Question

1. Scenario

History of Present Problem:

Josephine Peters is a 52-year-old female who is post-operative day one for anterior-lateral lumbar spinal fusion. Her pain has been controlled with oxycodone 5 to 10 mg PO every four hours. She has had no visitors today and has been resting comfortably between doses of pain medication. She had her chest tube pulled out three hours ago. Her last dose of oxycodone was 10 mg three hours ago. To support her back when she is out of bed, Josephine has a hard plastic back brace. She is currently sitting in a chair with the hardback brace in place.

Personal/Social History:

Josephine is divorced and has three children. She has chronic back pain and uses recreational marijuana (in a state where it is NOT legal) to manage this pain at home. She currently works as a nursing assistant in a skilled care facility. Her oldest son lives locally and has two teenage children.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

(Reduction of Risk Potential)

RELEVANT Data from Present Problem:	Clinical Significance:
RELEVANT Data from Social History:	Clinical Significance:

2. The Dilemma Begins…

Current Concern:

When the oldest son comes to visit at change of shift, the patient becomes visibly agitated and begins calling out loudly,

“Take this brace off me! “I have never had pain like this before!” The oldest son becomes angry and upset and approaches the nurse and states, “You need to go out and call the doctor right now, I cannot watch my mother be in pain. I don’t understand how you people can watch a patient suffer and do nothing about it!” When the oncoming nurse explains that she needs to complete report and briefly perform an assessment before she can call the primary care provider, he states angrily, “I can’t understand why you can’t just go out and call the doctor, you must not know what you are

doing!”

The nurse has all family members leave the room to complete the initial nursing assessment. Josephine begins to apologize profusely for how she was treated by her son and appears embarrassed. Her vital signs are T: 98.4 F/36.9 C P: 72 R:18 BP: 128/68. Her pupils are 3 mm/equal and reactive. Her pain is currently higher than it has been earlier and rates as a 7/10. After this assessment is completed, the nurse communicates to both the family and the patient the plan of care and contacts the primary care provider to address the need for more pain control.

What data from the current concern is important & RELEVANT; therefore it has clinical significance to the nurse?

(Reduction of Risk Potential)

RELEVANT Data from Current Concern:	Clinical Significance:

3. Resolving the Dilemma

   1. Interpreting RELEVANT clinical data, what is the essence of this clinical dilemma? (Management of Care)

2. What additional information is needed by the nurse to clarify the dilemma? (Management of Care)

3. What additional members of the healthcare team could be used in this situation? Why? (Management of Care)

4. What is the nursing PRIORITY? (Management of Care)

5. What are the PRIORITY nursing interventions? (Management of Care)

PRIORITY Nursing Interventions:	Rationale:	Expected Outcome:

6. What is the expected response of the patient and family that indicates nursing interventions were effective?

(Management of Care)

7. What response by the patient would indicate that a change in the plan of care and nursing interventions are needed?

(Management of Care)

8. What principles of therapeutic communication can be utilized to develop trust and encourage dialogue between the nurse, patient, and family? (Psychosocial Integrity)

9. How can you support and encourage active partnership with the family while you plan, implement, and evaluate patient care?

10. What is the patient and family likely experiencing/feeling right now in this situation?

(Psychosocial Integrity/Basic Care and Comfort)

11. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? (Psychosocial Integrity/Basic Care and Comfort)

12. What was learned from this case study that you will incorporate into your practice? (Management of Care)
    

Answer 1

1. Data from history which is important

She is a nursing assistant by profession.

It is Post operative day one after anterior lateral lumbar spinal fusion . She is on oxycodone 10mg fourth hourly. She uses recreational marijuana for pain in house.

2. Her pain scale has increased now it is 7/10, her dosage of oxycodone needs to be increased, brace is for back support not for restraining her.

Clinical dilemma :

1. There will be no pain is a dilemma,

2. Using of brace

What additional information is needed by the nurse to clarify the dilemma?

She should get in contact with

1.X ray technician, to see whether the fusion site is fine, also for taking x ray chest,  

2.Physician if the dose of oxycodone needs to be increased or any other medications to be started.

3.Surgeon if anything more to be taken care of

Nursing priority :

1. Make the son understand the situation

2.Reassure the patient

3. Give mental support and give her analgesics

4. Position her in a comfortable position

Nursing intervention

1.encourage her to move her toes

2. Listen to music

3. Check for any weakness of limbs,

4. Work in pase with physiotherapy department

Positive responses

1. Now the pain is reduced, she is happy

2. She is able to move from bed to chair on her own

Responses

1. Make them also involve in doing exercise for the patient

2. Encourage them to talk with patient in your presence.

Need of change of care plan

1. if they want to postponed the treatment a little later according to their availability.

2.if they have financial problems

Principles of therapeutic communication

Actively listen to them when ever they tell any complaints, focus on the main problem , try to clarify the medical doubts

How can you support and encourage active partnership with the family while you plan, implement, and evaluate patient care?

1. Ask how do you feel about your mother today

2. How many times you made her do the exercise

3. How long she slept

What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?

1. Informing the daily health progress of the patient

2.encourage them to be consistent with the treatment

3. Tell your previous experience