you (the LPN) are working in an urgent care center on a team with an RN, Physician, and NP. You receive a client (54 year-old-male) who is complaining of acute lower back pain that began four hours ago. The client has no previous history of back pain and denies any recent injury. The client has a history of hypertension and Marfan Syndrome. You perform data collection and the client's vital signs are: 174/90, 112, 24, 98.0 PO. You note that the client's skin is cool and clammy. The RN performs an assessment and notes a pulsatile mass in the client's abdomen. His lungs are clear and his pulse is regular. The physician orders two large bore IV's to be inserted but no IV fluids and nitroglycerine to lower his blood pressure.Answer the following questions:

Question # 1: What is the significance of the client's history of Marfan Syndrome

Question # 2: What vital sign(s) should the LPN immediately report? Why?

Question # 3: Why did the physician order IV's but no IV fluids?

 

Answer:

Question # 1: What is the significance of the client's history of Marfan Syndrome

The, significance of client's history of Marfan syndrome is that people with the condition present with a dilated aorta or an aortic aneurysm. This is consistent with the patient presentation of a pulsatile mass in the client's abdomen pointing to an aortic aneurysm.

Question # 2: What vital sign(s) should the LPN immediately report? Why?

The LPN should report thev

A. blood pressure - 174/90mmHg is high showing hypertension. Normal systolic pressure is a range of 90-139mmHg, whole the diastolic is 60-89 mmHg.

B. Pulse rate - 112 bpm is very high, this is known as tachycardia. Normal pulse rate range is 60-100bpm

C. Temperature - 98 degrees Fahrenheit in a sign of hyperthermia. The respiratory rate is normal.

Question # 3: Why did the physician order IV's but no IV fluids?

The physician ordered this because intravenous fluids may lead to hypervolemia and increased blood pressure which is already high and could cause rupture of the probable aortic aneurysm. These pressures need to be controlled first. The IVs were for intravenous antihypertensive drugs or antibiotics to reduce the blood pressure to normal ranges, and treatment any infection which could be the source of the fever or hyperthermia.