‫بسم هللا الرحمن الرحيم‬

7401124/2
Fundamentals of the nursing 2

Final Assignment
Lecture Time: 2- 4-Wednesday
Dr. Mahdia Al-Koni

Made by : Sultan M. Salman

(12219838)

THE Assignment
Mr. K. is a 63-year-old is a heart failure and diabetic patient who was admitted to emergency room after car
accident that caused abdominal trauma. Ahmad is a student nurse who is assigned to provide care for Mr. K.
When assessing Mr. K.; his lab results; Hb 10g, Hct 35%, neck veins distended when head of bed elevated 45
degree, ++ edema was palpated over the tibia, increased, shallow respirations28/m. Emergent abdominal
surgery was done, after operation, he was admitted to the intensive care unit, when Ahmad checked the order, it
was N/S 0.9% 500ml 8 hourly, strict Intake &Output, 2 units packed blood cells to be administered, folly
catheter to be inserted.
Answer the following questions regarding the case:
1. On the first day post operative, Mr.K.’s assessment data are as follows:
pH 7.10 RR 34
Paco2 60 HR 128
Pao2 80 BP 180/92
HCO3- 22
This is best described as: ................................................................................... ( 2 marks)
2.What is the reliable indicator of a patient’s fluid balance status? -----------------( 2 marks)
3.During assessment of the IV site on the second day post operative, Ahmad observed redness and tenderness
on palpation; he decided to discontinue the IV and restarted on the other hand, what is this type of IV
complications does Mr.K. had? ---------- ( 2 marks)
4.Which size of indwelling urinary catheter is best for Mr.K.? ..................... ( 2 marks)
5.The urinary catheter balloon must be inflated with: .................................... ( 2 marks)
6.Mr.K. has fluid volume excess related to heart failure as evidence by: (write three clinical manifestations as
illustrated ‫ يتضح‬in the case): (6 marks)
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7. dressing was applied over a wound, what are the purposes of dressing? ( 6 marks)
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8. Describe three nursing measures that prevent constipation. ( 3 marks)
a. _____________________
b. _____________________
c. _____________________

the answer :
1. On the first day postoperative, Mr. K.'s assessment data indicates respiratory acidosis. This is
characterized by a low pH (7.10) and an elevated Paco2 (60) due to increased respiratory rate
(RR) of 34. The other values, such as Pao2 (80) and HCO3- (22), do not show significant
abnormalities related to acid-base balance.
2. The reliable indicator of a patient's fluid balance status is the measurement of daily weight.
Changes in weight can help determine if there is fluid retention or fluid loss, indicating fluid
imbalance.

3. The IV complications that Mr. K. experienced are indicative of phlebitis, which is inflammation of
the vein. Symptoms such as redness and tenderness at the IV site suggest local irritation and
inflammation, leading to the decision to discontinue the IV and restart on the other hand.

4. The appropriate size of indwelling urinary catheter for Mr. K. would depend on his specific
needs and anatomy. Generally, a 16 or 18 French size catheter is commonly used for adult
patients.
5. The urinary catheter balloon must be inflated with sterile water according to the manufacturer's
instructions. Typically, 10 to 30 ml of sterile water is used to inflate the balloon.

6. Clinical manifestations of fluid volume excess in Mr. K., as evident from the case, include:
 Distended neck veins when the head of the bed is elevated 45 degrees.
 Palpable edema (++ edema) over the tibia.
 Increased and shallow respirations (respiratory rate of 28/m).

7. Purposes of dressing include:

 Protection of the wound from contamination and infection.
 Facilitation of wound healing by maintaining a moist environment.
 Promotion of patient comfort.

8. Nursing measures to prevent constipation include:

a. Encouraging an increase in dietary fiber intake through fruits, vegetables, and whole grains.
b. Promoting an adequate fluid intake to ensure hydration.
c. Encouraging regular physical activity and exercise to stimulate bowel movements.

Thanks