PCS #1

This is one of the scenarios from Chuck. I am going to write out each step as though it were a real PCS. I will submit it to EC for evaluation and will post the feed back in a future post as well as an edit or possibly a comment.

36 year old female s/p cholecystectomy 2 days ago. Right abdominal incision with DSD. JP drain in place, being removed after lunch. Indwelling Foley catheter. Fluctuating pain levels 5-9 on a 0-10 scale and maintains morphine PCA at this time.

Siderails x2

VS - TPR, BP Pain level 0-10 scale

Fluids - IV D5LR @ 120ml/hr

I&O

Mobility - ambulate in hall x1 assist, OOB to chair ad lib

AOCs:

Respiratory Management - IS x 10 every hour

Abdominal assessment

Comfort Management

Wound Management - DSD to abdominal incision

CP
#1 Acute Pain r/t tissue trauma aeb pain rating of 5-9 on scale of 0-10
Goal:
 Patient will report pain level of 3 or less on a 0-10 scale
Interventions:
1- assess IV site and patentcy of PCA
2- report break though pain to RN

#2
Ineffective airway clearance r/t retained secretions aeb weak cough
Goal
Patient will perform IS 10x every hour during pcs
1-Assess lungs immediately before and after IS
2 Encourage patient to perform 10 reps of IS every hour