Question

It is 1 hour post-op, The SICU nurse is reassessing the patient. Assessment findings for Mr. B include: Grimacing, can barely bend his fingers, coughing with some tears noted. Current vital signs are T97.8F, HR 130, B/P 168/102, breathing 25 breaths per minute on SIMV mode ventilation. What pain scale is appropriate for this patient? According to the scale, what is his score? Do his vital signs confirm this? What medications may be administered to control his pain? What should the nurse monitor after the med is administered?

Answer 1

The Richmond Agitation-Sedation Scale can be used to assess this patient. Based on this scale, Mr.B scores +2. That he is restless and agitated. The Lego pain assessment tool also used to evaluate the pain. He scores 8 where the pain is unbearable. His vital signs are showing elevated pulse and blood pressure.

It is essential for the patient through proper management of sedation and reduces complications. Analgesia can also be administered additionally. Already, the patient has tachycardia and hypertension which may increase the systemic vascular resistance and leads to myocardial ischemia. Opioid analgesics(Morphine and fentanyl patch) can be administered with caution. Non- pharmacological therapies such as touch, music, distraction can also be helpful.  So proper management of pain can reduce the deep sedation and muscle relaxants.

The nurse should record the vital signs more frequently. Assess for any adverse effects of medication such as respiratory distress, nausea, vomiting, the absence of bowel movements. Monitor the intake and output chart. Reassess the patient's pain every 2 hours to know the effectiveness of pain management.