What would be the priority nursing diagnosis? What is the first priority?
By Julie from California on March 25, 2006 in Nursing Care Plans
Man with intertrochanteric fracture, pain is 10 (on scale 0-10). Left sided facial droop, PERRLA 2-3mm, oral mucous is dry cracked, his neck is supple to palpation,hyperresonant sounds in bilateral lung fields. Patient is now tachycardic, breathing is even unlabored. Auscultate abdomen and hear gurgling sounds, palpation in abdomen is rigid. Redness on the left thigh with a 3inch scrape radiating to the buttocks. 3+radial pulses, skin is warm, pink dry. What is your nursing diagnosis? |
