The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia (PCA)on the second postoperative day.Which patient data does the nurse group together to establish the nurse's priority? (Select all that belong to the group.)

Question

Quizplus · Accepted Answer

According to the nursing process,the nurse groups interrelated data together to draw a conclusion.This patient is febrile with leukocytosis and clear epidural drainage,clinical indicators of a potential infection.Because fluid is leaking from the insertion site,microorganisms have a potential portal of entry,even though the fluid is of unknown origin.The nurse collaborates with the provider to discontinue the epidural catheter,initiate therapy to eradicate potential infection,and provide adequate pain management by another route.If the fluid is cerebrospinal fluid (CSF),the patient is at risk for a devastating neurological infection and sepsis.Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection.Low tension on the catheter,a respiratory rate within normal limits,and a low sedation level are desirable patient data.They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection.The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.

The Nurse Assesses a Patient Who Has an Epidural Catheter