Jason Brown is a 21-year-old college football player. It is the second postop day following surgical repair of a fracture of his right tibia and fibula. He has sutures over the anterior knee and lateral malleolus and a posterior splint on the right leg. He continues to report considerable pain. His vital signs at midnight were as follows: temperature, 98.3°F; pulse, 58 beats/min; respirations, 12 breaths/min; blood pressure 118/70 mm Hg. He reported his incisional pain as sharp, stabbing, and a 3 on a scale of 1 to 10 (10 = worst) at about 10 pm. He has a peripheral IV in his left forearm infusing D5 ½ NSS at a rate of 20 mL/hr. He is using a patient-controlled anesthesia (PCA) pump for pain relief. The nursing care for the morning includes routine am care, cast care, and a trip to physical therapy (PT). Shortly after morning report, the unit secretary catches you and says, “Jason says he needs a nurse. He is in terrible pain.”You enter the room. Jason is pale and diaphoretic. His sheets are damp with some wet spots. He says, “My leg hurts. It really hurts.” You ask him to rate his pain, and he answers, “At least an 8. I've been pushing my pain pump but I'm still in pain.” His IV site looks okay. You say, “I'm going to find out why it is hurting. I need to get your vital signs first.” His vital signs now are as follows: temperature, 98.9°F; pulse, 72 beats/min; respirations, 20 breaths/min; blood pressure, 124/78 mm Hg.
Prescribed Interventions
- Vital signs q4h
- Intravenous fluids: D5 ½ NSS at 20 mL/hr
- PCA—morphine sulfate 1 mg/mL, 1 mg q6min; lockout max 10 mg in 1 hr
- Zolpidem 5 mg prn at bedtime for sleep
- PT for weight bearing, as tolerated
Developing Clinical Reasoning and Clinical Judgment
- What is the significance of the changes in Jason's vital signs?
- What interventions for Jason's pain must occur immediately before administering nursing care and PT?
- How do you assess the following:
- Infection versus inflammation?
- Neurovascular compromise?
- IV patency?
Suggested Responses for Integrated Nursing Care
- Always compare vital signs with a baseline and the previous vital signs (see Chapter 2). While Jason's temperature is elevated slightly, it has not increased dramatically, as it would be with an infection. His respiratory rate and pulse rate were quite low at midnight. Since he is a young, healthy athlete, his resting pulse rate may be lower than what is often considered as the norm. You notice that his resting pulse rates on the night shift have been running from 56 to 60 beats/min. Another factor contributing to his decreased pulse rate may be the effect of the zolpidem that he took at 2200 to help him sleep. Therefore, while his morning respiratory rate and pulse rate are still within normal range, they represent a significant increase from his resting baseline. These are objective assessments that correlate with his identification of increased pain.
- One reason for an increase in pain with any postsurgical patient is the possibility of infection. Quickly assess all surgical incision sites and observe for redness, swelling, or a foul odor (Chapter 8). Due to short hospital stays, signs and symptoms of infection do not usually appear until after the patient is discharged. The assessment of the surgical site should also include checking for bleeding. Hemorrhage in the postoperative period is always a potential complication (see Chapter 6).
- In addition to infection, Jason is at risk for neurovascular compromise because of the trauma to his right leg as well as from the splint and dressing. Assess for neurovascular compromise and perform cast care (refer to Chapters 3 and 9). Jason's fracture has been placed in a splint rather than a cast, which is a more current surgical practice, but nurses still refer to the care of the affected extremity as “cast care.” Determine whether there are any signs of compartment syndrome (refer to Chapters 3 and 9). You need no additional equipment for this assessment, and it should take very little time; do this immediately.
- Upon assessment, you find that Jason's foot and leg are pink and warm with 2+ pulses, no edema, full sensation, motion, and capillary refill measuring less than 3 seconds. The incision sites show no redness, swelling, drainage, or foul odor, and no bleeding is evident.
- Another possible reason for his pain is that his IV may no longer be patent and, therefore, he would not be receiving any pain medication. You remember the wet spots on the bed as you begin systematically checking each of the IV administration-set connections. Your assessment of the IV site shows no swelling, and he reports no pain at the site. Your next check should be from the IV site to the IV tubing. You find that the connection of the IV tubing to the IV insertion catheter is loose and leaking. Determine whether the IV site is still patent (see Chapter 16). If the IV is still patent, replace the IV tubing (see Chapter 16). Check the medication in the PCA pump to ensure it is the correct medication. You will be required to check the PCA history to determine the amount of medication used as well as the amount remaining every 4 hours or according to facility policy (see Chapter 10).
- Contact the health care provider to explain that the PCA pain medication was infusing onto the bed linens, and obtain a prescribed intervention for an appropriate bolus dose so that Jason can obtain immediate pain relief. After 30 minutes, obtain another set of vital signs and perform a pain assessment. Document the evaluation of your interventions. Jason's pain will need to be controlled before initiating additional nursing care. Coordinating with PT to reschedule his therapy until his pain is controlled is a nursing responsibility.