Question

The nurse is admitting the patient to a medical unit. She is 68 years of age and has a history of ovarian cancer She had surgery 5 months ago and has had pain ever since the surgery. She reports that she has been taking oxycodone hydrochloride/acetaminophen (Tylox) tablets at home but that the pain is "never gone." The patient describes her pain as a "10" on a scale of 0 to 10, deep, occasionally cramping, and sharp or stabbing. She waves her hand over her chest and abdomen when asked to pinpoint the location of the pain. 1. How should the nurse document this assessment of pain? During a discussion with the pain management nurse, it is suggested that the patient be given a fentanyl acetate (Duragesic) transdermal patch for pain management. She comments, "Oh, good! I know that will help make my pain go away quickly 2. What would be the best response by the nurse? After consideration of her history and her pain, the pain management special ist recommends that the patient should receive patient-controlled analgesia (PCA). After discussing PCA therapy with her, an infusion is started with morphine as a basal infusion as well as interval self-dosing. The next morning while reviewing the infusion notes, the nurse sees that the patient dosed herself four times during the night. She is awake and states that her pain is now at a "5" and that she feels "a bit of relief now. Later that afternoon during rounds after lunch, the nurse sees that she is asleep and has not touched her meal. Her respiratory rate is 12, but she does not answer when the nurse calls her name. 3. What would the priority action by the nurse be? 4. What additional actions should be taken? During evening rounds, the patient is found to be unresponsive, with respiratory rate of 7 breaths/min. Her son, who was staying with her, said that he "pushed the button a few times" while she was asleep because earlier she was complaining of hurting but wouldn't push it herself 5. What would be the priority actions by the nurse? Answer all components of this discussion.

Answer 1

1.The nurse should document the assessment of pain and a better option to document is by using PQRST

Provocation:The patient is experiencing pain secondary to post op ovarian cancer state. Didn't relieve with the medication in home.

Quality:

She has a cramping and sharp or stabbing pain

Radiation:Region

She has pain in her abdomen and on chest ,probably radiating to chest from abdomen

Severity:The pain score 10 in a scale of 0 to 10

Time:The pain is continuous

2.The nurse should respond in the following way

• It is an alternative and works better compared to oral pill
• Reassure the patient that the action wil be slow and steady

3.The priority nursing action action

• Stop the infusion
• Wake up the patiwnt with strong stimuli pain
• Administer Antidote naloxone to reverse overdose
• If doesn't respond start CPR
• Raise alarm for code blue
• In firm the physician meanwhile

4.The additional actions to be taken are

• Administer oxygen to prevent hypoxia
• Continuously monitor vitals (SPO2 and respiratory rate)
• Documentation

5.The priority actions to be done by a nurse are

• Stop the morphine infusion
• Administer oxygen
• Administer antidote naloxone 0.4mg IV,if does not respond administer till 0.8mg and arouse the patient continuously
• Initiate rapid response team or CPR before itself
• Stabilise the patient
• Monitor vitals and keep aroused the patient till consciousness regains
• Shift to intensive care unit for further observation