High-pitched musical sound

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Reference no: EM133949001

Question

Lucy Lu is a 77-year-old Asian patient who is admitted to the surgical unit after a colon resection this morning. She has not been in the hospital before and is accompanied by her 80-year-old husband and her two daughters. Mrs. Lu has been in the United States for 30 years and speaks fluent English. She still values her Asian heritage. Her health has been deteriorating lately because of chronic bronchitis and stable angina. She smokes 1½ packs of cigarettes per day. She is 10 lb underweight for her height. Jim Stone is a 24-year-old senior nursing student and has been assigned to care for Mrs. Lu postoperatively. He takes her vital signs upon return from the postanesthesia unit: blood pressure is 110/58 mm Hg, temperature is 99.8° F orally, pulse is 112 beats/min, and respirations are 26 breaths/min. He asks her to rate her pain, and she states that it is a 6 on a scale of 1 to 10. She has a patient-controlled analgesia pump. Her surgical dressing is dry and intact.

1. Jim decides to check with the primary nurse and see if he can start administering oxygen to Mrs. Lu. The nurse tells Jim that it would be good. What is the preferred method of oxygen administration for this patient?

2. The primary nurse asks Jim to take Mrs. Lu an incentive spirometer and teach her what it is and how to use it properly. What should Jim include in his teaching plan?

3. Mrs. Lu complains of being short of breath. Three hours after she was admitted to her room Jim assesses her temperature and it is 101.2° F orally. Jim takes her other vital signs: blood pressure is 100/70 mm Hg, pulse is 112 beats/min, and respirations are 30 breaths/min. Her pulse oximetry is 88%. What nursing actions should Jim initiate to treat these changes in Mrs. Lu's condition?

4. Later, while Jim is listening to Mrs. Lu's lung through the stethoscope, he hears a high-pitched musical sound. What does this indicate?

5. What are 2 Nursing Dx for this patient? Two must be an actual problem and one at risk.

Reference no: EM133949001

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