Question

You are the nurse working the evening shift on a general post-operative surgical unit. You assess your patient, on admission to your unit after surgery. She tells you she was admitted from the ED this morning complaining of 1 day of severe nausea and vomiting. She had her appendix removed a few hours later and has been in the recovery unit for 3 hours. The aide got her up to the chair so she could eat her tray that just arrived from dietary. She is on a general diet. She is awake and alert x 3 but c/o the room spinning. She is still complaining of severe nausea and pain 8/10. Her VS are 98.6, 120, 24, 84/70 98% 10/10 pain. She has no IV fluids hanging. She has an order for Morphine sulfate 2mg IV push for pain and Ondansetron 4 mg IV push for nausea. She also has a prn antihypertensive medication ordered for a systolic BP over 160.

1. What is the priority issue of concern?

2. What are other areas of concern with the pt's assessment?

3. Why are these other areas not your first priority?

4. What do you think has to be done to help this patient?

5. What action would you take first? Calling for help is always a good choice but what do you do when help is coming. Cite evidence to support your suggested intervention.

6. What would be your suggested treatment for your second priority? Cite evidence to support your suggested intervention. (This may be a collaborative intervention i.e. a recommendation to a physician.)

7. What would be your suggested treatment for your third priority?

Answer 1

1. What is the priority issue of concern?

-Hypotension

2. What are other areas of concern with the pt's assessment?

-pain

-vertigo

-tachycardia

-nausea

3. Why are these other areas not your first priority?

- hypotension may be the cause of vertigo, this is leading to her tachycardia

- if it gets corrected the rest of the symptoms also get better

4. What do you think has to be done to help this patient?

-start iv fluids(As her BP is low with tachycardia it indicates there is a chance for hypovolemic shock, so to maintain her blood volume start iv fluid)

-analgesics

-check Hb and haematocrit ( to assess if there is any blood loss after surgery, by comparing the value of pre op)

5. What action would you take first? Calling for help is always a good choice but what do you do when help is coming. Cite evidence to support your suggested intervention.

-reasurance

-position her properly with head end elevated

-start iv fluid

6. What would be your suggested treatment for your second priority? Cite evidence to support your suggested intervention. (This may be a collaborative intervention i.e. a recommendation to a physician.)

-pain

- give analgesics according to the order after confirming, no blood loss from surgical site

7. What would be your suggested treatment for your third priority?

- vertigo

give Inj .Stemetil 1amp i.m stat after informing the consultant.