Patient
Mrs Joan Wong is a 60-year-old lady who has fallen from a ladder and fractured her right clavicle (#R clavicle). Initially there were concerns about her experiencing a brief loss of consciousness, however her neurological observations and vital signs are now within normal parameters. Whilst she has been an inpatient, she has been diagnosed with Type 2 diabetes.
Whilst participating in a physiotherapy session just before lunch Mrs Wong begins sweating profusely, appears a little confused and complains of dizziness. Your buddy nurse helps you to take a BGL and a set of obs. The results are as follows
T- 36.8, P- 74, RR- 18, BP 120/75. SaO2 – 97% RA. GCS – 15. Her BGL is 3.1mmol/L Per current pain score is 7/10.
1. Mrs Wong’s care plan identifies ongoing GCS assessment. What are the three areas of the
GCS and how does the nurse assess these.
2. The nursing care plan identifies pain as a patient problem. Discuss 3 nursing interventions and their rationale to address Mrs Wong’s pain.
3. Explain how you will assess the effectiveness of the nursing interventions you have identified in question 2.
4. Besides assessing blood glucose levels in a patient identify one other reason that a BGL
would be taken.
5. The urinalysis is positive for blood and ketones. Explain what these findings may indicate.
6. The medical team looking after Mrs Wong has ordered 2 hourly incentive spirometry during the day. You need to explain to Mrs Wong the following:
a. incentive spirometry
b. benefits of completing incentive spirometry and, c. how to undertake incentive spirometry.