Question

You are caring for a patient who just had gastric bypass surgery. She is 35 years old. Past medical history includes obesity and hypertension. Pain is being controlled with Demerol via Patient controlled analgesia (PCA) pump. The PCA pump is delivering Demerol continuously and on demand.

1. What data should the nurse obtain? What s/s should you be monitoring for while the patient is using a PCA pump?

2. Describe signs and symptoms of pain and what pain scale would you use?

3. Explain how you would check the PCA pump with another nurse.

3. What education would you provide to reduce the pain for the patient when moving or walking?

4. Identify actual nursing diagnoses related to Pain.

5. Develop a goal/outcome for the nursing diagnoses.

6. Develop 3 nursing interventions with rationales to help the patient meet the goal/outcome.

Answer 1

1.The following data has to be obtained

• Vital signs
• Intake and output
• Patient neurological status
• Post operative orders
• Assess for any adverse reaction
• The pain level of the patient
• The amount or quantity of medication to be induced

The following signs and symptoms has to be observed for

• Assess the respiratory rate, rhythm, oxygen saturation because this
• drug can lead to respiratory depression
• Assess the neurological status and wake up the client for sleepiness because overdose can lead to unconsciousness

2.The following are the signs and symptoms of pain

• Patient will be restless on bed
• Calling for help frequently
• Moaning
• Changes in facial expressions
• Moving their limbs while lying down
• May exhibit anger

The visual analogue scale is the best way to assess and rate the pain

3.Some of the education which can be provided to the patient while walking are

• To walk slowly and steadily without any tension or fear
• Encourage to take the pain killers as per order before walking
• Provide assistance this can reduce fear and improve the confidemve and courage to walk

4.Nursing diagnosis

Acute pain (in abdomen) related to surgical incision as evidenced by post operative day, pain medication

5.Goal

The patient will be having reduced pain and able to mobilise out of bed

6.Nursing intervention

• Monitor the pain level ,this can provide information to plan for care
• Monitor vital signs to rule out and prevent respiratory depression
• Mobilise the patient at the earliest, this can prevent unnecessary complications post operatively .