Stan Jordan is a 64 year married man. Stan has been admitted to hospital for a laparoscopic cholecystectomy following a 6 month history of symptomatic cholecystitis. Initial attempts to remove the gall bladder via laparoscopic cholecystectomy proved difficult due to severe adhesions. The surgeon Dr. Katter proceeded to remove the gall bladder via an open cholecystectomy.  Stan is transferred to recovery room where morphine using a Patient Controlled Analgesia (PCA) via a syringe pump is commenced as ordered by the anaesthetist. The client also has a peripheral IV line with Sodium Chloride 0.9% infusing.  Stan returns to the ward where his initial postoperative observations were satisfactory. Pulse 86bpm, BP 142/78, Temp 37 º RR 18.  30 minutes later another set of postoperative observations are attended. His observations are as follows: Pulse 110 bpm Blood pressure -  155/96 Temperature -  37.6º Respiratory rate -  22 Stan states his pain is increasing and he is becoming noticeably anxious.   a)   Outline your actions and nursing interventions in caring for Stan in response to his changed vital sign

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
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Stan Jordan is a 64 year married man. Stan has been admitted to hospital for a laparoscopic cholecystectomy following a 6 month history of symptomatic cholecystitis. Initial attempts to remove the gall bladder via laparoscopic cholecystectomy proved difficult due to severe adhesions. The surgeon Dr. Katter proceeded to remove the gall bladder via an open cholecystectomy.  Stan is transferred to recovery room where morphine using a Patient Controlled Analgesia (PCA) via a syringe pump is commenced as ordered by the anaesthetist. The client also has a peripheral IV line with Sodium Chloride 0.9% infusing.  Stan returns to the ward where his initial postoperative observations were satisfactory.

Pulse 86bpm, BP 142/78, Temp 37 º RR 18.  30 minutes later another set of postoperative observations are attended. His observations are as follows:

Pulse 110 bpm

Blood pressure -  155/96

Temperature -  37.6º

Respiratory rate -  22

Stan states his pain is increasing and he is becoming noticeably anxious.

 

a)   Outline your actions and nursing interventions in caring for Stan in response to his changed vital sign

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