ASSESSMENT
Katie Leaper, RN, obtain
s a nursing history on Ms. Devak’s admis-
sion to the intensive care unit. Ms. Devak indicates that she has
been healthy, having experienced only minor illnesses and chick-
enpox as a child. She has never been hospitalized, and knows of no
allergies to medications. Ms. Devak is not currently taking pre-
scription or nonprescription drugs. Physical assessment findings
include T 97.4° F (36.3° C) PO, P 100, R 18, and BP 124/68. Skin pale,
cool, and dry, with multiple scra
pes, minor abrasions, and bruises
on face and extremities. A linear bruise is noted on her chest and
abdomen from the seat belt. Lung sounds clear, heart tones nor-
mal, and abdomen tender but soft to palpation. Right leg align-
ment maintained with skeletal traction. One unit of whole blood
was infused prior to ICU admission, a second unit is currently in-
fusing. An indwelling urinary catheter and a nasogastric tube are
in place.