Please help Ms. Hayes is 34- years-old woman admitted to the emergency room yest
ID: 139874 • Letter: P
Question
Please help
Ms. Hayes is 34- years-old woman admitted to the emergency room yesterday complaining of nausea, vomiting, and right upper quadrant pain. An upper right quadrant sonogram resealed several large stone in the gallbladder and possibly smaller stones in the common bile duct, requiring an open cholecystectomy.
On the first postoperative day, Ms. Hayes’s vital signs are BP 170/98, P 92 and regular, R 28 and unlabored, and T 38.1º C (100.6º F) she report a pain level of 7 of 10, and her pulse oximetry reading is 92% on room air. Her incision is 5 inches long, running parallel to the right upper quadrant ribs, it is secured with retention sutures. Because of her obesity, the incision is taut in certain sections. There is no swelling and only slight redness along the incision. The sterile gauze dressing has a minimal amount of dried blood. She has an intravenous line of 5% dextrose running at 125mL/hr.
Ms. Hayes has been medicated for pain three times during the 12-hour night shift and is currently requesting more pain medicine. Crackles are audible during lung auscultation. She does not want to turn, cough, and breathe deeply because “it hurts.” She has gotten up one to urinate 750 mL of concentrated urine and has not a bowel movement. She denies having nausea and vomiting. She is asking when she can eat but remains on a clear liquid diet. She states that she is not comfortable in her bed. She appears anxious, expresses concern about her job, and wants to know when she can leave.
Refer back to this case study to answer the critical-thinking question
1. Identify three pieces of assessment data (i.e., defining characteristics) that the nurse could use to support the actual nursing diagnosis of Acute Pain for Ms.Hayes.
2. List a minimum of three actual nursing diagnostic labels ( not including Acute Paint) applicable to Ms. Hayes’s current condition.
3. Write two risk nursing diagnoses for Ms.Hayes.
4. On discharge, Ms. Hayes expresses a desire to improve her health status. I identify two health -promotion nursing diagnosis labels that may apply to her situation, and give a rationale for each.
Explanation / Answer
1) Assessment data that support acute pain are
1) She reports pain level of 7 of 10
2) Mrs Hayed has been medicated for pain three time during a 12 hr night shift and is currently demanding for more pain medications.
3) She does not want to turn cough and breathe deeply as "it hurts"
2) Actual nursing diagnosis
1) Anxiety related to recovery as evidenced by anxious look
2) Impaired skin integrity related to surgical incision
3) Activity intolerance related to pain.
3) Risk nursing diagnosis
1) Risk for impaired skin integrity related to wound dehiscence as manifested by obesity, and presence of cough
2) Risk for decreased cardiac output related to hypertension as manifested by blood pressure of 170/98
4) Health promotion nursing diagnosis
1) Imbalanced nutrition more than body requirement
Rationale- Due to obesity and hypertension
2) knowledge deficit related to the management of disease condition
Rationale- frequent questioning about leaving hospital,joining job, when to start eating and stop clear liquids.