The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia (PCA) on the second postoperative day
Which patient data does the nurse group together to establish the nurse's priority? (Select all that belong to the group.) a. Temperature 38.1° C (100.6° F)
b. Patient ready for oral analgesia
c. Low tension on epidural catheter
d. Respiratory rate 14, sedation level 1
e. Epidural drainage looks like medication
f. Hemoglobin 15 mg/dL, leukocytes 14,500
A, E, F
According to the nursing process, the nurse groups interrelated data together to draw a conclu-sion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a po-tential portal of entry, even though the fluid is of unknown origin. The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infec-tion. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.
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