Quote from pj4854
Just a quick question for anyone who may know the answer:
If ABGs indicate respiratory alkalosis, the patient is post-op surgery and you walk into his room and he states he has severe pain, the FIRST THING you would do is to:
1. Administer IV Morphine
2. Talk to the patient and try to relax him
There were 2 other answers which were ridulous. My feeling on this question is that you don't administer a drug like Morphine prior to assessing the pain. "Severe" is different to different patients. The question didn't state if it was a PRN med or if there was even an order. With computer charting you have to document prior to administering pain med and then reevaluate 15 minutes later w/IV drug. Respiratory alkalosis can be caused by fear, stress, pain, etc.
According to my instructor, you would just administer the Morphine (you would need to assume it was an ordered PRN). Her rationale is also that you wouldn't talk to the patient and try to relax him because that would not help the pain, and a pain assessment is unnecessary because he is post-op. Which makes me wonder why "talk to the patient and try to relax him" was even an option. I personally feel that taking a couple minutes to assess the pt (getting HR, BP, etc) and finding out how severe it truly is just makes sense. How long does it take to ask "on a scale of 1-10 with 10 being the worst, how bad is your pain?"
First, I don't know anyplace where you document anything you havent done. Written or computer. Isn't that illegal?? You must give the med first then document. Just because you use a computer doesn't mean things change. From a legal standpoint: What if you document you gave morphine but on your way to the patient room with morphine in hand your patient codes and you never give it???
You will learn with taking test in nursing is that you have to PICK THE BEST
ANSWER from the available
choices. Most of the time you can eliminate two obvious crazy answer and be stuck with two choices. It's a lot of things you can do as a nurse but they want to know what you will pick from the choices they provide. You can't think too much into it. This is why many ppl fail the school nursing exams and the NCLEX. You just need to think ABC's. Airway, Breathing, Circulation.
Repiratory Alkalosis is what happens when you breathe off too much acid. What happens when you don't have enough acid in your blood...it increases in alkalinity. Just reference your pH scale. Hyperventilation gets rid of too much CO2 (acid). So this patient has a breathing problem. If you don't correct this, the airway. is the next thing to go as hyperventilation can render a patient unconscious and they may not be able to protect their airway. You don't want that.
You say severe pain is different from patient to patient. Not really. PAIN IS THE 5TH VITAL SIGN
. You don't need a few minutes to assess pain by the way. Just a few seconds Quality:
assume that it's bad if they cant control their breathing as evidenced by tachypnea and abnormal ABG Severity:
Severe as reported by pt Location:
Surgical site perhaps?? Onset:
acute (they are post op) Duration:
it's not intermittent at this point. So CONTINUOUS Precipitating or relieveing factors:
Cause..surgical incision or procedure?? Relief: what do pt's normally get for severe pain post op.
Most likely if their pain is that severe they can't breath, mostly likely their HR and BP will be elevated. (read over SNS stimulation with stress)
Subjectively...severe pain is the same no matter who tells you. You use your nursing judgment to find objective data that corresponds to what the pt says. Now if a pt says 10/10 pain but yet they are eating, talking on phone or sleeping...ok, we still must report their pain and treat accordingly with NON PHARM and pharmacological interventions.
But a patient that YOU KNOW CAME RIGHT OUT OF SURGERY (you should almost always expect pain post op) and is having LABORED AND FAST RESPIRATIONS?? ABG reveals...labs are objective assessment data. Don't you realize you have all the assessment data you need? You don't always have to have a stethoscope or numbers to assess. You have to use your 5 sense in many cases. You don't have to always have a 1-10 pain scale to assess pain. They have analog and non verbal pain scales (i.e FACES) as well.
Just put yourself in the patients position. If you tell your nurse you are in severe pain and you are breathing fast and not feeling well would you want to hear: What is your pain from 1-10? Is it sharp or dull?? That is why answer choice #2 is out the door.
Treat the pain first and you'll correct the respiratory issue, suffering and your patient can thank you and describe how bad it was later. It's all about priority.