Case Study Question 5 of 6 The nurse cares for a 21-year-ol…
Case Study Question 5 of 6 The nurse cares for a 21-year-old male in the emergency department with cellulitis and uncontrolled pain. Nurses’ Notes 0930. Client being treated for cellulitis presented with a complaint of right arm pain not controlled by prescription narcotics. The client is alert and oriented but agitated, rating pain 10/10 pain. Denies shortness of breath or chest pain. Informed client of wait times, placed wristband on client, and had him return to the waiting room to be triaged. 1055. Notified by a family in the waiting room that the client was slouched in chair and “seemed dead.” Client was found to be unresponsive with constricted pupils, clammy skin, bradypnea, and circumoral cyanosis. Rt arm is red and swollen with blistered areas. 1100. Emergency response team activated. Vital signs obtained. 1105. Intranasal naloxone administered. Oxygen started at 2L per nasal cannula. Client starting to arouse. Vital Signs Time 1100 T ◦F/ ◦C 97.1F /36.1C P 48 RR 6 B/P 90/50 Pulse oximeter 86% Oxygen RA Pain Unable to report The client was given intranasal naloxone and supplemental oxygen. The nurse begins to gather other assessment data and provide for the client’s safety. For each possible task, select if the action should be done immediately, within the hour, or before the shift ends at 1900.