O is 83 years old and is in the nursing home. O has congestive heart failure, and has a history of having myocardial infarctions. O uses a walker at…

Question Answered step-by-step Mr. O is 83 years old and is in the nursing home. Mr. O has congestiveheart failure, and has a history of having myocardial infarctions. Mr. O uses a walker at the nursing home. He is incontinent and slightly confused. At 2130, the Nursing Assistant found you, the LPN and told you did that he had just changed Mr. O’s depends. Mr. O had a large, black tarry stool and was complaining of not feeling well. You as the LPN went in to focused assessment on Mr. O. Ben as the RN was not immediately available. His vital signs were; blood pressure 94/66, pulse 114, and respiratory rate 24. His pulse oximetry was 97%. He was pale and his skin was clammy. You ask him how he was feeling. Mr. O said he just didn’t feel well and could not get comfortable. He asked if he could have something for his belly. “It is really hurting!” You as the LPN assessed his abdomen and found that it was distended and Mr. O had diffuse abdominal pain. He rated his pain a 6 on a scale of 1-10. You find the RN and report what you have found to the RN.  Situation:  Background:  Assessment:  Recommendation:      Scenario #2 Perfusion/clotting Exemplar: MI Mrs. S is a 88 year old patient in a nursing home. She has a history of MI, CHF, and diabetes. She receives ASA on a daily basis, and has an order for Nitroglycerin sublingually prn chest pain. Mrs. S put her call light on. You, the LPN answered the call light. Mrs. S stated that she was having chest pain and rated it a 9/10 on the pain scale. You did focused assessment and get a nitroglycerin tab and call for the RN who is busy with a patient that has fallen. Mrs. S’s blood pressure was 90/52 before the nitroglycerin. Her HR was 120. Her breathing was labored at 36 and her pulse oximetry was 85% on room air. There was no relief to her chest pain and her blood pressure decreased to 80/52. The RN arrives in the room and you give her report.  Situation:  Background:  Assessment:  Recommendation:  Scenario #3 Concept: Reproductive Exemplar: Postpartum Hemorrhage Margie Colby, a 25-year-old primipara, is in the recovery room after a low forceps delivery of a nine pound, two ounce, term male. You, a LPN have been asked to work with the RN in the recovery room. The RN is working with another patient that is not stable, so she has asked you to watch the primipara patient, to take her vital signs every 5 minutes, and to weight her pads and chux every 15 minutes. Forty-five minutes after delivery, Margie’s vital signs are BP 100/60, pulse 88 and respirations 16. Her fundus is firm and is at level of umbilicus, no clots observed. She has a continuous trickle of bright red lochia. No change in perineal edema, ice pack applied and peripads changed. Peripads and chux weight indicate 300cc of blood loss.  Fifteen minutes later the fundus remains firm at umbilical level and midline. A constant trickle of bright red lochia persists with no clots expressed. Peripads and Chux weighed showing and additional 200 cc blood loss. Vital signs are now BP 90/52, pulse 110 and respirations 20. You report to the RN the following:  Situation:  Background:  Assessment:  Recommendation:  Health Science Science Nursing NURSING HEALTH ASS Share QuestionEmailCopy link Comments (0)