SNUG102 Nursing As A Profession

Question:

Bilateral legs intact, nil ooze or redness and plaster of Paris intact for left distal leg. Wound site on left hip intact- nil serous exudate ooze or redness. Wound site on right upper thigh has some breakthrough of haemoserous fluid, dressing reinforced- noted patient is for theatre today for a washout of same.[Input] Compound sodium lactate at 200m1ihr via IVC in left distal cubital fossa. site intact nit redness or serous ooze, flushed and patent. [output] noted Ms Foley is in a positive fluid balance. Daily weigh she now weighs 83.5kgs, when five days ago she was at S0kgs [Social] family to be called once she returns from theatre [General] Noted Ms Foley stated she did not sleep well last night and is feeling apprehensive regarding surgery this morning. She went on to say she has ‘bad dreams’ overnight. and has a sensation of suffocating until she sits up IriERN Harmon) 
 
10/08/2017 0800 Nursing addendum Theatre nurses have called and are ready for Ms Foley. On attendance she was lying flat on her bed, trying to sit up, and gasping for air. She is apprehensive, stating she is ‘scared’. and that she has a weird feeling that she can only describe as ‘a sense of impending doom’. Vital signs taken and are the following: Pulse 120bpm and regular, BP 100150, RR 34, Sa02 92% on RA. Her lips have started to turn blue and the nail beds on her fingers are cyanotic. She remains dyspnoeic and desperate for air. She is coughing. 
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