Nurses’ Notes   11:30: Patient complains of a severe…

Nurses’ Notes   11:30: Patient complains of a severe headache and fatigue. States, “I just want to go sleep. I am so tired; I am having trouble reading my admission paperwork. My vision is so blurry.” Her only other complaint is thirst. Laboratory Report   Lab Results Reference range BUN 20  mg/dL 10-20 mg/dL Creatinine (Serum)        1.3 mg/dL 0.9 to 1.4 mg/dL Glucose        160 mg/dL 70-110 mg/dL Potassium(serum) 3.2 mEq/L 3.5 to 5 mEq/L Sodium (serum) 150 mEq/L 135 to 145 mEq/L Chloride (serum) 98 mEq/L 96 to 106 mEq/L        Cortisol         50 mcg/dL 5-25 mcg/dL Vital Signs Time 11:00 1130 Temp 98.2 F 98.2 F HR 110 111 RR 23 22 B/P 151/87 162/99 Pulse oximeter 94% on RA 95% on RA Pain 0/10 7/10 After the 11:30 assessment, what is the nurse’s priority action?

A 63 year old male has presented to the ER with complaints o…

A 63 year old male has presented to the ER with complaints of mid-sternal chest pressure that has been ongoing for the last 2 hours.  Nurses’ Notes     1300 63-year-old male patient is being seen treatment area with sternal pain chest pain radiating down left arm that is worse with walking. Pain began 2 hours ago while walking outside. Patient also reports shortness of breath with activity. Reports taking a regular aspirin on the way to the hospital. Vital signs: T- 99 F(37.2C); HR- 110; RR- 28 bpm; B/P- 160/90; Pulse oximeter- 90% on room air; chest pain 8/10. Weight reported at 280lbs/127kg (BMI 35). Started on unit chest pain protocol. Oxygen applied, and nitroglycerin given. A peripheral intravenous line has been placed in the patient’s left arm. Morphine given. Labs drawn.   Laboratory Report     Lab Results Reference range Cholesterol (Total) 250 mg/dl 240 high WBC 10 x 103 cells/mm3 4.5 – 10.5 x 103 cells/mm3 Platelets 400,000/ mm3 140,000 to 450,000/ mm3 Potassium(serum) 3.9 mEq/L 3.5 to 5 mEq/L Sodium (serum) 140 mEq/L 135 to 145 mEq/L Magnesium (serum) 1.5 mEq/L 1.5 to 2.1 mEq/L Troponin T 0.5 ng/ml 0 to 0.04 ng/ml Creatine Kinase MB (CKMB) 170 IU/L 5 to 25 IU/L When the patient was connected to the cardiac monitor the below rhythm was observed.  The heart rate is noted to be 110 beats per minute with the above tracing. What is the nurse’s interpretation of the rhythm observed?