A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.

The healthcare provider prescribes a sepsis protocol.

Which intervention is most important for the nurse to include in the plan of care?

Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.

Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.

Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.

Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.

Correct Actions:

Administer calcium as prescribed - Administering calcium (usually IV calcium gluconate) corrects the calcium deficiency, stabilizes nerve and muscle function, and helps stop or prevent further seizures.
Monitor respiratory status - Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of hypoventilation, apnea, or oxygen desaturation.Maintaining airway and oxygenation is critical for safety and preventing hypoxia.
Correct Condition:

Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.

Correct Parameters to monitor:

Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure.

Monitor serum calcium levels - Maintaining calcium within the normal neonatal range prevents recurrent seizures, cardiac arrhythmias, or neuromuscular irritability.