NURS1002 Study Guide - Final Guide: Edema, Renal Compensation, Paresthesia
Document Summary
After auscultation of her chest, you hear crackles in both lung bases. Breathing: measure respiratory rate, evaluate work of breathing, measure oxygen saturation. Circulation: palpate pulse rate and rhythm, measure manual blood pressure ecg. Disability: assess level of consciousness (glasgow coma scale), evaluate speech and assess for pain. Exposure: measure body temperature, inspect skin integrity, inspect and palpate skin for signs of pressure injury; observe any wounds, dressings, drains, invasive lines; observe ability to transfer and mobilise; assess abdomen. Order a rapid response due to low spo2, high pulse and respiration rate and dangerously low bp. Spo2 saturation as it is below the optimal readings of 96-100, it is also out of the safe zone (<95%), indicating that there is not enough oxygen circulating her body and she is in danger of hypoxia. This is also indicated by her very high respiration rate (normal being 20), and low systolic bp (as it is lower than 90mmhg)
