FLUID OVERLOAD

The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the room, you see Mr. Robinson in bed breathing rapidly and he appears anxious. 1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: -↓ HGB, ↓ Hct, glucose Trending low PLTs, Trending high Creatinine, BUN, Sodium Recognizing a potential problem, you stop the blood, allowing saline to infuse TKO, and promptly collect a full set of VS before contacting the primary care provider: 2. What VS data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) Current VS: T: 98.2 F/36.8 C (oral) Provoking/Palliative: P: 102 (regular) Quality: Denies R: 28 (regular) Region/Radiation: BP: 138/89 Severity: O2 sat: 87% RA Timing: Additional Information: