Given Name: Emma
DOB: 28.09.1986 Gender: Female
Emma Peterson, 34 years-old female, had undergone a right side breast surgery due to breast cancer.
Primary survey: it is paramount to evaluate her condition thoroughly by deploying the ABCD (airway, breathing, circulation, and disability) assessment approach. After surgeries, the patient may get altered breathing patterns, airway obstruction, and altered circulation under the effect of general anesthesia postoperatively (Thim et al., 2014; Smith, & Bowden, 2017). Therefore, it is paramount to listen for wheezing, auscultate breathing sound, and observe all the vitals, including respiratory rate, heart rate, and blood pressure. As per the patient's clinical observations, her vitals were within the standard limit, and she was able to move her limbs. Though, she remains slightly tachypneic and tachycardia at 0600.
Pain assessment: Pain was assessed through a Verbal rating scale (Fry & Elliott, 2018; Buisman et al., 2016; Johnson et al., 2010). She rated her pain 3 out of 10.
Wound assessment: Her wound was intact and dry.
Nursing diagnosis: The patient is suffering from slight tachycardia and tachypnea. Postoperatively, there is a risk of wound infection and pain incidence (NANDA International, 2014).
Priority care: For pain management, analgesic (oxycodone hydrochloride) would be rendered. The dose must be monitored and adjusted as per the pain intensity (Hunnicutt et al., 2017). Further, the patient must be monitored for breathing patterns since Emma had slight tachycardia (Brugada et al., 2020). Additionally, the wound must be dried and covered by sterile dressing (Cancio et al., 2017).
Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., ... & Gomez-Doblas, J. J. (2020). 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) Developed in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC). European heart journal.
Buisman, M., Wagner, M. C., Hasiuk, M. M., Prebble, M., Law, L., & Pang, D. S. (2016). Effects of ketamine and alfaxalone on application of a feline pain assessment scale. Journal of feline medicine and surgery, 18(8), 643-651.
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Fry, M., & Elliott, R. (2018). Pragmatic evaluation of an observational pain assessment scale in the emergency department: The Pain Assessment in Advanced Dementia (PAINAD) scale. Australasian Emergency Care, 21(4), 131-136.
Hunnicutt, J. N., Ulbricht, C. M., Tjia, J., & Lapane, K. L. (2017). Pain and pharmacologic pain management in long-stay nursing home residents. Pain, 158(6), 1091.
Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of Nursing Management, 18(7), 832-845.
NANDA International. (2014). Nursing diagnoses: definitions and classifications, 2015-17.
Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard (2014+), 32(14), 51.
Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117.
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