A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Positive health promotion activities include inquiring about blood pressure, asking questions about self-care, executing pull-ups on a trapeze bar, and turning side to side.

Negative health promotion activities include requesting the nurse to perform wound care and avoiding looking at the residual limb.

Rationale

POSITIVE:

Inquires about blood pressure:

Inquiring about blood pressure shows awareness of cardiovascular health, which is important for individuals with peripheral vascular disease. Monitoring blood pressure regularly can help prevent complications and manage hypertension, a common comorbidity in peripheral vascular disease.

Asks questions about self-care:

Asking questions about self-care indicates engagement in the management of one's health post- amputation. Understanding self-care tasks, such as wound care, prosthetic use, and rehabilitation exercises, is crucial for optimal recovery and adjustment to life after amputation. Executes pull-ups on trapeze bar:

Engaging in physical activity, such as pull-ups on a trapeze bar, demonstrates motivation for rehabilitation and adaptation to life after amputation. Strengthening exercises can improve overall physical function and assist in adjusting to mobility with a prosthetic limb.

Turns side to side:

Turning side to side suggests mobility and activity post-amputation. Movement and repositioning are important for preventing complications such as pressure ulcers and promoting circulation in individuals with peripheral vascular disease.

NEGATIVE

Requests nurse to perform wound care:

Negative: While it's understandable for a client to initially require assistance with wound care post-amputation, relying solely on the nurse to perform wound care may indicate a lack of engagement in self-management and may hinder the client's transition to independence in managing their health post-amputation.

Avoids looking at residual limb:

Negative: Avoiding looking at the residual limb may indicate psychological distress or difficulty accepting the amputation. It's important for individuals post-amputation to gradually become comfortable with their changed body image and to address any psychological challenges through counseling or support groups.

B. Occult positive emesis refers to vomiting that occurs without the client's awareness, meaning that the vomitus may not be easily visible or readily apparent. Vomiting can lead to significant fluid loss and dehydration, which is particularly concerning in a client who has undergone a biliopancreatic diversion procedure (BDP).
A. Loose bowel movements may indicate gastrointestinal disturbances or malabsorption issues commonly seen after biliopancreatic diversion procedure (BDP). BDP involves rerouting a significant portion of the small intestine, which can affect digestion and absorption of nutrients and fluids.
C. Strong foul-smelling flatus may indicate bacterial overgrowth or malabsorption issues in the gastrointestinal tract, which can occur after BDP. While foul-smelling flatus can be uncomfortable and indicative of gastrointestinal disturbances, it may not require immediate intervention.
D. Poor night vision may suggest vitamin deficiencies, particularly deficiencies in fat-soluble vitamins such as vitamin A, which can occur after BDP due to reduced absorption of nutrients. While poor night vision should be addressed to prevent long-term complications, it may not pose an immediate threat to the client's health.