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0715

Night shift reports to you that Mr. O’Nella has been declining meals since his return from the OR because he is afraid to be in any further pain. He has also had intermittent nausea with a couple episodes of emesis post administration of Dilaudid po.  (Bonus – what could the night nurse have done differently?)

He slept very little and remains awake now. He’s on strict in & outs and voided 275 ml of dark Amber urine & his IVF of RL remain at 100 mL/hr with 725ml TBA. 

He had BW and an ECG this morning at 0615.  

 

0730: Your initial assessment yields the following information:

VS  
Temp  36.5oC
Pulse 118
Respirations 24
BP 96/58
SPO2 95% 2L NP
Pain 7/10 – ABD/Incision area

 

*Only changes from your previous H2T are listed below*

Head to Toe Assessment  
Neuro Lethargic, O X 3 spheres but slow to respond. Pupils 5+ bilaterally. 
Respiratory O2 is 95% with 2L via NP 
Cardiovascular Apical rate 116 strong & irregular. Cap Refill 3 sec bilaterally 
Abd Tenderness to all quads. C/O N&V – last emesis was at 0545 – decreased appetite
Skin Integrity Tanned, cool, & clammy

 

ABG’s Results
pH 7.29
PaCO2 48
HCO3 28

 

1. Based on your 0730 assessments, what fluid volume disorder could be occurring? /1  

 

2. What data from your morning assessment would support or validate your answer to #13? /6

 

3. Interpret the ABG’s. Is he in a respiratory or metabolic state and is it alkalotic or acidotic?  /1

 

4. Along with the ABG results, what other signs and symptoms does Sam have that would further indicate this type of acid-base imbalance? /6

 

 

 

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