At 1530, the nursing assistive personnel (NAP) reports the following:
Vital Signs
Blood pressure 148/82 mm Hg
Heart rate 118 beats/min
Respiratory rate 24 breaths/min
Temperature 101° F (38.3° C)
Spo2 92%
Based solely on her vital signs, what could be happening with M.N., and why?
You go to assess M. N. What do you need to include in your assessment at this time?
• Her blood pressure, pulse, and respirations are high, perhaps because of incisional pain, fever
(inflammatory process), or hypoxemia.
• Temperature is elevated; this might be because of an inflammatory response from having infection
(cholecystitis on admission) or a normal postoperative reaction.
• Her oxygen saturation is low. Incisional pain might cause splinting and shallow respirations, resulting
in atelectasis and/or hypoxemia. She might also be developing pneumonia or an embolus.
• Observe her general status. Is she restless or agitated? Is she alert and oriented in all spheres?
• Observe the color of her skin. Is it pale, flushed, cyanotic? Is she diaphoretic? Cool? Are respirations
labored? Is she using accessory muscles? Can you see her chest significantly rising and falling? Ask
her how she feels as she is breathing—does she feel short of breath?
• Auscultate and percuss her lung fields. Check her capillary refill time.
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