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Interventions/rationales, questions and INR meds

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1. A patient enters the ED with increased intracranial pressure and is assessed by the nurse to have an altered level of conciousness. Consciousness can be defined by:
A. Person aware of self and environment
B. Able to respond immediately to stimuli
C. Has cognition
D. All of the above
Answer: D all of the above
2. An expected outcome of a patient with an altered level of consciousness could be: Select all that apply
A. Brain death
B. Diabetes mellitus
C. Problems affecting reproduction
D. Recovery with residual damage
E. Paget’s disease
Answer: A, D
3. In patients with increased intracranial pressure, a nurse would anticipate which diagnostic procedures be performed immediately: Select all that apply
A. Myelogram
B. Endocrine function tests
D. CBC with differential
E. Serum glucose
Answer: A, B and E
4. Upon arrival to the ED, a patient with an altered LOC secondary to head trauma sustained in a car accident is being admitted by the charge nurse. What specific intervention would be of least importance upon assessment:
A. Assessing motor function and muscle strength bilaterally
B. Inserting a Foley catheter
C. Assess for airway patency
D. Establishing IV fluid access
Answer: B
5. A patient with an increased intracranial pressure is admitted to the unit after thorough assessment and diagnostic testing in the ED. The patient is in stable condition but has several episodes of hypertension. The nurse would anticipate which classification of drug to be administered prophylacticly by the attending physician:
A. Mannitol (Osmutrol) diuretic
B. Insulin
C. Potassium chloride (K-Dur) electrolyte
D. Dilantin (Phenytoin) anticonvulsant
Answer: D

My past experience with a patient with altered perfusion and cellular regulation was one that involved an elderly women who had undergone a radical mastectomy of the right breast.
Intervention: Perfusion/impaired tissue perfusion. Raise and maintain arm in a higher position than the heart.
Rationale: By maintaining a higher position than the heart, gravity will assist in keeping blood flow continuous and prevent venous stasis. Patients with radical mastectomies have had lymph tissue removed which normally helps the flow of fluids and blood back to the heart and other vital organs.
Intervention: Perfusion. Discuss lifestyle changes with the patient to prevent further complications secondary to pathology and subsequent treatment regimen.
Rationale: By educating the client on proper diet choices (low sodium, high fiber) and exercise program, the patient will obtain much more desired outcomes. Diet and exercise are important in not only perfusion related scenarios but almost any other pathological disorder.
Intervention: Perfusion. Assess presence, location or degree of swelling or edema formation.
Rationale: By close and meticulous inspection of impaired tissue and surrounding areas, the nurse can better establish projected outcomes of therapeutic regimen. Infection or absence of lymphatic drainage can occur quickly and over a short period of time.
Intervention: Cellular regulation/disturbed body image. Assess mental and physical influence of illness or condition regarding the patient’s emotional state.
Rationale: By assessing the mental and physical influence of the present illness a nurse can infer the direction that the desired outcome is headed. Factors such as pain and depression can influence negatively, the healing process.
Intervention: Cellular regulation/risk for infection. Assess the surgical site for signs and symptoms of infection, redness, heat or edema.
Rationale: By closely inspecting the surgical site prior to mastectomy, the nurse can assess by palpation and inspection for signs of impending infectious process.
Intervention: Cellular regulation/risk for powerlessness. Determine patient’s perception of current illness, disease process and treatment plan.
Rationale: By educating the patient and family about the course of action and signs and symptoms that are to be expected, the patient and subsequent family can mentally prepare for trials ahead. A person can start the grieving process and work through the stages faster if better prepared and lead to better outcomes of treatment.

A patient with an INR of 4 has an increased risk for bleeding due to the clotting time being almost triple what it would normally be under regular circumstances. The most likely medication taken while under this therapy is Coumadin(Warfarin). Interventions to include while a patient is on Coumadin therapy are:
1. Assess for bleeding and hemorrhage i.e bleeding gums, nosebleed, black tarry stools, hematuria, fall in Hct or Hgb or nasogastric aspirate.
Rationale: By assessing changes in any of these conditions, the healthcare team can tailor therapy to meet the client’s individual needs. If the effects of Coumadin therapy are too severe, vitamin K can be given as an antidote.
2. Monitor PT, INR and other clotting factors frequently during Coumadin therapy.
Rationale: Normal INR is 1.5 to 2 and an increase to 4 may or may not be the desired range and should be tapered to prevent further unwanted complications (hemorrhage).
3. Teach patient about certain foods to avoid while taking Coumadin to avoid decreasing its effect.
Rationale: Foods that are high in vitamin K can interfere with the therapeutic effect of Coumadin. Since Coumadin interferes with the synthesis of vitamin K in the liver, increasing the amount of vitamin K can alter the effect of Coumadin dramatically. Foods such as kale, collards and spinach are among some of the highest in vitamin K.

Resources: Davis’s drug guide for nurses pg1296, Davis’s pocket guide for nurses pgs118-119, 657-660, 467-471 and 843-848. High vitamin K foods:

2 thorough on Mon Nov 14, 2011 4:42 pm


You always do such a good job on these assignments. It shows that you put a lot of time and effort into them. Awesome job, Keith. cheers


Keith, I have also cared for a patient who had a masectomy due to breast cancer and I am SO glad you noticed that determining the patients perception of the disease process and surgery was an important intervention. I don't think we truly realize how much a surgery like this can affect someone's life and change their body image completely. My patient was very open with me and expressed what a traumatic time she was going through. It truly is a grieving process.


It looks like we are all on the same page with these nursing interventions. Great job!

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