The following 4 questions pertain to this case study:

Exhibits

The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Choice A Reason: Fluid Volume Overload

Fluid volume overload, also known as hypervolemia, occurs when there is an excess of fluid in the body. This condition is often characterized by symptoms such as swelling (edema), shortness of breath, and high blood pressure. In the context of the patient’s scenario, fluid volume overload would typically present with signs like jugular venous distention, pulmonary congestion, and possibly ascites. The patient’s blood pressure is 109/70, which is not indicative of hypertension typically seen in fluid overload. Additionally, the patient’s lung sounds are clear, which further suggests that there is no pulmonary congestion. The lab results do not show a significant decrease in sodium levels, which might be expected in fluid overload due to dilutional hyponatremia.

Choice B Reason: Fluid Volume Deficit

Fluid volume deficit, or hypovolemia, is a condition where there is a significant loss of body fluids. This can result from severe diarrhea, as seen in the patient’s case. Symptoms of fluid volume deficit include lightheadedness, weakness, and muscle twitching, all of which the patient is experiencing. The patient’s blood pressure is on the lower side (109/70) and he gets lightheaded when standing up, indicating orthostatic hypotension, a common sign of fluid volume deficit. The elevated BUN (30 mg/dL) and creatinine (1.8 mg/dL) levels suggest dehydration and reduced kidney perfusion. The high potassium level (5.6 mEq/L) can be attributed to the body’s attempt to conserve water and sodium, leading to potassium retention. The ECG changes in the T wave and PR interval are consistent with hyperkalemia, which can occur in dehydration and kidney dysfunction.

Choice A reason:

Offering peppermint aromatherapy during and after chemotherapy can be an effective non-pharmacological intervention for managing chemotherapy-induced nausea and vomiting (CINV). Aromatherapy with peppermint oil has been shown to reduce nausea and improve comfort in patients undergoing chemotherapy. The scent of peppermint can have a calming effect on the gastrointestinal system, helping to alleviate nausea. This intervention is easy to implement and can be used alongside other treatments to enhance patient comfort.

Choice B reason:

Administering antiemetics before chemotherapy is a standard practice for preventing CINV. Antiemetics, such as 5-HT3 receptor antagonists (e.g., ondansetron), NK1 receptor antagonists (e.g., aprepitant), and corticosteroids (e.g., dexamethasone), are commonly used to prevent nausea and vomiting associated with chemotherapy. These medications are most effective when given prophylactically, before the onset of symptoms. Administering antiemetics before chemotherapy helps to block the pathways that trigger nausea and vomiting, providing better control over these symptoms.

Choice C reason:

Keeping Ms. Anderson NPO (nothing by mouth) for the duration of the chemotherapy is not recommended for managing CINV. Keeping patients NPO can lead to dehydration and malnutrition, which can worsen their overall condition. Instead, patients should be encouraged to eat small, frequent meals and stay hydrated to maintain their strength and well-being. Proper nutrition and hydration are essential for supporting the body’s ability to tolerate chemotherapy and recover from its side effects.

Choice D reason:

Encouraging the patient to eat and drink when not nauseated is an important strategy for managing CINV. Eating small, frequent meals and staying hydrated can help maintain energy levels and prevent dehydration. Patients should be advised to eat bland, easy-to-digest foods and avoid foods that are greasy, spicy, or have strong odors, as these can exacerbate nausea. Encouraging patients to eat and drink when they feel well can help them maintain their nutritional status and improve their overall tolerance to chemotherapy.

Choice E reason:

Offering small sips of ginger ale can help manage nausea. Ginger has natural antiemetic properties and can be effective in reducing nausea and vomiting. Ginger ale, ginger tea, or ginger candies can be soothing and help settle the stomach. This simple intervention can be easily incorporated into the patient’s routine and can provide relief from mild to moderate nausea.

Choice F reason:

Encouraging Ms. Anderson to eat a high-protein meal prior to the chemotherapy infusion is not typically recommended for managing CINV. High-protein meals can be harder to digest and may increase the risk of nausea. Instead, patients should be advised to eat light, bland meals before chemotherapy to minimize the risk of nausea and vomiting. Light meals are easier on the stomach and less likely to trigger gastrointestinal discomfort.