97.5 Pulse: 40 RR: 16 BP: 88/44 o2:95%on 100% non-rebreather mask.
What is the priority nursing assessments?
What is the priority lab tests/diagnostic test?
What is the priority intervention?
What is the priority Potential & Actual Complications
What is the priority Nursing Implications?
What are the priority Medications?
Answer:
ANSWER
The patient had aa accident and thevital shows especially HR and BP is low, so there is a chance ofhypovolemia. The late symptoms of hypovolemia are bradycardia andlow BP. So the vital signs of the patient should be checked closelyespecially circulatory parameters like HR and BP.
Complete blood count, especially Hbshould be checked. Blood loss can results in anemia. At the sameelectrolytes like sodium, potassium should be checked.
Fluid resusitation to replace thelost fluid from the body and anemia can be corrected by bloodtransfusion.
The complications will behypovolemic shock and anemia.
The role of the nurse is to closemonitoring of neurologic, cardiovascular and respiratory status.Trendelenburg position can be given. The patient ECG can bemonitored to detect arrytmias related to electrolyte imbalance.Skinturgour can be checked.
Crystalloids like .9%NaCl, RL, 3%saline can be given.
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