A 74-year-old patient with a current diagnosis Alzheimer’s i…

A 74-year-old patient with a current diagnosis Alzheimer’s is 6 hours post-op from a total hip arthroplasty. During the floor nurse’s assessment, they note the surgical drain has an output 600 mL of bright red blood in the last two hours. The patient is pale, diaphoretic, and complaining of extreme dizziness when the head of the bed is raised. The nurse suspects the patient has internal bleeding secondary to the surgical procedure, and anticipates an order for a blood transfusion. Current Vitals:BP: 88/54 mmHg (Baseline: 130/70)HR: 118 bpm O2 Sat: 91% on room airHgb: 6.8 g/dL (Pre-op: 12.4 g/dL)The nurse assesses the patients current mental status, and determines the patient is confused and cannot state their name or date of birth. Which action by the two nurses at bedside is an acceptable way to verify the patient’s identity?

The patient now has clear lung sounds, stable vital signs an…

The patient now has clear lung sounds, stable vital signs and has returned to baseline status. The nurse is providing discharge education related to lifestyle changes and monitoring for complications related to heart failure and their chronic pulmonary disease.  The nurse instructs the patient to call the clinic if they experience a weight gain of more than pounds in one day or pounds in one week.

The nurse gains IV access, draws blood for the ordered labs…

The nurse gains IV access, draws blood for the ordered labs and places the patient on 1 L O2 with a nasal cannula. The patient’s O2 sat increases to 94%. The nurse reviews the diagnostic results once they are available, which confirm a diagnosis of vaso-occlusive crisis. The patient is admitted to the medical floor for further treatment. The nurse is planning care for the client. Which nursing diagnosis related to vaso-occlusive crisis should the nurse prioritize in the client’s plan of care?