Justin Cavanaugh is a 24-year-old male who is brought to the ED by ambulance following a motor vehicle collision in which he was the restrained driver. On the scene, he was complaining of chest pain that was worse when he took a deep breath in or coughed. His vital signs upon arrival to the ED are HR 102, BP 142/88, RR 32, and SpO2 97% on room air. He is currently complaining of pain to his chest (8/10) and his forehead (5/10) where he has a laceration. A chest X-ray confirmed a right pneumothorax and the plan is to insert a chest tube.
1. How do the patient's vital signs reflect his current situation? Do ny of them concern you and if so, why?
2. What should be the focus of your assessment of this patient? What specific abnormal findings might you notice?
3. What is the priority nursing diagnosis for this patient?
4. The patient is ordered Percocet (Oxycodone 5mg/Acetaminophen 325 mg) 2 tablets for pain <8/10 and morphine 4 mg IVP for pain >8/10. Which would you administer?
5. What would be important to monitor after giving this medication based on this patient's diagnosis?
6. How do you know that the pain medicine was effective?