58-year-old female presented into the emergency department with neurological changes, having had an unresponsive episode at home.
She had just returned from an overseas vacation and has become unwell.
Acute Preliminary health assessment.
Pulse: 102 irregular
O2 saturations 94%.
On presentation to the hospital, she was complaining of nausea, headaches, blurry vision, and was disoriented to time and place.
Glasgow coma scale (GCS) is EO 3, VR 4, BMR 6 total 13.
Liz lives at home with her husband Marcus. They have two adult children that do not live close.
She had been treated for breast cancer 5 years ago. Her treatment consisted of radiation and chemotherapy and she has not required any further treatment.
At present she is not taking any regular medication only paracetamol for her headaches.
Review the previous data:
Acute Secondary health assessment.
Vital signs are:
Pulse 64 BPM
Respirations 18 RPM
Blood pressure 120/75
O2 saturations 93% RA
Pain score 5/10
Using critical thinking and problem solving, prioritize your nursing interventions to reflect the changes in Liz’s condition.
List the data changes and the rationale behind your decisions.
Discuss your nursing interventions in order of priority, for example pain, would you consider that level of pain significant, what nursing interventions could you apply,
Please discuss oxygen saturations, what nursing interventions could you apply prior to administering oxygen therapy,
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