The nurse must have a fundamental knowledge base about surgical procedures to fully understand Anna's risks. Although her vital signs were initially stable, her status has changed with the increase in pain and clinical presentation. This situation requires the nurse to complete a new assessment, including vital signs. During the assessment, the nurse must use critical thinking skills, pulling from her knowledge about surgery and infection, to problem-solve the underlying issues that may be contributing to her increasing pain, restlessness, and agitation.
The nurse’s priority is to assess Anna’s pain further. It is critical to determine the nature, location, and intensity of the pain and inquire about any other associated symptoms that might be present, including nausea or vomiting, which could indicate paralytic ileus.
The surgical site should also be inspected again, along with auscultation of her bowel sounds to assess for borborygmus, signs of infection, hematoma, or dehiscence, which could cause increased pain and might require immediate intervention. Given Anna’s low urine output, the nurse should also consider dehydration as inadequate fluid intake could contribute to restlessness, abdominal discomfort, and constipation. Fluid replacement should be considered in collaboration with the medical provider to avoid fluid overload in patients with hypertension.
A medication review, including any analgesic or opioids administered for pain, should also be completed. If Anna did not receive any pain medication as scheduled, this could be contributing to her increasing pain at this time. Pain medication can also contribute to constipation.
If not already addressed, patient education regarding the importance of deep breathing exercises, coughing, and early ambulation to prevent post-surgical complications should also be considered and done. Helping Anna understand the expected course of recovery and what symptoms to report to staff allows her to have some control over her recovery process. It helps with early intervention if problems develop, especially after discharge.
As the nurse, you completed a full nursing assessment with vital signs and medication review. You found that the patient had a low-grade fever with redness and drainage around the incision site. A call was made to the surgeon, reporting the new findings. The surgeon came to the unit and completed a wound culture before ordering a new antibiotic with dressing changes every four hours. Anna’s pain was managed with her new treatment plan, and the crisis was averted with early intervention. Knowledge base is vital to critical thinking and is foundational for positive patient outcomes.