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/MumblingÓ 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 ??