Action #1: Administer mg Morphine IV for breakthrough pain
While Ryan appears alert and oriented, his pain is rated eight on a visual analog scale of 10. The physician recommends that Ryan receive NOW for breakthrough pain. It implies that administering morphine IV should be a priority action. Besides, the goal is to have Ryan’s pain level rated five. In their comparative study, Ankumah et al. (2020) discovered that IV morphine is effective in pediatric pain management for acute cases such as preterm contractions. Accordingly, administering mg Morphine IV on Ryan will ensure that the goals of definitive care are attained. Assessment data shows that Ryan's pain should be reduced to a rating of five. Therefore, morphine should be administered to facilitate smooth recovery from pain after the ORIF procedure.
Action #2: Input consult For Pain Management into the Electronic Order System
Pain management is crucial early rehabilitation of patients, especially among postoperative patients. Management and control of pain entail tracking and recording transitions that the patients undergo as they recover from pain. In this case, the physician recommends that a pain management system should be consulted once the patient has been discontinued from the patient-controlled analgesia (PCA) pump. The goal of pain management is to have the pain reduced to a rating of five on a scale of 10. The physicians recommend that Morphine IV should be administered every 4-6 hours to achieve a reduced and stable status of 5 out of 10. It implies that there is a need for an effective management system to monitor the patient’s progress. In a retrospective study, Chiu et al. (2015) found out that patients using the Electronic Order System received their analgesia, had less postoperative pain, and used minimal narcotics, unlike patients under paper-based ordering systems. Accordingly, EOS should be considered a priority to facilitate effective pain management.
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Action #3: Call the Physician to Get Orders for Nicotine Patch and Report Urinary Output with Amber Urine
Ryan is two hours post-open reduction and internal fixation (ORIF), which implies that the fractures, wounds, bruises, and fractures are gradually healing. Ryan has a craving for smoking cigarettes and was heard requesting to be given a cigarette or a patch. At this point, smoking and intake of nicotine related substances are discouraged since it undermines the wound healing process. In a retrospective study, Stefan et al. (2020) discovered that it is safe for physicians to order Nicotine Replacement Therapy (NRT) such as transdermal nicotine patches in the perioperative period to reduce risks of craving and enhance the hospital experience for active smokers undergoing surgical procedures. The nicotine patch will also assist in preventing the patient from experiencing delirium
The assessment data indicate that Ryan’s urine in the Foley bag is colored, and the output in the past 2 hours is 40 cc. It implies that he has decreased urine output since an expected urine output should be 30 cc per hour and 60-100 cc in two hours. Notably, the urine output is of critical concern and should be reported urgently.
Action # 3: Decrease O2 to Nasal Cannula and Continue SpO2 Monitoring
According to assessment data, the oxygen saturation is 94% when Ryan is on 4L Nasal Cannula. The physician has recommended that Ryan receive ABGs every 4 hours. The data also indicates that Ryan’s blood pressure is normal at 130/80 mmHg and a recommendable heart rate of 94 bits per second. It implies that there is no need for High-flow oxygen therapy of 4L/per min since it has been supplemented by other delivery approaches such as ABGs. McDonald (2014) notes that while supplemental oxygen helps patients with breathlessness, clinicians should be aware of its potential adverse effects. Additionally, there is a need for minimization of hyperopia and hypoxia by monitoring flow rates and delivery systems ( McDonald, 2014) . In the case, therefore, there is a need for decreasing flow rates to avoid hyperoxia, since there are two delivery systems in place, ABGs, and Nasal Cannula.
Incorrect action: Apply Anti-embolism Stockings Bilaterally
The patient is in post-open reduction and internal fixation (ORIF) after having fractured right femur, among other fractures such as sternal and rib fractures. Notably, Ryan could be having peripheral arterial disease, including arterial bypass grafting. It explains why the patient is seen seated up with thigh-high anti-embolism socks on the left leg only. Anti-embolism stockings are discouraged since it exerts external pressure, which reduces the flow of blood on the lower limbs leading to ischemia or necrosis of the tissue. Besides, the dressing on multiple abrasions appears dry, which implies that there is no imminently anticipated clotting of blood.
References
Ankumah, N. A., Tsao, M., Pedroza, C., Sibai, B. M., Blackwell, S., & Refuerzo, J. (2020). 747: The comparative effectiveness of intravenous acetaminophen versus intravenous morphine for analgesia of preterm contractions. American Journal of Obstetrics & Gynecology , 222 (1), S472-S473.
Chiu, T., Wolfe, S., Magid, S., & Urban, M. (2015). Electronic ordering system improves postoperative pain management after total knee or hip arthroplasty. Applied Clinical Informatics , 06 (03), 591-599. https://doi.org/10.4338/aci-2014-12-ra-0114
McDonald, C. (2014). Low-flow oxygen: How much is your patient really getting? Respirology , 19 (4), 469-470. https://doi.org/10.1111/resp.12290
Stefan, M., Pack, Q., Shieh, M., Pekow, P., Bernstein, S., & Raghunathan, K. et al. (2020). The association of nicotine replacement therapy with outcomes among smokers hospitalized for a major surgical procedure. Chest , 157 (5), 1354-1361. https://doi.org/10.1016/j.chest.2019.10.054
