VS = vital signs, just need to fill in blanks, no need to get to crazy 180 SECTI
ID: 138875 • Letter: V
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VS = vital signs, just need to fill in blanks, no need to get to crazy
180 SECTION TWO Priority Setting and Decision Making an intraocular lens implant and is taken to a room for monitoring. She has an eye patch on her right eye and you assess the following 1. Pain level 0, P 88, BP130/82, pulse ox 96% 2. Eye patch clean and dry 3. Readily responds to verbal stimuli Collaborative Learning Activity: With a partner, do the following: (1) select the one nursing diagnosis that is a priority at this time, (2) provide a rationale for your selection, and (3) list the nursing interventions that assist you to meet the needs of the patient. All of the following nursing diagnoses may apply to Mrs. G Risk for injury, Deficient knowledge, Fear, Anxiety, Risk for infection, Ineffective health maintenance Impaired home maintenance Nursing Diagnosis Rationale Nursing Interventions Mrs. G is discharged and given eye drops and eye patches for daily use. Mrs. G and her daughter are given postop instructions. Mrs. G's daughter will take Mrs. G home and stay with her today and will visit every day during the week. On the third postop day, the office nurse calls Mrs G Based on the questions asked by the office nurse and Mrs. G's responses, identify the response that requires fur- ther follow-up. Provide a rationale for the questions asked by the office nurse. Office Nurse Follow-Up Questions 1. Your eye drops are ordered 4 times per day. Mrs. G's Responses Are you able to put them in yourself? 2. How often are you taking the medication 1. I put the morning and afternoon drops in and then my daughter helps with the evening and night eye drops. 2. I took one tablet last night but have not used any this acetaminophen for pain? 3. Are you having any discharge from the eye?3. I have drainage that is clear and I do have some itching. 4. It is important that you do not pick up heavy 4. I am taking it easy. The only problem I have is some mornin objects or bend from the waist. constipation. Question 1 Rationale: Question 2 Rationale: Question 3 Rationale Question 4 Rationale: apyright2018, Elsvier Inc. All rights reserved.Explanation / Answer
intervention priority no rationale vital sign #1= first intervention it need to assess first because without knowing vital we cant go for sign surgery consent. if vitals increased or decreased that time may need to shift the timing of surgery. so it is important and first prioritised to know about the status of vital organs.
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