T.M. returns to your unit the next afternoon from the postanesthesia care unit (PACu). He is in a bilateral
spica cast, has a Foley catheter, and has a family-controlled patient-controlled analgesia (PCA) device for
pain control.
You assess T.M. and chart the following findings.
What are your top five priorities while providing nursing care to T.M. postoperatively? How
will you address these areas?
1, Respiratory status: Assessment and frequent monitoring because T.M. has a morphine PCA and
because respiratory depression, although rare, can be a complication. T.M. will be immobile,
and encouragement of good aeration is important. The nurse might want to involve a child life
specialist to bring pinwheels or bubbles to encourage deep breathing.
2, Pain management: Maintaining good pain control will enhance physical recovery. T.M. will be
more inclined to resume normal swallowing, feeding, and spirometry.
3, Neurovascular status: Casting puts the patient at risk for neurovascular compromise, and frequent
checks of lower extremities for sensation and circulation are critical. Cast must be assessed for
any bleeding or limb swelling that compromises neurovascular status. The RN can be held liable if
permanent tissue and muscle damage occurs within a short period of time.
4, Skin integrity: T.M. will be immobile with a new cast. Checking bony prominences, keeping bed
clear of items that might cause breakdown, and wound and skin assessment should be performed
frequently.
5, Safety: T.M. is at risk for injury because of his history of seizures. Close monitoring for seizure
activity and administration of seizure medications should be timely. Managing the environment is
important to protect him if seizure activity does occur and to address challenging mobility issues.
This would include keeping the bed in the lowest position, side rails up and padded, and safety
equipment (O2
and suction) at the bedside.
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