Author Question: A client recovering from total hip replacement surgery is experiencing pain exacerbated with ... (Read 106 times)

karlynnae · **on:** Jul 22, 2018

A client recovering from total hip replacement surgery is experiencing pain exacerbated with movement and tells the nurse, I have no idea how I can return home since I live alone.. The client's BMI is 35.

Which of the following nursing diagnoses would be a priority for this client? 1. Ineffective Coping
2. Pain
3. Imbalanced Nutrition: More than Body Requirements
4. Impaired Physical Mobility

Question 2

A client is admitted with the diagnosis of sickle cell crisis. Which tasks would the nurse perform first based upon the following clinical findings: temperature 102F, O2 saturation of 89, and complaints of severe abdominal pain?

1. Give Tylenol (acetaminophen) grains X (650 mg)
2. Apply oxygen per nasal cannula 3L/minute
3. Administer morphine sulfate grain intramuscular
4. Assess and document peripheral pulses

amanda_14 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2. Pain

Rationale:
Unless the client's pain is controlled, the client will not be able to participate in interventions to address the impaired physical mobility. The diagnoses of ineffective coping and imbalanced nutrition can be dealt with after pain and impaired physical mobility have been addressed.

Answer to Question 2

2. Apply oxygen per nasal cannula 3L/minute

Rationale:
Hypoxia is often the cause of a sickle cell crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering the oxygen will improve the pain and increase the oxygen saturation of body tissues. Therefore, applying the oxygen should be the first action by the nurse. Although the temperature is elevated, and will increase oxygen demands in the body by increased basal metabolic activity, administering Tylenol is not the first action the nurse should take, because a sickle cell crisis is caused by oxygen deprivation in tissues, not by the fever. Morphine sulfate is a narcotic for pain, but it should be given after the oxygen is started, since the symptoms are caused by hypoxia. The morphine will decrease the pain and decrease metabolic oxygen needs by decreasing basal metabolic rates; therefore, supply is increased and demand is increased. Full body assessment, including peripheral pulses, is significant to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present from the sickling of the cells during sickle cell crisis.