Question

You are the RN working on a surgical unit, and you are assigned the following four clients:

1. A 62-year old male with a history of COPD and CHF, who had a cholecystectomy
2. A 28-year old female with a head injury from a motorcycle accident who had burr hole surgery
3. A 43-year old female with controlled AFib who has a broken right leg from falling off a horse
4. A 62-year old college professor who had a stroke while playing tennis

Their surgeries were all unremarkable, and they are all 1-day postoperative. You heard the following updates in change-of-shift report this morning:

1. 02 sat 92% on 2L, lung sounds diminished bilaterally, non-productive cough
2. Persistent confusion and slight restlessness, moves all extremities
3. Pain level is 8/10, up from 5/10 last night. Right pedal pulses weak, right foot swollen.
4. Complaining of headache at 10/10, unrelieved by pain medication.

Questions:

1. Which of these clients should the nurse see first? Explain your answer.
2. What other information is needed (if any) to make your decision.

Answer 1

The nurse should see and assess the patient with stroke who is complaining headache pain of 10/10.

We should always manage pain first and assess for any emergency unless there is no cardiac or respiratory emergency on that instant.

This is post stroke headache. This is usually unrelieved by normal alagesics.use of tricyclic antidepressants(amitriptyline), antiseizure (garbapentole)drugs can relieve the pain.

pain may be the sign of cerebral edema , or intra cranial bleeding .

Grab the information of GCS score and vital signs confirm the nurses decision and act proper nursing intervention.