Question

Name: _____________________________________ D#: ______________________Directions: Read case scenario and answer questions below.Case Scenario: Your unit received Mrs. C as admission from the post-anesthesia care unit (PACU) Mrs. C is 82-yrs old and underwent Right Colectomy (Right-Sided Colon Resection) to remove a non-malignant tumor. Vitals were stable in PACU. Mrs. C has “PIV in Right AC” (peripheral IV catheter in right arm), indwelling urinary catheter, nasogastric tube (NGT), and “O2 per NC at 4L/min” (oxygen through nasal cannula going at 4 liters). Mrs. C received Morphine Sulfate 5 mg through IV push in the PACU and has a PCA (patient-controlled analgesia) Morphine Sulfate 1 mg every 10 min. You assess the level of consciousness and note Mrs. C is slow to respond to your questions.

1.) What may be the reasoning that Mrs. C is slow to respond to your questions and what do you need to be continually assessing for/monitoring for in patients with PCA?

2.) What are some other priority post-surgical assessments to look for?

3.) Name 2 priority nursing diagnoses for Mrs. C (include 1 “actual” diagnosis and 1 “risk for” diagnosis)

4.) Plan 3 nursing interventions that relate to your nursing diagnoses. Set 1 goal with 2 expected outcomes for Mrs. C at the time of discharge.

5.) How will you implement these nursing interventions?

6.) When Mrs. C is ready for discharge how will you evaluate whether your nursing interventions and overall care plan was effective?

Answer 1

1.

Mrs. C may have drowsiness due to increase sedation by PCA leads to slow down the response. The nurse should inform the doctor and reduce the amount of infusion rate.

The nurse should continually need to assess the pain level to understand the effectiveness of PCA, vital signs, oxygen saturation, level of consciousness, nausea, and vomiting.

2.

Answer: The priority assessment for the post-surgery patient are

- patency of airway

- vital signs

- level of consciousness

- Oxygen saturation

- the surgical site with the drain system

3.

Answer: The nursing diagnosis are

1. Acute pain related to surgery as evidence by verbalization of having pain and pain score of 8

2. Risk of infection related to the presence of unhealed surgical wound

4.

1. Acute pain related to surgery as evidence by verbalization of having pain and pain score of 8

Goal: To reduce the pain level

outcomes:

- report of pain relieved or controlled verbally by the patient

- The patient appeared relaxed, able to do activities without complaint of pain.

Nursing intervention

- assess the pain level every day

- Administered analgesic as per advice by the doctor

- Provide comfortable position to the patient.

2. Risk of infection related to the presence of unhealed surgical wound

Goal: To free from infection

Outcomes:

- To reduce the potential for infection by identifying the risk factors

- Maintain safe aseptic environment

nursing intervention

- assess for the sign of infection on the surgical site

Maintain proper personal hygiene

- Perform daily dressing of the wound site

Question 5

The nursing intervention can be implemented only after proper education of the patient and the family members regarding hoe to perform at home and asked to demonstrate in front of the nurse so that they can confidently do at home and correct any mistakes during the demonstration.

Question 6

The overall care is effective or not can be identified by comparing with the expected outcomes that are plan before the administration of the intervention. If the outcomes are achieved then we can tell that the plan is effective.