Question

Mrs. Perez’s nurse receives her from the post anesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit:

Interview the patient and/or husband, and complete a history.

Take vital signs and complete a physical examination.

Create a care plan for the patient having acute pain postoperatively.

Write an admission note using SOAPIE format (Subjective Data, Objective Data, Assessment, Plan, Implementation, and Evaluation).

Match the nursing process steps with each of the four activities the nurse completes to admit Mrs. Perez. (They are listed above, 1-4).

Assessment

Diagnosing

Planning

Implementation

Evaluation

Mrs. Perez is given morphine sulfate 4 mg IV push (IVP) every 2 hours for severe pain she experiences and demonstrates with a tense, grimacing facial expression. The nurse would provide the medication, and what other interventions would she implement to resolve Mrs. Perez’s acute pain related to tissue trauma as evidenced by reports of pain level at 8 out of 10?

Position patient for comfort.

Ask the husband to leave, as pain is best worked with in the absence of visitors in the room.

Educate the patient in severe pain about how to use her incentive spirometer, and ask for a return demonstration before leaving the room.

Insist that the patient drink at least 1 quart of water for the evening to maintain hydration.

Pain is the fifth vital sign. When the nurse assesses the patient’s pain and provides the morphine sulfate 4 mg IVP to Mrs. Perez, what will she need to do about 15 minutes after dose administration?

Assess Mrs. Perez’s pain.

Plan for Mrs. Perez’s acute pain.

Implement interventions on the care plan to treat Mrs. Perez’s pain.

Evaluate Mrs. Perez’s response to the pain medication and interventions to decrease her pain.

Mrs. Perez’s pain is a dynamic patient care problem. It is expected to be most severe directly after surgery and will improve over time, given healing occurring at the incision line over time. Three days after surgery, Mrs. Perez’s pain and its treatment by nursing will change to reflect the evolving patient care needs and the subsequent healing. Which of the statements below would the nurse expect on the third day after surgery?

Pulse rate of 104 beats/minute with patient reporting pain at 7 of 10

Nursing diagnosis of Acute pain related to postoperative tissue inflammation as evidenced by increased pain with movement.

Grimacing facial expression and clutching abdomen when reporting pain to the nurse

Patient will verbalize a pain level of 5 of 10 within 15 minutes of receiving prescribed pain medication

Answer 1

1. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit:

·        Interview the patient and/or husband, and complete a history.

·        Take vital signs and complete a physical examination.

·        Create a care plan for the patient having acute pain postoperatively.

·        Write an admission note using SOAPIE format (Subjective Data, Objective Data, Assessment, Plan, Implementation, and Evaluation).

Match the nursing process steps with each of the four activities the nurse completes to admit Mrs Perez. (They are listed above, 1-4).

a. Assessment

Involves the subjective data and objective data :

•       Interview the patient and/or husband, and complete a history to obtain subjective data

•        Take vital signs and complete a physical examination to obtain objective data and

b. Diagnosing:

Prioritize the nursing diagnosis if multiple diagnoses need to be addressed.

Each nursing diagnosis is assigned a clear, measurable goal for the expected beneficial outcome based on the evidence-based Nursing Outcome Classification.

c. Planning :

•        Create a care plan for the patient having acute pain postoperatively.

After the determination of the nursing diagnoses upon agreement of nurse and patient, a plan of action can be developed to address the problems.

d. Implementation

Execution of the plan of actions to achieve the goals (Short term and Long term)

e. Evaluation

Assessment of set goals being achieved or not, re-planning to achieve the goal.

•        Write an admission note using SOAPIE format (Subjective Data, Objective Data, Assessment, Plan, Implementation, and Evaluation).

Admission note is not a part of “nursing process”

It must include the summary of subjective and objective data collected for the assessment, the overall plan to address the problems and the implementation and evaluation of the initial plan of care directed by the authority.

2. Mrs Perez is given morphine sulfate 4 mg IV push (IVP) every 2 hours for the severe pain she experiences and demonstrates with a tense, grimacing facial expression. The nurse would provide the medication, and what other interventions would she implement to resolve Mrs Perez’s acute pain related to tissue trauma as evidenced by reports of pain level at 8 out of 10?

Answer: •    Position patient for comfort

Comfortable position can reduce the patient’s pain to some extent.

·        Ask the husband to leave, as pain is best worked with in the absence of visitors in the room.

Presence of support personnel can have a positive effect on the patient in managing pain.

·        Educate the patient in severe pain about how to use her incentive spirometer and ask for a return demonstration before leaving the room.

Education must be provided to a patient in comfort to ensure proper understanding and effectiveness.

·        Insist that the patient drink at least 1 quart of water for the evening to maintain hydration.

Hydration of post-operative patient can be maintained by IV fluids.

3. Pain is the fifth vital sign. When the nurse assesses the patient’s pain and provides the morphine sulfate 4 mg IVP to Mrs Perez, what will she need to do about 15 minutes after dose administration?

Answer: Assess Mrs Perez’s pain.

As pain is the fifth vital sign and the morphine sulfate a potent drug, the patient’s response to pain medication has to be assessed again to ensure effectiveness.

The respiratory rate also has to assessed carefully as the morphine sulfate can depress the respiratory centre. The nurse must record baseline data or vital signs for comparison, 15 minutes after IV administration of morphine to assess whether the patient is experiencing adverse effects of therapy.

·        Plan for Mrs Perez’s acute pain.

·        Implement interventions on the care plan to treat Mrs Perez’s pain.

·        Evaluate Mrs Perez’s response to the pain medication and interventions to decrease her pain.

4. Mrs Perez’s pain is a dynamic patient care problem. It is expected to be most severe directly after surgery and will improve over time, given healing occurring at the incision line over time. Three days after surgery, Mrs Perez’s pain and its treatment by nursing will change to reflect the evolving patient care needs and the subsequent healing. Which of the statements below would the nurse expect on the third day after surgery?

•        Nursing diagnosis of Acute pain related to postoperative tissue.

inflammation as evidenced by increased pain with movement. Intensity or severity of postoperative pain reduces overtime with interventions. The patient may not experience severe pain after the third day of surgery.

The pain occurring as a result of postoperative tissue inflammation may be intensified with movement on the third day and can be managed with analgesics.

On each day the nursing diagnosis should be revised and modified according to the patient’s condition.

The ·        Pulse rate of 104 beats/minute with patient reporting pain at 7 of 10

Can be expected on first days

·        Grimacing facial expression and clutching abdomen when reporting pain to the nurse

Shows high-intensity pain.

·        Patient will verbalize a pain level of 5 or 10 within 15 minutes of receiving prescribed pain medication

Expected even on the first day with strong analgesic like morphine