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NUR 100C (Fundamentals of Nursing Clinical)

Week 2: Assignment (Thursday, May 13, 2021)

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Case Study # 1

Mrs. Perez’s nurse receives her from the post-anesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit:

1. Interview the patient and/or husband and complete a history.

2. Take vital signs and complete a physical examination.

3. Create a care plan for the patient having acute pain postoperatively.

4. Write an admission note.

1. Match the nursing process steps with each of the four activities the nurse completes to admit Mrs. Perez. (They are listed above, 1-4).

A. Assessment

B. Diagnosing

C. Planning

D. Implementation:

E. Evaluation

2. Mrs. Perez is given morphine sulfate 4 mg IV push (IVP) every 2 hours for severe pain she experiences and demonstrates with a tense, grimacing facial expression. The nurse would provide the medication, and what other interventions would she implement to resolve Mrs. Perez’s acute pain related to tissue trauma as evidenced by reports of pain level at 8 out of 10?

A. Position patient for comfort.

B. Ask the husband to leave, as pain is best worked with in the absence of visitors in the room.

C. Educate the patient in severe pain about how to use her incentive spirometer and ask for a return demonstration before leaving the room.

D. Insist that the patient drink at least 1 quart of water for the evening to maintain hydration.

3. Pain is the fifth vital sign. When the nurse assesses the patient’s pain and provides the morphine sulfate 4 mg IVP to Mrs. Perez, what will she need to do about 15 minutes after dose administration?

A. Assess Mrs. Perez’s pain.

B. Plan for Mrs. Perez’s acute pain.

C. Implement interventions on the care plan to treat Mrs. Perez’s pain.

D. Evaluate Mrs. Perez’s response to the pain medication and interventions to decrease her pain.

4. Mrs. Perez’s pain is a dynamic patient care problem. It is expected to be most severe directly after surgery and will improve over time, given healing occurring at the incision line over time. Three days after surgery, Mrs. Perez’s pain and its treatment by nursing will change to reflect the evolving patient care needs and the subsequent healing. Which of the statements below would the nurse expect on the third day after surgery?

A. Pulse rate of 104 beats/minute with patient reporting pain at 7 of 10

B. Nursing diagnosis of Acute Pain related to postoperative tissue inflammation as evidenced by increased pain with movement.

C. Grimacing facial expression and clutching abdomen when reporting pain to the nurse

D. Patient will verbalize a pain level of 5 of 10 within 15 minutes of receiving prescribed pain medication.

5. List five additional pieces of data that the nurse who admits Mrs. Perez to the nursing unit would want to know before initiating care. Next to each item, identify whether it is subjective or objective. Write examples of the five data that would be appropriate for a postoperative mastectomy patient.

6 Identify two types of health care team members with whom the nurse would expect to collaborate while caring for Mrs. Perez.

7. Write four questions that the nurse could ask to obtain primary data on Mrs. Perez. From what sources could the nurse obtain secondary data?

8. Write a patient focused, measurable, and realistic short-term goal for Mrs. Perez, whose priority nursing diagnosis is Acute Pain.

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