Please enable JavaScript.

Coggle requires JavaScript to display documents.

Admitting Dx: Dislocated C2 Fracture; C1-C2 Laminectomy with Fusion. …

- - - - Nursing Interventions:
        Frequently assess the patient for pain, and adequate pain relief after medication administration. Determine the "location, characteristics, onset, duration, frequency, quality, and severity of pain." Otherwise known as the "PQRST" pain assessment (Wayne, 2023).
        Assessment of the severity of the patient's pain, using the 0 out of 10 scale. "Using a pain scale with 0 being no pain and 10 being the worst pain imaginable, a numerical value can be assigned to the patient's perceived intensity of pain." (Fink, 2000)
        Monitor vital signs often post-operatively, paying close attention to heart rate and blood pressure, which can rise during episodes of pain. "Autonomic responses to pain: profuse sweating, alteration in BP, HR, RR, dilation of pupils" (Wayne, 2023).
        Rationale: Pain is subjective to each patient; therefore, a standardized tool (PQRST and 0 to 10 scale) is necessary to measure the severity, location, and quality of the pain experienced by the patient. Frequent assessments and specialized questions regarding pain can assist the nurse in providing and analyzing if proper pain relief has been successful. Heart rate, blood pressure, and respiration rate can increase when a patient is experiencing pain so vital sign assessment is also important. "Proper nursing assessment of acute pain is imperative for the development of an effective pain management plan" (Wayne, 2023).
        
        Patient Teaching: Provide the patient with alternative/non-pharmacologic methods of pain relief. Such as: distraction, meditation, guided imagery, heat and cold applications, massage, and allowing the patient to participate in their spiritual/cultural practices that address pain safely. (Wayne, 2023)
        Rationale: The patient may experience break-through pain and/or it may be too soon for the next dose of pain medication, or the patient may refuse to take medications and prefer other pain relief measures. Therefore, patient teaching regarding other pain relief options must be available to them.
        Patient Teaching: The importance of staying ahead of the pain and not waiting until the pain is unbearable to then request pain medications. Teach the patient to call for the nurse when they first start to feel an increase in their pain level.
        Rationale: "It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required" (Wayne, 2023).
        
        Evaluation: The goal was met as evidenced by proper pain relief. Patient stated a diminshed pain level of 2 from a 6 (out of 10) 30 minutes after the administration of pain medication.
      - Collaborative Interventions & Rationale: Collaborate with physical therapy (PT) and the patient care technicians (PCTs) to report to the RN if the patient complains/states they're experiencing pain during interactions they may have with the patient, along with notifying PT and the PCTs regarding being mindful when handling the patient, as the patient is required to keep head midline and is unable to turn their head and neck. Also, when interacting with the patient, stand in front of their line of view when speaking. This promotes unison amongst members of the healthcare team when it comes to communication during patient care, and promotes patient welfare/healing. Collaboration allows an approach to pain management that can hopefully catch/address pain earlier before it worsens. Once the RN is notified the patient is experiencing pain, she/he can do an assessment and provide the ordered pain relief.
  - - - Nursing Interventions:
        Monitor surgical incision site for any purulent drainage, excessive bleeding, redness, swelling, unrelieved pain or tenderness.
        Monitor the patient's vital signs: HR, RR, BP, Temperature, Pain
        Monitor the patient's labs for increased WBC.
        Rationale: Surgical patients are at higher risks of developing infections post-operatively. It is important to monitor and assess the patient regularly for indications of an infection. This includes: physical assessments of skin, monitoring vital signs and lab values. "Fever is often the first sign of an infection. A temperature of up to 38º C (100.4º F) 48 hours post-op is usually related to surgical stress after 48 hours. A temperature greater than 37.7º (99.8º F) may indicate infection; a very high temperature accompanied by sweating and chills may indicate septicemia" (Vera, 2023).
        
        Patient Teaching: Teach the patient and caregiver regarding the importance of hand washing before and after using the bathroom. Along with the importance of washing their hands before changing the bandage/surgical dressing on the patient's incision site.
        Rationale: Prevents the spread of infection. Provides an aseptic environment in which organisms cannot grow and cause an infection. "The aseptic technique decreases the chances of transmitting or spreading pathogens . . . (Vera, 2023).
        Patient Teaching: Encourage the patient to eat foods high in protein and Vitamin C to promote wound/incision healing of the skin.
        Rationale: "Adequate nutrition enables the body to maintain and rebuild tissues and helps keep the immune system functioning well" (Vera, 2023).
        Patient Teaching: Signs/Symptoms of Infection teaching to the patient and caregiver. (swelling, irritation, redness, wound drainage, unrelieved pain, fever).
        Rationale: Patient and/or caregiver will be able to monitor for s/s infection and be able to notify nurse and provider if they notice any indications of an infection.
        
        Evaluation: The goal was met as evidenced by the patient's vital signs within normal range and no signs or symptoms of an infection during my 12 hour shift.
      - Collaborative Interventions & Rationale:
        Collaborate with physical (PT) and occupational therapy (OT) so the patient doesn't physically digress or experience physical immobility complications after surgery. Working with PT and OT will help to gain physical strength in order to provide care for oneself. Including but not limited to: safely showering, eating, washing hands, brushing teeth, ambulating, and other daily care activities. Care for the incision site to prevent infection will also be taught by the RN with collaborative assistance from PT and OT as to how safely perform actions with the correct body mechanics. Collaboration with a dietician to promote healthy food choices that promote healing, by providing lists of foods that are high in protein and vitamin C.