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Mr. Petrov, 72 years old, presented to the ED with increased…

Mr. Petrov, 72 years old, presented to the ED with increased work of breathing as evidenced by intercostal retractions and the use of accessory muscles. Mr. Petrov has a history of COPD, Hypertension, and Chronic Kidney Failure.  He receives dialysis 3 times per week at a local hemodialysis clinic.  He has had a tracheostomy for the last 18 months and uses a passy muir valve to communicate.   It has now been 24 hours since Mr. Petrov was admitted for respiratory failure and immediately placed on a ventilator for respiratory support.  The nurse enters the room to perform an assessment and notices the following findings: ● T: 102.3F ● HR: 110 ● Green sputum was removed during trach suctioning. ● Increasing confusion  Answer the questions below based on the current presentation of the patient and appropriate nursing care. Priority Action to Take [priorityaction1]            Condition Most Likely Experiencing [condition] Parameter to Monitor [parameter1] Priority Action to Take [priorityaction2] Parameter to Monitor [parameter2]

An 82-year-old patient is recovering from abdominal surgery…

An 82-year-old patient is recovering from abdominal surgery 5 days ago and is being cared for on the surgical floor before being discharged to a post-acute facility for further recovery. The patient has dysphagia and is receiving enteral feeds four times per day through an NG tube. The nurse has just assumed care of the patient and is performing the first assessment of their shift.  High Priority: A must-do. Failure to perform this action may cause harm to the patient. Not Relevant: Nice to do, but will not cause harm if the nurse does not do it.  Will Cause Harm: Do not do this. Performing this action may cause harm to the patient.  There will only be one “Yes” per row. High Priority  Not Relevant Will Cause Harm Elevate the head of the bed 30-45 degrees during feeds. [answer1] [answer2] [answer3] Check the measurement marking on the NG tube every hour. [answer4] [answer5] [answer6] Encourage ambulation with assistance. [answer7] [answer8] [answer9] Encourage the use of opioid medications to relieve post-operative pain. [answer10] [answer11] [answer12] Assist with oral hygiene care at least twice per day.  [answer13] [answer14] [answer15] Assess respiratory rate and effort.  [answer16] [answer17] [answer18]