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1. Pain Level- Mrs Chan check pain level pain can be indicator of abnormality she
have a pain Mild, increase pain , access pain and dressing change intermitted or
consistent when change the dressing in a day how many time change the
dressing in a week.
2. Size- Mrs Chan check wound size like length , width, Depth her wound size is
big, small, medium and how long and how deep .
3. Presence of infection- Mrs chan check the infection may be defined as presence
of bacteria or other organism. Infection can discrupt healing and damage tissues
or produce spreading infection like Redness, Pain, Heat.
4. Choice of Dressing- Mrs Chan wound dressing like dry non- adherants,forms,
normal saline compresses,Hydrocolloids, Island dressing etc.
R
egualr Medications- Mrs chan pain relief medications she takes a Fosomax, Vit
D, Calcium, Fentsnyl patch, PRN endone........................................................................................
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Question 2.
Review the vital signs chart (attached pdf) and evaluate the following aspects:
a) List each of the vital signs recorded at 06:30 in the table below:

List the vital sign

Respiratory Rate 21-24

O2 Saturation 95-97

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O2 Flow Rate >5-11

Systolic BP 110

Heart Rate 90

Temperature 38.5-39.5

4 Hour Urine Output

Consciousness Alert

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b) Complete the ADDS score for each vital sign recorded at 06:30 in the table below,
then total the ADDS score.

ADDS Score
Respiratory Rate 1
O2 Saturation 0
O2 Flow Rate 2
Systolic BP 0
Heart Rate 0
Temperature 2
4 Hour Urine Output -
Consciousness 0
Total ADDS 5

c) List the abnormal signs and then describe the abnormality using correct
terminology.
The Abnormal signs for Mrs Chan are Respiratory rate, body temperature and O2 flow
rate.
Respiratory rate- the adult respiratory rate is normally between 12-20bpm but her
respiratory is just over at 12-24bpm over 20. Because she has a Tachpynea
O2 flow rate- the adult flow rate is normally between .................................................................................
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Scenario - Further Information

Mrs Chan is seen by the doctor, who documents her assessment as follows:

 82 year old lady with confusion and hyperthermia.

 Air entry R=L no adventitious sounds.

 Large laceration to her right thigh, glass remains imbedded in the wound.

 Right leg has obvious bone deformity - requires further investigation to evaluate possible
fractures.
A chest, abdominal, pelvis and hip X-ray are to be completed. Intravenous normal saline 1L is
prescribed to run over 4 hours.

d) Note the ‘Actions Required’ section of the ADDS chart and explain who should
accompany Mrs Chan when she leaves the ward to go to the X-ray department.
You would need to ensure that you confirm this with the RN.
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Question 3
Mrs Chan has been prescribed an IV solution of normal saline, which contains sodium
chloride and water.

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a) Explain the following concepts related to body fluid compartments and intravenous
fluids:
(i) Define the terms solute and solvent and how it relates to the prescribed
solution
Solute is the substance that dissolves in solution and Solvents are substances that
dissolve the solute. In the sodium chloride and water solution, sodium is the solute
and water is the solvent, when mixed together they become a solution used as the
prescribed solution.............................................................................................................................
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(ii) In your own words, explain what osmosis is and how it works in the three
fluid compartments of the body
Osmosis is the physical process where by solvent moves across from a less
concentrated solution to more a concentrated solution to create a balance.The
process is absorbing the solution as a means of transport to other areas of body..............................
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(iii) Why is Mrs Chan’s IV fluid an isotonic solution?

Because she loses blood and dehydrate and also Mrs chan has low fluid volume
and isotonic solutions have the equal amount of sodium concentration as all
around the body cells.........................................................................................................................
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(iv) Why this solution is used to treat dehydration?

Dehydreation can be caused by losing too much fluid in the body so saline
contains sodium and chlorine so it replaces lost fluid and prevents some types of

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electrolyte imbalances. We can also use solution of dextrose and water to treat
dehydration. ......................................................................................................................................
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(v) Correctly match the terms listed below to either Active or Passive transport:
 No energy required
 Osmosis
 Endocytosis
 Requires energy
 Diffusion
 Sodium-potassium pump

Active Transport Passive transport

Endocytosis Diffusion

Sodium-potassium Pump Osmosis

Requires Energy No energy required

(vi) Describe the difference between hydrostatic pressure and colloid osmotic
pressure (also known as oncotic pressure) in relation to transport of fluids
across a capillary membrane.
-Hydrostatic pressure caused by heart pumping- this pressure wanting to push
through the blood out of the vessel.
Colloid osmotic pressure( ONCOTIC Pressure) caused by solutes in blood- this
pressure wanting to pull water into the blood vessel
Passive transport- Fluid transported across without any energy input th cell.

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Active transport- the cell provides the energy (ATP) that drives the transport
process. .....................................................................................................................................................
. Facilitated diffusion – substance is helped’ across the membrane by Proteins
molecules act as “carrier” OR A protein molecule forms a “channel”. Still move
from HIGH concentration to LOW concentration................................................................................
(Refrence by- Herlihy2011)
Refrences-
1 . Sarah,(2016), Isotonic,Hypotonic & Hypertonic IV Fluid Solution NCLEX.
Retrieved from -hypertonic-iv-fluid-solution-overview-for-nursing-students-with-
quiz
2.

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