Priority nursing diagnoses

A 70-year-old female is admitted to your unit for changes in bowel/bladder function. Her initial lab work was WNL. Her baseline vital signs were BP 124/62, HR 84, RR 20, Temp 98.4.  The MD performed a bowel resection after it was determined that the pt has colon cancer. Post-operatively the pt is taken to a medical/surgical unit. She has an IV of NS at 100ml/hr., and an NGT to intermittent suction, a foley catheter, and a midline abdominal dressing that is dry and intact.

You are assigned the patient post-op day one. Her VS @ 0700, BP 100/60, HR 104, RR 24, Temp. 99.2 orally. the pt is alert and oriented; her color is pale. the NGT is draining brownish-green mucous, the abdominal dressing is D/I, and the IV is at 100 ml/hr. The pt says, “I’m so tired and I feel so nauseous, and it hurts to move.”

The physician ordered the pt to be out of bed. When sitting at the bedside at 1000, the pt states, “I don’t feel very well.” after waiting 30 seconds, the nurse assists the pt to the chair. The pt becomes dizzy and her bp is 90/64, HR 114, and the urine output has been 70 ml since 0600.

1) What would you do first with this pt? List 3 priority interventions you would implement at this time?

2) List 2 categories of medications that you may be administering to this pt and give an example in each category? (remember, the pt has an ng tube)

3) State 2 priority nursing diagnoses?A 70-year-old female is admitted to your unit for changes in bowel/bladder function. Her initial lab work was WNL. Her baseline vital signs were BP 124/62, HR 84, RR 20, Temp 98.4.  The MD performed a bowel resection after it was determined that the pt has colon cancer. Post-operatively the pt is taken to a medical/surgical unit. She has an IV of NS at 100ml/hr., and an NGT to intermittent suction, a foley catheter, and a midline abdominal dressing that is dry and intact.

You are assigned the patient post-op day one. Her VS @ 0700, BP 100/60, HR 104, RR 24, Temp. 99.2 orally. the pt is alert and oriented; her color is pale. the NGT is draining brownish-green mucous, the abdominal dressing is D/I, and the IV is at 100 ml/hr. The pt says, “I’m so tired and I feel so nauseous, and it hurts to move.”

The physician ordered the pt to be out of bed. When sitting at the bedside at 1000, the pt states, “I don’t feel very well.” after waiting 30 seconds, the nurse assists the pt to the chair. The pt becomes dizzy and her bp is 90/64, HR 114, and the urine output has been 70 ml since 0600.

1) What would you do first with this pt? List 3 priority interventions you would implement at this time?

2) List 2 categories of medications that you may be administering to this pt and give an example in each category? (remember, the pt has an ng tube)

3) State 2 priority nursing diagnoses?