Question

Mrs. Lane is 1-day post-op total abdominal hysterectomy. She is 42 years old. Morphine sulfate 5 mg is ordered direct IV injection q3h prn pain. She is on a clear liquid diet and has not voided since the urinary catheter was removed at noon. She is ambulating with assistance to the bathroom. The abdominal dressing is stained with dried dark red drainage. VS at noon are T: 99, P:82, R:22, BP:130/76, pulse ox 96%. Fine crackles are audible in the lower bases of the lung fields. It is 4PM and she is requesting pain medication. She states her pain level is a 4 out of 10. Her last pain shot was administered at 2:00pm. An incentive spirometer is at the bedside.

Prioritize the following nursing interventions as you, the nurse, would do them to initially take care of Mrs. Lane. Write a number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state an evidenced based rationale for each intervention (cite your source for the intervention).

INTERVENTIONS	PRIORITY #	RATIONALE
Inform Mrs. L. that the pain medication is not due for another hour
Cough and deep breathe; demonstrate abdominal splinting; use incentive spirometer
Ambulate to the bathroom
Take Vital Signs
Assess abdomen and surgical dressing

Mrs. Lane void 400ml after ambulating to the bathroom and states that she feels much better. She relates the following to you:

1. Her mother had a hysterectomy but died 10 days after from surgical complications.
2. She is glad that she does not have to worry about irregular periods any more.
3. She fully trusts her doctor but wonders whether the right thing was done
4. She lives alone

All of the following nursing diagnosis apply to Mrs. Lane:

Risk for infection, Acute pain, Anxiety, Ineffective breathing pattern, Imbalanced nutrition: Less than body requirements, disturbed body image, Sexual dysfunction, Impaired skin integrity, Risk for activity intolerance, Deficient knowledge.

Learning Activity:

• Select the ONE nursing diagnosis that is priority at this time
• Provide a rationale for your selection
• List the nursing interventions that assist you to meet the needs of the patient.

NURSING DIAGNOSIS	RATIONALE	NURSING INTERVENTIONS

At 6 pm, Mrs. Lane states that she is having pain. Mrs. Lane’s pain is at a level of 8 out of 10. She has not received any pain medication since 2pm. You take out an ampule labeled hydromorphone 10mg/mL and administer 0.5mL to Mrs. Lane. After administration of the hydromorphone, you r4ealize that hydromorphone is not morphine sulfate.

Based on the situation just described, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing interventions for this situation and identify your follow-up action plan for Mrs. Lane.

Priority Problem                                                                                                                                                                    New Action Plan

                                                                #1               #2               #3                  #4              #5                #6

         Nursing Interventions

1. Stay with the patient
2. Document drug and amount given
3. Monitor respiratory depression and circulatory collapse
4. Fill out an incident report
5. Notify your RN and instructor STAT
6. Notify physician STAT

Answer 1

The priority nursing intervention are

1. Monitoring the vital signs is the baseline to know the patient status
2. Assess the abdominal and surgical dressing to know about how the wound status, as there is dark colored stain it has to be changed before ambulation
3. Fasten the abdominal belt after dressing to provide comfort
4. Encourage to use incentive spirometry for enhancing the function of lungs
5. Encourage to cough and deep breath to remove secretions and improve breathing
6. Inform the patient the next duy for pain medication is after an hour
7. Finally ambulate the patient to bathroom.

Nursing diagnosis

Deficient knorrrelated to surger as evidenced by her fear whether the right procedure was done.

Rationale

This is because her mother deceased after 10 days of surgery ,which could have made her psychologically think about it.

Nursing intervention

• Assess the knowledge level of the patient
• Educate about the disease condition and its management
• Provide psychological support

Priority problems

• Medication error

Nursing intervention

1. Monitor vital signs ,respiratory rate,rhythm, oxygen saturation .As respiratory depression and circulation collapse can happen(C)
2. Notify the RNand the instructor
3. Inform the physician stay
4. Document drug and amount given
5. Fill out an incident report
6. Stay with the patient