What would your initial assessment be in a patients room


Problem:

You enter a patient's room and based in the previous nurse assessment, what would your initial assessment(s) be?

Previous nurse: Patient reports pain 8 out of 10, last IV dose of analgesia at 1400.  We have been encouraging patient to watch TV, and we have his foot elevated on 2 pillows. Patient is frequently asking for a drink and a cigarette but refused all his meals.  Patient received 7 units of regular insulin given at 1730 for a blood glucose of 220.  Patient has been requiring 2 mg of hydromorphone every 3 hours for pain.  Patient has been intermittently agitated throughout the day.  Patient is alert and disorientated. When awake, mild tremors noted in hands and arms.

 

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