A nurse is caring for a client who has a pressure injury.

Exhibits

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Day 4:

Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal. Increased redness at wound borders and purulent drainage noted.

Temperature 38.9° C (102° F)

BP 118/56 mm Hg

Heart rate 102/min

Respiratory rate 22/min

Pulse oximetry 95% on room air

Hct 38% (37% to 47%)

Hgb 12 g/dl (12 g/dL to 16 g/dL)

WBC 12,000/mm (5,000 to 10,000 mm)

A. Perform a Glasgow Coma Scale assessment: Disability assessment follows circulation in the ABCDE model. A GCS assessment helps determine neurologic status and identify any signs of altered consciousness or traumatic brain injury.

B. Establish IV access: Next in the sequence is Circulation. Rapidly establishing intravenous access is vital for administering fluids and medications to stabilize hemodynamics and support perfusion in trauma settings.

C. Open the airway using a jaw thrust maneuver: The primary survey follows the ABCDE approach, starting with Airway. Opening the airway using a jaw thrust is critical in trauma patients to maintain spinal precautions and ensure airway patency.

D. Determine effectiveness of ventilatory effort: After ensuring an open airway, assess Breathing. Evaluating ventilatory effectiveness helps identify whether oxygenation and ventilation are adequate or if the patient needs support such as bag-valve-mask ventilation or intubation.

E. Remove clothing for a thorough assessment: Exposure is the final step. Removing clothing allows the nurse to fully assess for hidden injuries, bleeding, deformities, or signs of trauma while also ensuring measures are taken to prevent hypothermia.

Rationale for Correct Answers:

• Constipation: Constipation is a common side effect of opioids like oxycodone due to reduced gastrointestinal motility. This risk is heightened in postoperative clients with decreased mobility and altered routines.
• Oxycodone prescription: The prescribed oxycodone every 3 hours PRN increases the likelihood of opioid-induced constipation. Regular opioid use without a bowel regimen can result in significant discomfort or ileus.

Rationale for Incorrect Answers:

• Dysrhythmias: Although the potassium is at the low-normal end (3.6 mEq/L), it does not yet pose a significant risk for dysrhythmias in a stable client without cardiac history or other electrolyte disturbances.
• Hypoglycemia: The casual glucose level of 120 mg/dL is within normal range and does not indicate a risk for hypoglycemia. There’s no diabetic medication involved that would lower blood glucose unexpectedly.
• Hypovolemia: The client has a steady IV fluid infusion, a dry and intact surgical dressing, and no clinical signs of fluid loss. These findings do not support a risk of hypovolemia at this time.
• Impaired circulation: The neurovascular check reveals normal findings: warm toes, intact movement and sensation, and strong pedal pulses. These results suggest adequate perfusion, not impaired circulation.

• Neurovascular check: Normal neurovascular status (warm toes, movement and sensation intact, 2+ pulses) reflects healthy circulation post-surgery and does not correlate with any acute complications.
• Potassium level: Although 3.6 mEq/L is at the lower end of the normal range, it is still adequate and not linked to any current complications like dysrhythmias without other triggers.
• Glucose level: A casual glucose of 120 mg/dL is not clinically concerning and falls within expected limits. It does not suggest hypo- or hyperglycemia in a non-diabetic postoperative patient.
• Femur dressing: The dry and intact dressing indicates that the surgical site is not actively bleeding or infected. It does not signify any increased risk for a complication such as hypovolemia or impaired healing.