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:

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

2. Take vital signs and complete a physical examination.

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

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

Answer 1

Complete history:

1. Identification data

2.family history

3. Personal history

4. Obstetrical history

5. Past medical history

6.Past surgical history

7. Present medical history

8. Present surgical history

II. Vital signs

Note temperature, pulse, respiration and BP

Physical assessment:

. head to food assessment and mental status examination

III. Plan for post operative pain:

Assessment	Nursing diagnosis	Goal	Nursing Intervention	Rational	implementation	Expected outcome
Subjective data: Monitor whatever patient verbalizes on pain	Pain related to surgical intervention	reduce pain	1. Asses intensity, duration, srvereity of pain.	1. To know the nature of pain		Patient will get rid of pain after nursing intervention
Objective data: Note the patient facial expressions on pain.			2. Provide diversion am therapy	2. To reduce pain perception
			3. Give incisional pillow.	3. It reduces pain on incisional site.
			4. Give comfortable bed.	4.alleviating pain.
			provide comfortable position.	6. Reduce pain perception
			7.Teach relaxation techniques	7. It maximize comfort
			8. Psychological support	8. Make patient adaptation9.
			9. Give ablgesics as per order9. Reduce pain.

IV. admission notes:

Subjective data:

Note exactly patient verbalizes.

Objective data:

Made on our observation

Pain assessment scale

Assessment:

Write head to foot assessment as mentioned on physical examination

Plan, implementation and evaluation:

It mentioned on above care plan.