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CRITICAL THINKING CASE STUDY

ANALGESICS

RJ, a 79-year-old man, underwent abdominal surgery for resection of his


colon. After the surgery, his physician prescribed morphine 10 mg every 3 to 4
hours as needed. RJ did not ask for pain medication because he is worried he
might become addicted. A day after the surgery, RJ’s nurse noted that he was
restless and grimaced whenever he moved in bed. He refused to breathe deeply
or cough when instructed to do so. The nurse compared RJ’s vital signs to his
baseline findings and noted an increase pulse rate and a drop in systolic blood
pressure of 6 mm Hg.

1. Should the nurse give morphine? Explain your answer.

Yes, since the patient shown signs of pain and discomfort. And since it is
prescribed, giving it to the patient is allowed. Also, the nurse should inform the
patient that morphine will not give him an addiction if and only if it is used
properly and that the nurse will monitor his vital signs regularly. But if RJ refuses
to take the medication, the nurse cannot force him. Simply, find other alternatives
to alleviate his pain. The nurse then should report these symptoms to the doctor.

2. What would your reaction be to RJ in regard to his restlessness, grimacing,


and refusal to breathe deeply and cough?

RJ showing signs of pain like grimacing and restlessness as well as his


refusal to breathe deeply and cough is very likely, the nurse should take into
account that he is most likely minimizing any movement or activity in order to
avoid inflicting any more pain due to the effects after surgery. The nurse should
also administer morphine, as requested by the patient, and encourage to do
deep breathing and coughing.

3. What is the significance of the change in vital signs?

Since RJ showed signs of high pulse rate, it is from the pain he is feeling.
Increased pain may cause shock-like symptoms. The nurse should administer
morphine and continually monitor his vital signs.

4. What classic side effects if opioid analgesics should the nurse assess?

Side effects of narcotics include respiratory depression, orthostatic


hypotension, drowsiness, mental clouding, constipation, and urinary retention.
5. What are some possible non-pharmacologic measures that might be
helpful in alleviating RJ’s pain?

Non-pharmacologic measures that may decrease pain are changing


positions, good body alignment and support, back rubs, and relaxation
techniques.

The second postoperative day, RJ began asking for morphine every 3 hours. On
the fifth day, the physician discontinued RJ’s morphine and prescribed
acetaminophen with codeine.

6. Why was the opioid analgesic order changed?

The order was changed to prevent opioid dependency. By the third to the fifth day,
pain should have lessened, and a less potent opioid or mixed drug is usually
prescribed.

7. RJ does not want to ambulate. What is an appropriate nursing response?

Pain may diminish the capacity and willingness of R.J. to ambulate. Encourage
R.J. to ambulate 1 hour after morphine administration.

MEN’S HEALTH AND REPRODUCTIVE DISORDERS

MT, age 16 years, is a high school senior who is 59.3 inches tall and weighs
126 pounds. He is having increased feelings of discomfort about not fitting in
with the other students at school because he has not yet begun sexual
maturation. He is a good student and an accomplished violinist in the school
orchestra. His father states that he also was a “late bloomer”, but both parents
are concerned about MT’s increasing social withdrawal and seem determined to
seek medical intervention for him. The nurse at the clinic assesses the needs and
status of MT and his parents.

1. What is the patient’s primary complaint?

He feels he does not fit in with the other students because of the fact that he has
not yet begun sexual maturation and that he’s a “late bloomer,” thus, making him
feel uncomfortable and withdrawn.

2. What is concerning MT’s parents?

They are concerned about the increasing social withdrawal of MT and are
determined to seek medical intervention for him.
3. What information must be included in the history and physical
examination?

The following data from the patient must be collected:

 Family history of delayed puberty


 Information from physical assessment to determine baseline status before
beginning therapy and for any potential adverse effects
 Contraindications or cautions to the use of the drug, may be history of allergy
to any testosterone or androgen, hepatic dysfunction and cardiovascular
disease and prostate cancer.
 Skin color, lesions, texture and hair distribution
 Affect, orientation and peripheral sensation
 Results from abdominal examination and serum electrolytes, serum
cholesterol and liver function tests
 Laboratory investigations
 Radiographs of the long bones to assess for testosterone effects on growth
 Evidence of endocrine deficiencies
 Head trauma or midline facial defect

4. What education should the nurse prepare before the parents decide
whether to start their son on androgen therapy? The decision is made to
prescribe testosterone 30 mg every 12 hours by buccal tablet (held inside
the cheeks until it dissolves). MT will be on this regimen for 4 months,
during which time he is to come to the clinic at monthly intervals.

The nurse needs to educate the parents and the patient himself about the
androgen therapy effects. Androgens will help maintain and sustain masculine traits
growth, and that androgens will have the same impact on male reproductive organs
as testosterone. This drug can decrease the function of the thyroid and boost the
clearance of creatinine. With this in mind, MT has to visit the clinic on a regular
basis.

5. MT asks why he will be treated for 4 months. What will the nurse reply?

The nurse will tell him that he must be treated for 4 months in order to improve
the secretions of his gonadotropins. After 4 months, the progress will be checked
again to see if endogenous puberty has occurred or not and if no further
interventions are required.
6. About what adverse effects do MT and his parents need to be educated?

Possible adverse effects include: Deep vein thrombosis, venous


thromboembolism, pulmonary embolism, benign prostatic hypertrophy, hepatic
disease, Alopecia, Polycythemia, Hirsutism, Gynecomastia, sleep apnea, priapism,
and mood changes.

7. What physical and psychosocial parameters will be assessed at MT’s


monthly visits?

The following must be assessed:

 Skin color, lesions, texture and hair distribution


 Affect, orientation and peripheral sensation
 Liver function
 Serum cholesterol and electrolytes
 Bone growth (through radiography)

8. What special hygiene needs does MT have while on this regimen?

MT is advised to frequently wash his face with mild soap to avoid spreading or w
orsening of his acne as a negative effect of treatment. He must also regularly take
baths to diminish oil in skin and exercises to maintain a healthy body weight since
the treatment enhances growth in height and weight.

9. When should MT have x-rays taken? Explain your answer.

Once every four months, depending on the instructions given by the doctor. This
is to verify the status of bone density, as treatment (frequently known as osteopenia)
may have influenced it.

10. During a clinical visit, MT mentions that he heard that the use of anabolic
steroids might improve his chances of making the wrestling team. What
should he be told about the safety and efficacy of anabolic steroid use?

Because of the use and abuse of anabolic steroids, there are several known
health dangers. Short stature and acceleration of epiphyseal maturation of the long
bones may happen for pre-pubertal adolescents. Side effects such as paranoia,
sleeping disorders, euphoria, confusion, hepatic dysfunction, gynecomastia,
testicular atrophy, severe nodular acne and infertility may also happen. Steroid use
must be controlled in order to prevent adverse effects from occurring and possibly
make them severe and hard to cure.

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