Identify what observations and nursing cares would the nurse commence for Mrs Windsor following her return to the ward at 1300hrs?

Identify what observations and nursing cares would the nurse commence for Mrs
Windsor following her return to the ward at 1300hrs? How often should these
observations be monitored? Include your rationale.
It is now two hours since Mrs Windsor returned from theatre. The frequency of
observations is continued at half hourly intervals. As the RN looking after her, you
are going over the observations and updating the charts.
Question 5 5 marks
Between 1300hrs to 1500hrs, the following observations have been recorded for Mrs
Windsor (see charts). Include in your discussion on the observations the following
areas:
a) Would any of the observations cause the RN to be concerned? WHY?
b) What actions should the RN undertake in relation to their concerns?
The following observations were then recorded over the next hour (see ADDS chart
for 1600hrs and 1630hrs). As the RN looking after the patient, there seems to be
some concern in relation to the Mrs Windsor’s present condition.
At 1640hrs, the nurse-call bell is activated within the four bed area where Mrs
Windsor is situated. When the RN answers this, another patient informs you that Mrs
Windsor has slumped her head to one side.
As the RN looking after Mrs Windsor, you assess the overall and immediate
situation. Upon pulling down the sheets, it is noted that there is a pool of blood
around the waist of Mrs Windsor. The emergency call bell is activated. The following
observations are noted (at 1645hrs) (see chart).
Question 6 15 marks
Using the 5 Rights of Clinical Reasoning, discuss the priorities of care, and its
rationale that would be appropriate at this time considering Mrs Windsor’s history
and the procedure that was performed.
Question 7 5 marks
Complete, and attach, an SBAR that the RN would utilise when calling the doctor to
explain the essence of the emergency.
Over the next 15 minutes, the surgical team have assessed the presenting situation
and it is concluded that Mrs Windsor will be taken to theatre for an exploration of the
anastomosis and the effects of the bleed into the abdominal cavity. Mrs Windsor is
intubated and wheeled to theatre. Her children are informed of the presenting crisis.
Question 8 10 marks
Discuss the clinical indications and provide a rationale (WHY) for each of the
medication orders which has been written up for Mrs Windsor. Include the nursing
responsibilities that would be associated with the medication orders.
Mrs Windsor is returned to the ward after having an oversewing of a leak at the site
of the anastomosis. A blood transfusion is in progress for 2 units of whole blood.
Question 9 10 marks
List the post-operative care that Mrs Windsor would require during the next 24 hours
and WHY.