Here is the case. A 48 years old woman who just had abdominal surgery. And she is having an IV infusion of 5% dextrose running at 500mL in 6hours. The IV stopped running and her infusion site is swelling and pallor. She is also complaining about the IV is hurting her. She is feeling pain, discomfort and general malaise. She has hypertension and intermittent episodes of gout in her past health history. Here are her vital signs.
BP 148/62, Pulse:62, Temperature:36.5, Respiratory rate:26, SpO2 % in room air.
What are the significance and importance in this case?What should the care plan be? like an actual problem and potential problem? Impaired tissue integrity?
Online teaching has limited my study nowadays. May anyone please give me some help?
Raise up her limbs to avoid accumulation of the fluid?
Impaired tissue integrity is related to leakage of intravenous solution into surrounding tissue as evidenced by swelling and pollar around the infusion site.
Acute pain is related to the IV infiltration, secondary to the abdominal surgery and past health history of Intermittent episodes of gout as evidenced by a chief complaint of pain and general malaise and a high respiratory rate.
For the related factors, should I both use "is related to IV infiltration" or should I be more detail on the cause of such problem, just like the first diagnosis?
Acute pain is related to the IV infiltration, secondary to the abdominal surgery and past health history of Intermittent episodes of gout as evidenced by a chief complaint of pain and general malaise and a high respiratory rate.
Can you tell us why you think the IV infiltration is the primary cause of her acute pain?
OK I will give it a look. I just noticed some e-book might also give me a help. Thank you for your help!
You definitely need to read up on the disease process, surgical procedure, complications, etc. in order to write the care plan. Without the basic knowledge there's no way you'll be able to do it.
Specializes in Endoscopy/Gastroenterology, General Surgery.
6 hours ago, Wuzzie said:
Can you tell us why you think the IV infiltration is the primary cause of her acute pain?
I want to ask you the same question. Many data are presented here but you are only focusing on one thing; IV infiltration. Just because the patient specifically complained about this IV issue doesn’t mean that is the primary source of pain. This patient just had an abdominal surgery, why do you think her acute pain is secondary to abdominal? Your tunnel version is still there. When someone has a surgery, he/she is mostly likely to have some sort of dressings. Have you thought about checking her dressings? What should a normal initial post-op dressings look like? What should be the colour of the drainage and how much amount should you expect? By the way, as a nurse you must never remove an initial dressing (fresh post-op) without having surgeons to assess first.
I have mentioned about conducting head-to- assessment. This will help you to organize your data by system and have a more clear of the picture.
1 hour ago, Wuzzie said:
You definitely need to read up on the disease process, surgical procedure, complications, etc. in order to write the care plan. Without the basic knowledge there's no way you'll be able to do it.
You need to know the basic care for any post-op patients. What are the priority focus in caring any post-op patients?
Other than just pain, can you see the possible relationship between the abdominal surgery and her abnormal respiratory rate, and why she is in pain and discomfort? (This is the biggest hint I can give; thats half of the answer)
NG KIU HO
19 Posts
Impaired tissue integrity is related to leakage of intravenous solution into surrounding tissue as evidenced by swelling and pollar around the infusion site.
Acute pain is related to the IV infiltration, secondary to the abdominal surgery and past health history of Intermittent episodes of gout as evidenced by a chief complaint of pain and general malaise and a high respiratory rate.
For the related factors, should I both use "is related to IV infiltration" or should I be more detail on the cause of such problem, just like the first diagnosis?
Thank you for your help!