- The nurse asks you to obtain a complete set of vital signs for one of the persons to whom you are assigned. The measurements are as follows: temperature 101.5º F, heart rate 104 beats/min, respiratory rate 22 breaths/min, and blood pressure 90/60 mm Hg. Which of these vital signs are of concern? What subjective data could be stated? What is your first action after collecting these vital signs?
The person for whom you are caring had the following for breakfast: 4 fl oz of milk, 6 fl oz of coffee, scrambled eggs, and one piece of toast. The person voided 4 fl oz of urine this morning. What is the person’s fluid intake in milliliters? What is the fluid output in milliliters?
26 Comments
Channdara Gnoy
3/11/2014 12:27:55 pm
1. All of the vital signs are of concerned but the high temperature is most important because the temperature maybe the cause of the low blood pressure, fast heart and respiratory rate. A subjective data that could be stated by the person is he/she feels hot and lightheaded. After collecting the vital signs I would ask if the person wants any water or needs anything, make sure the person is safe to leave alone so I can go report the vital signs to the charge nurse.
Reply
Miriam Lopez
3/12/2014 04:02:54 pm
True channdara all of the vital signs are out of range we should be concerned and report it to the nurse....
Reply
diana armstrong
3/12/2014 10:19:08 am
1. I would definitely be concerned with a slightly high temperature followed by rapid heart rate. Subjective matter would be any complaints the resident/client is currently having and how often. Continue collecting data and offer water do to a slightly low blood pressure reading. Ask the client that I or nurse will return momentarily, sit tight and hand a call button in case assistance is needed. This will give me time so that I can give my observations and data to the nurse in a promtly manner. wait for further directions from my nurse.
Reply
diana armstrong
3/12/2014 02:28:32 pm
correction voided amount is 120 ml * ;)
Reply
Diana Armstrong
3/14/2014 02:41:41 am
this is question?
Cara Mendenhall
3/12/2014 02:59:30 pm
1. All of the vital signs are out of the normal range causing a concern for the resident's health. After triaging the resident subjective data is collected and documented e.g. resident c/o of nausea, fatigue, hot, dizzy and feeling of not being able to catch their breath. I would collect as much information as possible, make sure call light is with in reach, reassure the resident that we'll be right with them and then immediately report to the charge nurse.
Reply
Brittany Wynne
3/14/2014 02:11:01 pm
Very good! Very thorough!
Reply
Cara Mendenhall
3/12/2014 03:13:09 pm
2. Input of fluid is 4fl oz + 6fl oz =10fl oz one fl oz is equal to 30ml so 30x10 = 300ml of input. Output is only 120ml of fluid. I would document and report to the head nurse.
Reply
Miriam Lopez
3/12/2014 03:54:50 pm
1.) I should be concerned about the high fever so I would report this to the nurse but first I would ask the resident if he/she would like some water or anything else before I would leave the room.
Reply
Channdara
3/13/2014 01:59:07 am
Don't forget to record the subjective data the person is telling you about how he/she is feeling. For example feeling hot, light headed and dizziness.
Reply
Miriam Lopez
3/13/2014 12:51:26 pm
:-)
Adriana royal
3/14/2014 02:47:54 pm
i agreed with you miriam. but i would take the vitals again and make sure .
Reply
laura contreras
3/13/2014 03:12:08 pm
I agree all vital signs are a bit out of normal range. After recording vital signs i would ask the resident what hes feeling? Where? ( leaveCall light in reach, rails up if needed ect. Ect. Ect)I would also take a close look to see if anything seams unusual. Imidietly notify the nurse about the unusual vital signs, residents symptoms, and what i have observed, so she/he can go assess the resident.
Reply
lcontreras
3/13/2014 03:30:09 pm
Is the resident retaining input/intake anyone?
Reply
diana armstrong
3/14/2014 02:35:55 am
isn't intake/input the same? I would say from the observation with this resiednt/client, the intake is not the same as the output....si or no?
melissa
3/14/2014 08:17:23 am
input is more than output but it would become a concern after a 24 hour period
melissa
3/14/2014 08:19:25 am
the input and output will become a concern after a 24 hour period if there not the same
Melissa
3/14/2014 08:29:00 am
all vitals are a concern but i would mainly be worried about high fever which probably causing all other vitals to be out of normal range.i would notify nurse immediately and encourage resident to drink plenty of fluids and i would make resident as comfortable and safe as possible.the subjective data would be any symptoms residents tell me he is feeling
Reply
Lizette lucero
3/14/2014 08:35:17 am
All vital signs are out of normal range so I would document and then ask resident how they feel and then also record that and immediately report to the nurse making sure of course that my resident has everything they need by there side before leaving (like there call light and water)
Reply
Stephanie
3/14/2014 03:26:54 pm
I agree good answer !
Reply
karina lopez
3/14/2014 09:33:54 am
Increased Body Temperature above usual range Fever is a sign of a variety of medical conditions, including infection. May be the reason why hes BP is low So you definitely need to report to the charge nurse right away make sure your resident is safe and comfortable before you leave .. and do every 15 minutes checks on that resident
Reply
Brittany Wynne
3/14/2014 02:09:23 pm
Reply
Adriana royal
3/14/2014 02:40:28 pm
#1. vital signs are a concern . I would be concerned about the temperature of the resident. i would reporte it to the nurse or LVN in charge.
Reply
Susie ortega
3/14/2014 02:55:14 pm
Vital Signs and nutrition post due by 3/14 @ 1700. answer each question and respond to @ least one post. thank you!
Reply
Stephanie
3/14/2014 03:21:52 pm
1.) All Vital signs are of concern are a charge nurse should be notified immediately!
Reply
7/5/2016 12:36:13 am
What is the person’s fluid intake in milliliters? What is the fluid output in milliliters?
Reply
Leave a Reply. |
AuthorMartin Ponciano (A.K.A. "Mr. 'P'" Tin-tin, Martin, Uncle Martin P-Dizzle). Just your average twenty-something, journeying through this wonderful realm, an eternal student of life, humbly in pursuit of self-actualization Archives
April 2017
Categories |