Prioritizing Care....?

[WannaBeNrse]

Hi,

I have a scenario here (homework) and I am supposed to prioritize care, but I am not quite sure if I'm on the right track.

Here is the scenario: Patient is a 45 y/o female, 3 days post op (TAH); has an IV because she vomited last night. Vital signs are stable, no emesis in 12 hours. She complains of incisional pain rated 6/10; incision is slightly reddened with scant yellow drainage; hand with IV is pale, cool to the touch, and edematous. Client states she has to void.

Soooooooo..... should I give her the bed pan first, because voiding is a physiologic need and can be easily relieved? Or, since her pain level is quite high, would you administer her pain med first, since moving to go to the BR or even just turning to use the bedpan might aggrevate the pain further? (she gets tylox every 4 hours for pain prn). and what about the signs of infection on her incision? and the problems with the IV? should these be last on my priority list? this needs to be within the scope of practise of an LPN- so can I just put a new IV in the other hand, or is this sth that an LPN would report to the RN?

I guess my main question is, would you rate the need to void or the incisional pain as first priority?

Thanks!!

[UM Review RN, ASN, RN]

This is what I'd do, whether it's right or wrong.

1). Turn off the IV fluids.

2). Position patient on the bedpan.

3). Take the patient's temp.

4). Give patient the po pain med.

5). Pull the old IV. 6). Patient should be ready to get off the bedpan. Elevate the hand to a pillow with a warm pack for comfort. Make sure the skin's ok at the hand and at the peri area, and make sure that there's no vag bleeding. Take the rest of the vital signs.

7). Inspect and document the wound drainage (and don't forget to document the IV infiltration). Call the doc and report the patient's vital signs and the color, amount, and location of the wound drainage. Tell him if the patient is voiding OK and has good bowel sounds--or not. Ask if he wants a wound or blood cultures. Explain that you just pulled the IV and confirm that you need to reinsert a new one. Ask if he wants IV antibiotics, any stat Xrays, and if he wants to continue/increase/decrease the IV fluids.

Well, that's how I would've done it. I hope it's right. Good luck. Any questions, feel free to post again.

[WannaBeNrse]

Thank you!!!

But I do still have questions: Why would you pull the IV right away? Because the edema indicates fluid retention, or because it's not needed since the vomiting has stopped? Could I as an LPN make that call and pull the IV, or do I need Dr. or RN orders first?

If her pain is so bad that she doesn't want to move, could you give the pain med first and have her go to the bathroom/ bedpan half an hour later, or can you not wait that long? Sorry if thats a stupid question, I am a complete newbie (first semester :))

[UM Review RN, ASN, RN]

You'd pull the IV right away to minimize damage to the hand. The patient might still need an IV because that wound sounds like it's going to need antibiotics, and the doc will most likely select an IV antibiotic.

At my hospital, I would delegate the pulling of NORMAL IV's to someone else, but if that IV is already infiltrated, I want to pull it myself and check it closely and get her comfortable before I document about it.

As far as her pain vs using the bedpan goes -- I'd ask the patient which she feels she needs first. Sometimes they need the pan regardless of the pain, other times the pan can wait while they take a pill. Still -- make sure you get a temp before you give that water. Only takes a second, and that way you'll be sure it's accurate.

[truern]

3 days post-op she should be getting up to the bathroom..

clearly the IV needs to go..

does she have a fever, even lowgrade?

personally, I'd want the tylox first and then go potty. Getting up after my TAH hurt like the dickens!

[truern]

3 days post-op she should be getting up to the bathroom..

clearly the IV needs to go..

does she have a fever, even lowgrade?

personally, I'd want the tylox first and then go potty. Getting up after my TAH hurt like the dickens!

edited to add angie oplasty's post was spot on!!

[Daytonite, BSN, RN]

remember maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs) and list the tasks/problems.

• incisional pain rated 6/10 (physiological need for comfort)
  
• hand with iv (physiological need for fluids) is pale, cool to the touch, and edematous (physiological need for safety from physiological threat)
  
• client states she has to void (physiological need for elimination)
  

on the hierarchy this is how they would fall in priority:

1. client states she has to void (physiological need for elimination)
   
2. incisional pain rated 6/10 (physiological need for comfort)
   
3. hand with iv is pale, cool to the touch, and edematous (physiological need for safety from physiological threat)
   

what i would expect the lpn working with me to do is take care of the patient's toileting situation immediately. then, take care of the pain situation. finally, report the iv situation to me. unless lpns in your state are allowed to do anything with ivs do not mess with my patient's ivs. let this rn assess and trouble shoot the iv problem. in any case the other two problems need to be taken care of first.

i've never had many patients that were willing to wait to go to the bathroom while the nurse got their pain medication. more patient's will try to crawl out of bed on their own while the nurses are getting the pain med just to empty their bladder and end up falling. when a patient calls and tells you they have to "go" you best get them a bedpan or get them to the br asap.

[Daytonite, BSN, RN]

why would you pull the iv right away? because the edema indicates fluid retention, or because it's not needed since the vomiting has stopped? could i as an lpn make that call and pull the iv, or do i need dr. or rn orders first?

because i was an iv therapist for many years and i know what i am doing with ivs and because i worked in states where lpns couldn't touch ivs, i always kept watch on my patient's ivs and i read the riot act to anyone who tinkered with my patient's ivs without telling me what they did. an iv hand that is pale, cool to the touch, and edematous indicates an infiltration. the iv flow merely needs to be cut off initially. removing the iv cannula can wait once the infusion is stopped since the problem (infiltration) is solved by stopping the iv flow. doctors orders are not needed to make that call, but someone who has authority in the facility to perform iv therapy can make that call. once there is a doctor's order for iv fluids and a problem has occurred with an iv, the person with authority to perform iv therapy can make a decision to d/c a bad iv and restart it.

if her pain is so bad that she doesn't want to move, could you give the pain med first and have her go to the bathroom/ bedpan half an hour later, or can you not wait that long?

no. could you "hold it" for half an hour waiting for a pain pill to work? i've been a nurse for many years. most people who are hospitalized are embarrassed or don't want to bother the staff to help them potty. so, when they finally ask for help to "go" they really need to "go". to wait another half hour is asking for trouble.

[WannaBeNrse]

Thank you guys sooo much!!! I'm still torn on the BR vs pain med thing, because taking her to the bathroom might further aggrevate her pain, so maybe if she has her med first, at least in can start working.... and walking there three days post op will probably be sloooow (i remember from my c-section ;-)), so that would further delay her pain med....maybe i'll just say that i'd ask the patient what she feels she needs to have taken care of first. then i think i report the IV thing to the RN, i really dont think i should turn it off..... geez this sounded so easy but it really isn't ... anyway, thank you all for helping!!

[Valerie Salva, BSN, RN]

1, Stop IV.

2. if in too much pain to get up to b/r, offer bedpan.

3.Give pain meds.

4. Pull old IV, have RN start a new one, or LPN can do if it IV certified and if facility policy allows.

After the pain med has had time to work, then offer to assist pt to the b/r.

[Daytonite, BSN, RN]

Thank you guys sooo much!!! I'm still torn on the BR vs pain med thing, because taking her to the bathroom might further aggrevate her pain, so maybe if she has her med first, at least in can start working.... and walking there three days post op will probably be sloooow (i remember from my c-section ;-)), so that would further delay her pain med....maybe i'll just say that i'd ask the patient what she feels she needs to have taken care of first. then i think i report the IV thing to the RN, i really dont think i should turn it off..... geez this sounded so easy but it really isn't ... anyway, thank you all for helping!!

I've been a nurse for a long time and a patient as well. The next time you need to go to the bathroom, don't. Hold off for 5-10 minutes while you "wait for pain medicine" and another 30 minutes, the time it takes for the pain medicine to work. Consider the time you may need to wait for someone to come back to help you get to the bathroom. Rate your discomfort. Then re-think the time to help a patient go pee vs. the time it takes to get a pain med for the patient and remember to go back 30 minutes later and toilet them. There is a lot of wasted time in there.

[UM Review RN, ASN, RN]

I've been a nurse for a long time and a patient as well. The next time you need to go to the bathroom, don't. Hold off for 5-10 minutes while you "wait for pain medicine" and another 30 minutes, the time it takes for the pain medicine to work. Consider the time you may need to wait for someone to come back to help you get to the bathroom. Rate your discomfort. Then re-think the time to help a patient go pee vs. the time it takes to get a pain med for the patient and remember to go back 30 minutes later and toilet them. There is a lot of wasted time in there.

True. I've done the dance in bed a few times myself.