{"id":137684,"date":"2024-09-13T10:58:09","date_gmt":"2024-09-13T10:58:09","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=137684"},"modified":"2024-09-13T12:54:11","modified_gmt":"2024-09-13T12:54:11","slug":"patient-data-2","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/13\/patient-data-2\/","title":{"rendered":"The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion"},"content":{"rendered":"\n<p>Patient Data<\/p>\n\n\n\n<p>History and Physical<\/p>\n\n\n\n<p>The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.<\/p>\n\n\n\n<p>Nurses&#8217; Notes<\/p>\n\n\n\n<p>0700: Labs were drawn and completed during a preadmission visit. After changing clothes and settling into bed, she was placed on continuous monitoring. Admission process was completed.<\/p>\n\n\n\n<p>0800: A PIV was started in her right antecubital with a 20-gauge intracath. IVF of NS was started at 50 mL\/hr. The cardiac surgeon came to see the client and answer her questions about the procedure.<\/p>\n\n\n\n<p>0830: The client reports no known allergies. Vancomycin 1 gram in 250 mL NS was started at 125 mL\/hr as endocarditis prophylaxis.<\/p>\n\n\n\n<p>0840: The client was awaiting transfer to OR. Vancomycin was infusing at 125 mL\/hr.<\/p>\n\n\n\n<p>0845: The client says, &#8220;I don&#8217;t feel well.&#8221; Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108\/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.<\/p>\n\n\n\n<p>0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.<\/p>\n\n\n\n<p>Orders:<\/p>\n\n\n\n<p>1140<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Diphenhydramine 25 mg IV now<\/li>\n\n\n\n<li>Methylprednisolone 100 mg IV now<\/li>\n<\/ul>\n\n\n\n<p>The nurse is implementing the plan of care.<\/p>\n\n\n\n<p>For each body system, select to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.<\/p>\n\n\n\n<p><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\"><strong>The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Nursing Interventions by Body System<\/h3>\n\n\n\n<p><strong>1. Cardiovascular System<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Monitor Vital Signs:<\/strong> Continue to monitor the patient\u2019s blood pressure, heart rate, and rhythm closely. Given her history of bradycardia and current hypotension (BP 108\/46 mmHg), vigilant monitoring is essential to detect any significant changes that may indicate worsening conditions or complications from the reaction.<\/li>\n\n\n\n<li><strong>Assess for Symptoms of Hypotension:<\/strong> Observe for symptoms such as dizziness, lightheadedness, or changes in mental status that could indicate worsening hypotension or shock.<\/li>\n<\/ul>\n\n\n\n<p><strong>2. Integumentary System<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Monitor Skin Reaction:<\/strong> Observe and document the extent and progression of the flushing, redness, and hives. This will help in assessing the severity of the allergic reaction and effectiveness of interventions like diphenhydramine and methylprednisolone.<\/li>\n\n\n\n<li><strong>Apply Cool Cloths:<\/strong> Continue using cool cloths to alleviate discomfort from flushing and burning sensations. This also helps in managing systemic reactions and provides symptomatic relief.<\/li>\n<\/ul>\n\n\n\n<p><strong>3. Neurological System<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Assess Mental Status:<\/strong> Regularly check for changes in the patient\u2019s mental status, such as confusion, irritability, or decreased responsiveness, which could indicate worsening of the reaction or a potential secondary issue like low blood pressure.<\/li>\n\n\n\n<li><strong>Monitor for Headache and Dizziness:<\/strong> Given the patient\u2019s report of a headache and dizziness, monitor these symptoms closely as they could be associated with her low blood pressure or allergic reaction.<\/li>\n<\/ul>\n\n\n\n<p><strong>4. Gastrointestinal System<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Monitor for Nausea and Vomiting:<\/strong> Assess the patient for signs of nausea and vomiting, which are part of her symptoms and could contribute to dehydration or electrolyte imbalance, especially if she cannot tolerate fluids or medications.<\/li>\n<\/ul>\n\n\n\n<p><strong>5. Respiratory System<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Assess Respiratory Status:<\/strong> Although not directly indicated, monitor for signs of respiratory distress or difficulty breathing as anaphylaxis can sometimes progress to involve the respiratory system. Ensure that the patient is not exhibiting wheezing or shortness of breath.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Explanation<\/h3>\n\n\n\n<p>The patient is exhibiting signs of an allergic reaction to vancomycin, including flushing, redness, hives, dizziness, and hypotension. These symptoms suggest an adverse reaction that needs prompt intervention.<\/p>\n\n\n\n<p><strong>Cardiovascular monitoring<\/strong> is crucial because her low blood pressure may be exacerbated by the reaction, necessitating close observation to prevent complications like shock.<\/p>\n\n\n\n<p><strong>Integumentary assessments<\/strong> are important to gauge the severity of the allergic reaction and the effectiveness of interventions such as antihistamines and corticosteroids. Applying cool cloths helps in providing symptomatic relief and managing discomfort.<\/p>\n\n\n\n<p><strong>Neurological monitoring<\/strong> helps in tracking any changes in mental status or exacerbation of symptoms such as headache and dizziness, which could be linked to her low blood pressure or reaction.<\/p>\n\n\n\n<p><strong>Gastrointestinal monitoring<\/strong> is essential because the patient&#8217;s nausea could impact her ability to tolerate oral medications or fluids, potentially leading to dehydration.<\/p>\n\n\n\n<p><strong>Respiratory assessments<\/strong> are included to ensure that there are no signs of respiratory distress, as severe allergic reactions can progress to involve the respiratory system, although this was not initially evident in this case.<\/p>\n\n\n\n<p>Overall, the selected interventions focus on addressing the symptoms of the allergic reaction, monitoring for complications, and ensuring patient comfort and safety.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Patient Data History and Physical The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-137684","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/137684","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=137684"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/137684\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=137684"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=137684"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=137684"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}