CNS: altered state of consciousness; any anxiety or restlessness; any light headedness or dizziness; speech and communication; Pain: provokes; quality; radiates; severity; time; any analgesia given and patient’s response
CVS: pulse rate; regular or irregular; strength of the pulse; equality;
BP the trend of BP; what is the patient usually BP; Auscultation heart sounds; murmurs; apical impulse rhythm and location
Temperature: the trend of temperature; is the patient on antibiotics
RESP: RR; depth of breath; work of breath; does work of breath change when patient sitting up; can patient talk during breath; patient’s response to high flow oxygen; auscultation: any crackles ; location and quality of crackles; does it clear with cough; Any wheezing.
Renal: Fluid balance chart; patient’s urine output and fluid balance since operation; previous urea and electrolytes results.
GIT: Is abdo distended; any bowel sounds; oral intake; any nausea or anorexia; the previous BSLs; any treatment for the hyperglycaemia; hepatojugular test; history of the amount and colour of drainage fluid.
Integument: The size of bruising on the surgical site; is the patient on any anticoagulation medication; the amount and quality of the ooze at the surgical site; how long does the patient have the leg ulcers; colour of the skin; is it dry or clammy.
Blood tests: Compare the results with previous ones
2. State five (5) specific acute patient problems the registered nurse should identify from data in the initial scenario. Provide a pathophysiological rationale and hypothetical/actual reason for each of the potential problems identified, and explain how each may lead to adverse outcomes for this patient if such problems remain unmanaged. 15 marks 1 Congestive heart failure: this patient is predisposed to heart failure because the past history of anterior myocardial infarction, CABG, and hypertension.
Hypovolemia which is possible from preoperative, intraoperative and postoperative blood loss and inadequate fluid intake , decreases the preload.
Then the preload would cause reduced blood pressure and activates the sympathetic nervous system. Activated sympathetic nervous system increases the heart rate, contractility and vasoconstriction. As a result, cardiac workload and oxygen demand are increased. However the oxygen supply is reduced due to anaemia and hypoxemia. Imbalanced oxygen supply and demand and increased cardiac workload aggravate the myocardial dysfunction which is caused by myocardial infarction. Additionally, decreased coronary perfusion pressure due to hypotension leads to myocardial ischemia.
Myocardial ischemia also exacerbates myocardial dysfunction. Heart failure would eventually take place. Pulmonary oedema could possibly happen due to increased pulmonary venous and capillary pressure secondary to the increased left end-diastolic pressure. Cardiogenic shock and multiorgan failure will appear due to poor perfusion.
2 APO: Blood damps in the lungs because of the left ventricle failure lead to increase the pulmonary venous pressure which results in increased pulmonary capillary pressure. Increased pulmonary capillary pressure pushes fluid to the interstitial space and into the alveoli eventually. APO affects gas exchange then could leadto respiratory failure. Sever hypoxemia will cause hypoxia which can result in multiorgan failure, cardiac arrest,and even death. 3 Hyperglycaemia ：hospitalisation and surgery act as stress and stress activates the release of catecholamines ,cortisol and glycogen.…