4. Generate Solutions: What actions would most likely achieve the desired outcomes for this client? Which actions should

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4 Generate Solutions What Actions Would Most Likely Achieve The Desired Outcomes For This Client Which Actions Should 1 (72.86 KiB) Viewed 51 times

4. Generate Solutions: What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Take Action: Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. Evaluate Outcomes: What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)
A 52-year-old woman married to a veteran fell down a flight of stairs 10 years ago and sustained an acute herniated disk at the L4-L5 spinal level. A laminectomy and diskectomy relieved her pain for about 3 years. Two additional surgeries later, including a recent spinal fusion, failed to provide pain relief, but she could ambulate with a cane. The client was admitted to surgical unit yesterday to implant a spinal nerve simulator as a last resort for pain management. On admission from the postanesthesia care unit yesterday afternoon, she reported that her legs were still “numb” because of her epidural anesthetic. Her vital signs were within her baseline, and her pain level was a 2 on a 0-to-10 pain scale. During the night, the client was unable to void and required a straight urinary catheterization. The night nurse documented that her legs were still numb from the epidural she had received during surgery. She reported increased pain during most of the night. This morning, the surgeon stated that she could be discharged to home in the care of her very attentive husband. The client received an oral dose of codeine with acetaminophen about an hour ago. Upon assessment, the nurse documents the following assessment findings: • Blood pressure = 166/88 mm Hg • Pulse rate = 86 beats/min • Respiratory rate = 28 breaths/min • Pain level = 8 (on a 0-10 scale) • Reports that she remains unable to void more than "a few dribbles," although she has been drinking water frequently • Reports numbness from her waist down to her toes • Is barely able to move her legs • Requires maximum assistance to get out of bed into a chair 1. Recognize Cues: What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. Analyze Cues: What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Prioritize Hypotheses: Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.)