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Asked by MinisterDanger7303

On Sunday at 13:42hrs, you are about to leave to have your lunch break when Mr McFarlane’s wife calls you from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please can you come and have a look at him?” On entry to Mr McFarlane’s room, you notice the following:

He is lying in a supine position
His breathing is short and shallow
Pale and clammy skin with slight cyanosis around his lips and peripheral extremities
His eyes are closed and not opening when you call his name; eyes open with trapezius squeeze (painful stimuli), and the best motor response is localising.

You have taken a set of vital signs and get the following findings:

RR: 9/min, SpO2:  74% Room Air, BP: 100/60mmHg, HR: 45/min and irregular, Temp: 38.7OC, BGL 2.5 mmol/L

 

 

The Emergency Team have stabilized the condition of Mr McFarlane. However, his condition remains at risk.

Considering your current concerns about Mr. McFarlane, revise his care plan on the template below:

Identify and explain at least one (1) expected outcome(s) Write ONE nursing intervention with rationale that could be instigated for each diagnosis.
Specify at least one (1) member of the multidisciplinary team that may be able to support your suggested interventions.

please don’t use diagnosis pressure ulcers / increase anxiety or stress / falls risk / increase pain

Nursing diagnosis/Client problems

Expected outcome

(please use smart form)

Nursing intervention Rationale

 Multidisciplinary member to provide support

 

 

An increased risk of an VTE 

 

(please use SMART form)      

 

 

An increased risk of secondary potential hypoxia brain injury due to being 74% SPO2 during emergency situation 

 

(please use SMART form)      

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING NCP106

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