Patient Charge Nurse Explained for Students (Easy Guide)

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Original Question

A New Patient The charge nurse notifies you that you will be receiving a new patient from the post-anaesthesia care unit. Maria Amor is a 64 year old female who uses the pronouns she/her/hers. Report from PACU Nurse It is 1330. You take charge of Mrs. Maria Amor when she arrives at the postoperative oncology unit. Her partner is currently speaking with the physician while awaiting the arrival of his wife on the unit. This is the report from the post anaesthesia care unit (PACU) nurse. Hello, I am Marites, the nurse in the PACU. I’m giving report on Mrs. Maria Amor, aged 64, who has just undergone a modified radical mastectomy of the left breast with resection of lymph nodes. She is a patient of Dr. Yu. The surgery went as planned without major problems. She’s been in the recovery room for 45 minutes. She is drowsy but easily awake and she is oriented to person, place and time; respirations are 16 / min, SpO2 at 96% on room air. HR is 72 / min, BP is 122/75 mmHg; Ringers Lactate is running at 100 mL / hr; her chest bandage on the left breast is serosanguinous over an area of ​​approximately 1 x 2 cm; a Jackson Pratt drain is in place at the level of the left axilla and has drained 30 ml of serosangiunous fluid; she has an indwelling urinary catheter which will be taken out tomorrow, her urine output is normal. She rated her pain at 5/10 when she woke up. The initial loading dose of 3 mg via the PCA pump was administered 15 minutes ago. A reminder of the preoperative instructions for self-administration of analgesia via PCA was given. The VS should be repeated at 1345., following the PCA bolus. At 1530, you enter the patient’s room to perform another assessment. During the assessment, she rates her pain as 8/10. She had received both Acetaminophen and Ibuprofen within the past 2 hours. You note that she continues to be drowsy but rousable; she has attempted patient controlled analgesia 6 times; she has some nausea, no emesis; dressing and drain intact, drainage on dressing 2cm X 2cm. Her vital signs are within her expected range. Which intervention will you incorporate to help manage Mrs. Amor’s pain? Increase PCA dose as per physicians order You increase the PCA dose of morphine as per the physician’s orders then proceed to call the physician. Why are you calling the physician? To change the anti-emetic After you state your name, you continue to use SBAR to relay your concerns about using dimenhydrinate as it can cause drowsiness and you have just increased the intermittent dose of morphine given via PCA. You recommend a change of antiemetic. Dr. Yu agrees with you and gives the following order: Discontinue dimenhydrinate Start Ondansetron 4mg IV q8h PRN for nausea It is 1800. Mrs. Amor is showing signs and symptoms of an opioid overdose including respiratory rate of 6 and although she can be roused, she falls back to sleep right away (3 on the sedation scale). As outlined in the PCA prescription, the PCA infusion has been stopped, 40% O2 by Venturi mask is being administered, and a dose of naloxone was required to restore consciousness. Her respiration rate is now 12 / min. All you have to do is call the physician. Mrs Amor is stable and another nurse is in the room monitoring her so you can call the physician. You introduce yourself and indicate which unit you are calling from. Which of the following reports contains the most relevant information that you must provide to the physician? I am calling about Mrs. Maria Amor, a 64-year old woman, who had a modified radical mastectomy of the left breast with lymph node removal this morning. I just turned off the PCA pump because her respiratory rate was 6 / min and she was at 3 on the sedation scale. She received a single dose of naloxone. Currently her respirations have increased to 12 / min and oxygen saturation is 95% on 40% oxygen. She has a history of hypertension, her current BP is 110/60. She has no history of lung problems. Her medications for analgesia need to be reviewed due to the stopping of the PCA. The physician thanks you for recognizing the emergency situation and treating Mrs. Amor appropriately. She indicates that she will come to the unit shortly to re-evaluate the patient and the orders for analgesia. The physician came to review the post-PCA prescriptions and the following orders for analgesia were given: hydromorphone 2 mg PO q 4 h PRN hydromorphone 1 mg PO q 2 h PRN in between doses if not relieved Mrs. Amor was given a 2 mg PO hydromorphone dose two hours ago, then a 1 mg PO half dose 30 minutes ago for 3/10 pain relief. She is currently awake and alert and her VS are within her baseline limits. It is 1930. Your shift is ending and you are preparing to give your handover report. After introducing Mrs. Amor and her reason for admission, how will you communicate the episode of respiratory depression in your handover report? “Mrs. Amor was on PCA, but following an episode of respiratory depression, PCA was stopped at 1800. Only one dose of naloxone was needed. She is currently awake and alert, with respirations at 16 / min and SpO2 at 95% on room air. She received a 2 mg PO hydromorphone dose one hour ago and at last check, she rated her pain 3/10.” Questions 1.What recommendation will you give as part of your SBAR shift report about Mrs. Amor? 2. Create a care plan using critical inquiry to support clinical decision making and client choice. Perform a comprehensive assessment of the patient’s health, history, health status, and desired goals. Involve the patient in the care planning process by asking them about their health goals and preferences. By involving the client, nurses can ensure that the care plan is aligned with the patient’s goals and preferences which can improve patient engagement and compliance with the care plan. Perform an ongoing assessment and evaluation as the patient’s health and goals can change. Adjust the care plan accordingly.

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