The nurse cares for postoperative clients using PCA pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which client should the nurse assess first?
1. Client after jejunostomy for cancer of the colon
2. Client after internal fixation of an ankle fracture
3. Client after amputation during first hospitalization
4. Client with emphysema who had a lung tumor resection
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3. The nurse assesses the client after an amputation first. This is the client's first hos-pitalization, so the client has a higher risk of respiratory depression because the client is "opioid naive.". The client can misunderstand how to use the button, mistake the button for the call bell, or ask a visitor to operate the button. PCA use for the client is justified because orthopedic surgery is very painful in the early postoperative period. The nurse remembers to assess the client's respiratory status frequently and instructs the UAP to measure the respiratory rate frequently and to report the results to the nurse.
1. PCA for client pain management after jejunostomy surgery is suitable because the surgery includes a significant vertical abdominal incision in addition to forming the jejunostomy; this makes client movement and breathing very painful. If the client does not receive adequate pain control, the client is likely to be reluctant to move or cough and deep breathe, increasing the risks of atelectasis, pneumonia, and other complications of bed rest.
2. Orthopedic surgery is very painful in the early postoperative period. justifying the use of PCA.
4. The client with COPD is probably the second client the nurse assesses, because of the chronic pulmonary disease; however, PCA use is justified for this client because the client is already at high risk for hypercapnia, or increased serum carbon dioxide level. If the client hypoventilates because the pain is too great, the client is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respi-ratory acidosis and respiratory failure. The PCA provides a more consistent blood level of medication, avoids the peaks and troughs of intermittent dosing, and uses a lower total amount of medication in the process while providing adequate pain con-trol without causing respiratory depression; thus, the PCA is an integral part of de-creasing the risks of surgery for this client.
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