Question

Mr. B is a 52 year-old man in the surgical intensive care unit after a liver transplantation the previous day. He has a 15-year history of hepatic cirrhosis secondary to alcohol abuse. He is intubated and receiving multiple vasopressor medications for hypotension. He also has a triple lumen subclavian central line with TPN infusing. 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? Morphine 5 mg IV has been administered by SICU nurse 30 minutes ago. On reassessment, Mr. B was found to be restless and turning his head left and right with both eyes closed. What is this patient most likely experiencing? What medications will help relieve this symptom? Is he still in pain? How will the nurse confirm this? What is the next nursing action? 3.The SICU nurse just got off the phone with the physician and he ordered for Mr. B to have” Versed 2mg IV q4 prn anxiety and Morphine 2mg IV Q 2 hours with first dose to be given now.” After administering these two medications slow IV push with 2nd RN to witness waste, what non-pharmacological interventions can the nurse implement to reduce pain and anxiety in Mr. B? What s/s should the nurse monitor in this patient? In regards to his hypertension, should the vasopressor meds be discontinued and why? Now that Mr. B may be requiring future doses of Versed in addition to pain medication, what tool should also be implemented during assessment of this patient? 4.It is 8 hours post-op and patient had 3 doses of Morphine and 2 doses of Ativan via IV. During routine assessment, SICU nurse notices Mr. B has a decreased response to verbal stimuli. He attempts to turn his head towards verbal stimuli but eyes remain closed and he did not move extremities. According to these findings, what is this patient most likely experiencing? What are the risk factors to developing this? What medication will help improve his cognition? What nursing interventions may be necessary for this patient?

Answer 1

As the patient cannot verbalise the appropriate pain scale would be the facial expression scale. The grimace on the patient face indicate a severe pain with the score between 7-9.

As most the analgesics primarily metabolised and excreted by the hepatobillary system, fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. The vital signs of the patient confirm that the patient is in severe pain with tachycardia and hypertension.

After administering the medication patients vital signs should be monitored along with po2 values. With follow up on facial expression.

The patient on reassessment is experiencing an anxiety. The symptoms can be treated by inj.medazolam ,again pain should be assessed using facial expressions scale. The facial expressions can also change due to agitation also. The nursing action should be reassess the patient after administering medazolam injection.

Nursing interventions other than pharmacological interventions:

- use presence, touch and demeanor to remind the patient is not alone.

- accept patient defense, donot dare, argue or debate.

-lessen sensory stimuli by keeping a quiet peaceful environment.

- acknowledge reports of pain immediately

- get rid of additional stressor's or some of discomforts.

- diversional therapy via music

The nurse should monitor vital signs for every 30mins along with facial expression pain scale. The hypertensioned noted may be due to pain. Vasopressor can be decided according to the consecutive vital signs recording. Along with the other monitoring it essential to use Glasgow coma scale as the patient is being sedated.

The patient might be experiencing a vasomotor collapse or impaired motor function, symptoms of midazolam overdose. The risk factor is using the versed along with opioid and tricyclic antidepressant.

Flumazenil is the antidote for this toxicity and hence it will help improve the cognition.

Close monitoring of the patient with assessment of GCS. Support the respiration of the patient with appropriate equipment. If patient experience hypotension administer I. V fluids and vasopressor as per physicians order. Reposition the patient to trendelenburg position. And administer Flumazenil as per orders.