Just wondering if anyone could lead me in the right direction. This assignment is really kickin my butt!
*50 yr old woman, 4 hours post-op abdominal hysterectomy for menorrhagia and fibroids. She has orders to ambulate in 2 hours (6h post-op)
*You enter her room & find her sleeping. When you wake her, she lifts her head off the bed, looks at you, mumbles about her pain and falls right back to sleep.
*Her PCA is set at 1mg Morphine q 6 minutes on demand.
*She has made 10 demands for morphine in the last 12 minutes.
*O2 sat 96% on 2L non-humidified oxygen by NC.
*Respiratory rate = 14
*Complains of severe dry mouth
*Lips cracked and dry, family member wetting them with wash cloth.
*She has on bilateral sequential compression devices (SCDs).
Based on this info, what is the priority nursing diagnosis?
Priority nursing interventions?
What about the order to ambulate?
PCA 1mg Morphine q 6min on demand (Morphine - risk for respiratory depression)
(don't know what other meds she's on) Dosing is at standard level.
oRecent spike in pain--- what is the cause????
RR= 14 norm= 12-20
O2Sat = 96% on 2L by NC (low end, not good)
SCD's to prevent dvt
Sleeping/Mumblingà Sedation/Decreased level of consciousness? Many possible causes.
No other information given!!
Acute pain r/t incision site
Risk for Insufficient Fluid Volume and Imbalanced Electrolytes
Dry cracked lips, severe dry mouth,
Risk for Hemorrhage r/t ineffective vascular closure /alterations in coagulation
-need to check for bleeding
Risk for Infection
Risk for thromboembolism r/t immobility, vascular manipulation, surgery ??
Dec 21, '09
pain, acute r/t surgical incision aeb x demands in x mins. (possibly check her orders for an order for supplemental pain meds and sometimes even adding phenergran can make the difference) (you must wake her and make her reposition every hour or so this will help get her ready to ambulate. also gaining better control of her pain will allow her to ambulate). i've had this surgery and it can be done!
risk for respiratory depression r/t morphine use
risk for hemorrhage r/t surgical procedure
risk for thromboembolism r/t inability to ambulate
Dec 23, '09
I think that pain would be the first priority. With the other vitals WNL, I would address the pain.