Nursing Interventions for Judy: Managing Post-Surgery Pain and Nausea

QUESTION

Judy (pronouns: she/her/hers), 55-years-old, was admitted for a colon resection for a cancerous tumor. The surgeon ordered a morphine sulfate patient-controlled analgesia (PCA) pump to help control the pain. The client has not had surgery before, so she is unsure what to expect. Judy has a history of cancer and diabetes mellitus type 1.​ Vital signs T 97.6 °F (39.1 °C) oral​, HR 48, BP 90/50, RR 10, and SpO2 89% on room air. The client is nauseated and reported dizziness and a headache. She rates her pain 8 out of 10 on a pain scale and is uncomfortable to move and unable to rest.​ Generating Solutions Prior to discharge, the nurse reviews the nursing diagnosis and establishes nursing actions in the plan of care to help meet client goals.​ Match the nursing action with the appropriate nursing diagnosis. Nursing Diagnosis Nursing Action Administer supplemental oxygen as ordered to maintain SpO2 saturation levels of at least 90%. Describe satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10. Evaluate the client’s vital signs, including temperature and blood glucose levels. Check baseline vital signs and blood glucose levels and monitor trends. Perform

ANSWER

Nursing Interventions for Judy: Managing Post-Surgery Pain and Nausea

Introduction

Judy, a 55-year-old patient with a history of cancer and diabetes mellitus type 1, has undergone a colon resection for a cancerous tumor. She is currently experiencing significant pain, nausea, and dizziness. This essay will discuss appropriate nursing actions matched with the relevant nursing diagnoses to address Judy’s post-operative condition and help her achieve optimal pain control and comfort.

Nursing Diagnosis 1: Impaired Gas Exchange Related to Decreased Oxygen Saturation (SpO2 89%)

Nursing Action: Administer supplemental oxygen as ordered to maintain SpO2 saturation levels of at least 90%.
Judy’s low oxygen saturation level is a concerning issue that requires immediate attention. Administering supplemental oxygen helps improve oxygenation and prevents further complications related to impaired gas exchange. This action aligns with the goal of enhancing respiratory function and ensuring adequate oxygen supply to body tissues.

Nursing Diagnosis 2: Acute Pain Related to Surgical Procedure (Pain Rating 8/10)

Nursing Action: Describe satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10.
Judy’s reported pain level of 8/10 indicates inadequate pain control, hindering her ability to rest and recover comfortably. Describing satisfactory pain control as a level less than 3 to 4 helps set a clear goal for pain management. This action aligns with the objective of alleviating pain and improving Judy’s overall comfort.

Nursing Diagnosis 3: Risk for Imbalanced Blood Glucose Levels Related to Diabetes Mellitus Type 1 and Surgical Stress

Nursing Action: Check baseline vital signs and blood glucose levels and monitor trends.**
Judy’s history of diabetes mellitus type 1 and the stress of surgery place her at risk for imbalanced blood glucose levels. Monitoring baseline vital signs and blood glucose levels and observing trends helps detect any fluctuations promptly. This action supports the goal of maintaining Judy’s blood glucose within a safe range and preventing complications associated with uncontrolled diabetes.

Conclusion

Addressing Judy’s post-operative condition requires a comprehensive approach to manage her pain, improve oxygenation, and monitor her blood glucose levels effectively. The nursing actions identified for each nursing diagnosis align with specific goals related to Judy’s well-being and recovery. By implementing these interventions, the healthcare team can optimize Judy’s post-surgery experience, ensuring she achieves adequate pain control, oxygenation, and blood glucose management for a smoother and more comfortable recovery process.