42-year-old male patient presents in the ICU with a diagnosis of MVA

1657
42-year-old male patient presents in the ICU with a diagnosis of MVA. Vital signs are as follows: P 85, RR 13, BP 102/42, O2 sat 91% on room air, Temp 38, Pain 6/10.  The patient’s EKG shows a normal sinus rhythm with occasional ectopy.  Head-to-toe assessment is as follows: neurologically follows commands, PERLLA, respirations even and unlabored, clear breath sounds with incentive spirometer exercises measuring 1350mls, cardiac S1 and S2 heard, bowel sounds in all 4 quadrants, urine output in urinal measuring 750mls of clear urine, controlled movement in all 4 extremities, patient has been delirious and disoriented.  Skin is warm and pink, edema noted on left arm with a hot red patch of skin above central line dressing. Triple lumen central line has been flushed and Curo caps have been placed on the ends.
2001
Patient becomes agitated and becomes diaphoretic.  Vital signs are as follows: P 105, RR 18, BP 100/38, O2 95% on room air, Temp 38.5, pain 6/10.  Patient states “I can tell you are a new nurse, you don’t know what you’re doing”.

The nurse has received the following orders.

Select which 3 orders are of the highest priority?

a. Titrate O2 to saturation of 90%
 

b. Educate patient on correct use of incentive spirometry
 

c. Maintain MAP 65 mmHg
 

d. IV Bolus 500ml normal saline
 

e. Give patient 1:1 sitter for delirium
 

f. Take urine sample for culture and sensitivity for possible UTI
 

g. Give Tylenol for hyperthermia