1. Lisa, a 52 year old athletic woman had recovered from the flu whichshe had two weeks prior. She fell getting out of bed one morning. After a second attempt to stand and walk she called her husband who took her to Sunnybrook hospital emergency. Within 10 hours she became paralyzed from head to toe and was transferred to ICU where she was on a ventilator for 3.5 months. She was diagnosed with Guillain Barre. Write a SOAPIE documentation note and DAR Data Action Response ? 2. By day 2 Lisa was paralyzed from head to toe. She could not smile, blink, swallow or talk. She had edema in her legs. She had a reddened area on her left calf that was warm to touch and her toes were pale and cold on her left foot. Lisa’s daughter asks “Why are her legs swollen and what is this read spot”? What may be the cause of the red, warm area on her calf? What are the appropriate nursing interventions to prevent DVT? Identify Subjective and Objective Data?. 3. By day 10 Lisa was requiring frequent suctioning of green mucous via her endotracheal tube. Her oxygen saturation had dropped to 88. He temp was 39.5 and her pulse was 98. Lisa’s husband asks you why the oxygen alarm keeps ringing on the monitor and why Lisa’s hand and face feel hot. Why ? What are the most appropriate interventions is this scenario? How can this be prevented moving forward because Lisa will be in ICU for a long time? Identify Subjective and Objective Data? 4. Lisa has not had a bowel movement in 3 days. Why and what is an appropriate nursing intervention? Identify Subjective and Objective Data? 5. Lisa has cloudy foul smelling urine noted by the RN when the foley catheter bag was being emptied. Lisa has a temperature of 39.4. Lisa’s sister, Mary asks what the smell is. Why? What are the most appropriate interventions is this scenario? How can this be prevented moving forward because Lisa will be in ICU for a long time? 1. Identify subjective and objective data.2. Identify what would be an appropriate intervention for Lisa’s nursing diagnosis ? 6. Lisa has red elbows and heels. Lisa’s friend Jan asks how they are preventing skin breakdown. Why ? What are the most appropriate interventions is this scenario? How can this be prevented moving forward because Lisa will be in ICU for a long time? 7. Lisa is an avid snowboarder and her son qualified for the Canadian Olympic Team. “We have to make sure that mom’s muscles and joints still work when this is over” Why ? What are the most appropriate interventions is this scenario? How can this be prevented moving forward because Lisa will be in ICU for a long time? Identify subjective and objective data? 8. Lisa often has tears coming from her eyes. She may be crying but we don’t know because she cant communicate. She has a family member at her bedside all day every day as well as many friends visiting. Can you imagine being completely aware and being unable to communicate or move. What would it be like for you? What are the most appropriate interventions is this scenario? How could you develop a long term plan for Lisa? Identify subjective and objective data? Health Science Science Nursing NURSING NUR 110 Share QuestionEmailCopy link Comments (0)
Recent Comments