The following 4 questions pertain to this case study:

Exhibits

In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment is:

Choice A reason:

Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.

Choice B reason:

Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.

Choice C reason:

Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.

Choice D reason:

Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.

Choice A: Agency policy

While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.

Choice B: Type of intervention

This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.

Choice C: Pain severity

This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.

Choice D: If family members are present in the patient’s room

The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.

Choice E: The patient’s psychosocial condition

This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.

Choice F: Risks for adverse effects

This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.

Choice G: Workload of the nurse

While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.

Choice H: The patient’s physical condition

This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.