Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

Choice A rationale:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

Choice A rationale:

Aspiration prior to injection of enoxaparin is not recommended. Key reasons for this contraindication include:

Absence of Large Blood Vessels in Subcutaneous Tissue: Enoxaparin is administered subcutaneously, targeting the fatty tissue layer beneath the skin. This tissue generally lacks large blood vessels, significantly reducing the risk of accidental intravascular injection. Aspiration, traditionally intended to prevent such occurrences, becomes unnecessary in this context.

Potential for Hematoma Formation: The act of aspiration itself can create a vacuum within the subcutaneous tissue, leading to trauma and bleeding at the injection site. This can result in hematoma formation, causing discomfort and potential interference with medication absorption.

No Evidence of Benefit: Research studies have not demonstrated any clear advantages of aspiration when administering subcutaneous enoxaparin injections. In fact, some studies have suggested a potential increase in bruising and bleeding associated with aspiration.

Manufacturer Guidelines: Enoxaparin manufacturers explicitly advise against aspiration in their product instructions, aligning with current evidence-based practices.

Choice B rationale:

Massaging the injection site after administering enoxaparin is also not recommended.

Rationale for this contraindication:

Accelerated Absorption: Massaging can increase local blood flow, potentially accelerating the absorption of enoxaparin. This could lead to higher-than-intended drug levels in the bloodstream, increasing the risk of bleeding complications.

Discomfort and Hematoma Risk: Similar to aspiration, massage can create mechanical stress on the injection site, potentially causing bruising, discomfort, or hematoma formation.

Choice C rationale:

While a 1-mL syringe with a 32-gauge needle is a suitable option for subcutaneous injections, it's not the only correct choice. Considerations for syringe and needle selection:

Needle Length: The needle should be short enough to ensure subcutaneous administration, typically ranging from 5/8 to 1 inch in length.

Syringe Size: The syringe size should accommodate the volume of medication being administered, providing clear visibility of the dose.

Patient Comfort: Smaller-gauge needles (like 32-gauge) are often preferred for subcutaneous injections as they tend to cause less discomfort. However, other factors, such as medication viscosity and patient preferences, may influence needle selection.

Choice D rationale:

The abdomen is the preferred injection site for enoxaparin due to several reasons:

Abundant Subcutaneous Tissue: The abdomen generally has a thicker layer of subcutaneous tissue, providing ample space for medication absorption and reducing the risk of intramuscular injection.

Ease of Access: The abdomen is often easily accessible for self-injection or administration by a caregiver, promoting patient comfort and convenience.

Reduced Pain: Subcutaneous injections in the abdomen are typically less painful compared to other potential sites like the arms or thighs.

Additional considerations for enoxaparin administration:

Rotate Injection Sites: To prevent tissue damage and promote consistent absorption, it's crucial to rotate injection sites within the recommended areas (abdomen, thighs, upper buttocks).

Monitor for Adverse Effects: Observe for any signs of bleeding, bruising, or allergic reactions following enoxaparin administration.

Adhere to Storage Guidelines: Store enoxaparin at room temperature and protect it from light to ensure its efficacy.