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42-year-old female who recently had a cholecystectomy (gallbladder removal). Vital signs: Temp 102.1 F, BP 80/60,...

  • 42-year-old female who recently had a cholecystectomy (gallbladder removal).
    • Vital signs: Temp 102.1 F, BP 80/60, HR 110, RR 20, SPO2 98%
    • Assessment: Alert and oriented x4, Cardiac S1S2 present, Respiratory WNL, GI tender/pain in right upper and lower quadrant, GU clear, yellow urine
    • Orders: Vital signs Q4H and PRN, Morphine 2 mg IV Q4H PRN for moderate-severe pain, Percocet 5/325 mg 2 tabs Q6H PRN for mild-moderate pain
    • Problem: Patient is having pain rating 8 out of 10 on 0-10 pain scale even though she has been given 1 dose of Morphine IV and 2 tabs of Percocet (2 hrs apart). No pain medication is due soon
  • What is your recommendation? (ISBAR)
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Answer #1

Some of the recommendation for this patient are

  • Cold sponge to reduce the body temperature
  • Intravenous fluid to increase blood pressure
  • Cox 2 inhibitor can help reduce the pain compared to otger NSAID
  • Needs a physician visit.
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