Archie Bald

Question 1

Collect information/cues

What data is important to the nurse?

Answer 1

low BP
high HR
high resp rate
Left lower quadrant abdo distended and pain
haem 28%
BS Left lung assym # ribs plus haem
left lower leg compound #
hypovolaemic (absolute)

Question 2

Process information

What is the clinical significance to the nurse?

Answer 2

Haematocrit 28%
internal bleeding
CT scan?

Question 3

Identify the problem

What types of shock is Archie experiencing? what signs and symptoms is he display that support your answer?

Answer 3

Absolute Hypovolaemic Shock

• low BP
• High HR
• bleeding through wound
• no pulses

Question 4

Identify the problem

What were the causes of Archies shock states? what are other causes of these types of shock?

Answer 4

low BP
Increased HR
Increased RR
Blood loss

asdfsaf

Question 5

establish goals

What nursing goal will guide your plan of care?

Answer 5

replacement of fluid to increase tissue and organ perfusion

Question 6

Take action

what interventions will you initiate based on this priority?

Answer 6

Blood transfusion
Pain management
Monitor urine output
Regular vital signs
Physical assessment
Blood type and cross match test
Neurological assessment
Neruovascular observation
Insert another canulla
NBM
NG tube
IDC
Monitor Fluid Balance
- drains
- urine

Question 7

Evaluate

what is the worst possible/most likely complication to anticipate?

Answer 7

SIRS
MODS - kidneys and liver

Death

Question 8

Evaluate

what nursing assessments will you need to initiate to identify this complication if it develops?

Answer 8

Regular vital signs
Physical assessment
Blood type and cross match test
Neuro assessment
Monitor Fluid Balance
- drains
- urine