Question

Yoa Li is a 26-year-old male who was transferred to our unit this morning at 0630 from the PACU. He had an open emergency appendectomy during the night and was in the recovery room for 1.5 hours.

He has no drug allergies, and is nothing by mouth (NPO) except for ice chips. While in recovery, he complained of pain 7/10 twice, and was given 4 mg of morphine by slow IV push. A PCA pump was started right before he was transferred to us, and he was given a standard loading dose of 2 mg IV bolus. The provider administered a morphine bolus 5 mg IV push at 1500 as Mr. Li was complaining about increasing pain. In the last 9 hours, he has had a total of 60 mg of morphine.

I completed vital signs, pain, and sedation assessment on the patient right after the morphine bolus was administered 30 minutes ago. His vital signs were: BP: 116/62 mmHg, HR: 72/min, RR: 12/min, and SpO2 94%. He rated his pain as 3/10 and he was sleepy but easily wakened. However, he was complaining of increasing nausea. I administered 10 mg of IV prochlorperazine as ordered prn for nausea.

The patient is due for a follow-up check on vital signs and sedation level. Continuing patient and family education on the use of PCA is also a good idea.

What are potential nursing diagnosis for this patient based on the above information?

What will you want to monitor for in this patient?

How would you educate the family and patient on the use of the PCA?

Answer 1

Question no 1

Potential nursing diagnosis are

1. Acute pain related to appendectomy
2. Risk for infection related to the surgical procedures
3. Fluid and electrolyte imbalance related to vomiting
4. Imbalance nutrition less than Body requirements related to medically imposed restrictions as evidenced by NPO
5. Fatigue related to imbalance nutrition
6. Deficient knowledge related to the PCA and ccondition

Thing to monitor in patient

1. Check for pain scale reading Every 2 hrly
2. Check temperature as they can indicate infection if any
3. Check pulse of it is maintained
4. Check BP as it can indicate if any hemorhage is in place
5. Check bowel movements as complications like paralytic illeus can occur
6. Check for spo2 and provide spirometry
7. Check level of consciousness and respiratory rate as morphine is given

PCA education

• This is a pump that allows the analgesics to be administered into vein through cannula .
• This can be used as set by nurse when you experience pain .
• No need to call and wait for a nurse
• This machine will also use IV fluids to flow into as the vein should he kept patent
• When pain increase it has to be started and the modes can be adjusted by patient,dose is determined by nurse and it preset
• Family should always check on breathing problems
• Morphine can cause respiratory depression so should be used cautiously
• Nause , vomiting should be checked
• Family should check if patient become disoriented or unconscious the it should he stopped