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5. What are your top five priorities while providing nursing care to T.M. postoperatively? How will you address these areas? Respiratory: try to get up and move as able, CTDB, incentive spirometer. Neurovascular: assessing extremities, does he have feeling/sensations. Pain management: make sure
they are able to use PCA pump. Infection control: catheter care. Skin: assess skin around the casts for breakdown. Always worried about safety. 6. Using the FLACC pain scale, what pain score would you assign T.M.? Why is the FLACC scale an appropriate tool? 2-4 depending. 7. Which of these nonpharmacologic interventions would be age appropriate for this patient? (Select all that apply.)a. Encourage “positive self-talk” such as, “I will feel better when the cast comes off.” b. Offer a favorite DVD or video. c. Use bubbles to “blow the hurt away.” d. Educate T.M. on pain and relationship to the procedure. e. Read a favorite book. f. Use guided imagery.T.M. is stable throughout the day, and the physician writes the following orders: Patient can PO ad lib. Resume home schedule of 520 mL PediaSure via G-tube from 10 PM to 6 AM. Remove Foley catheter.8. Describe instructions for setting up with a Mic-Key button. What is the hourly rate you will set your feeding pump? 65 mL/hr9. When you remove the Foley catheter, what will your education and nursing plan include for T.M. and his mother? Tell the kid to drink plenty of fluids, keep the area dry to prevent the cast from getting wet. 10. Which of these statements by T.M.'s mother would indicate that further education is needed? (Select all that apply.)a. “I need to check the toes on T.'s feet several times a day for the first week or so to see if they are warm and he is able to wiggle them.” b. “I need to keep his feet elevated when I get him home.” c. “It is okay if I give him a tub bath. Because it is a synthetic cast, I can dry it with a blow dryer.” d. “Because T. uses pull-up diapers, I will need to use plastic tape to protect the cast opening.”
e. “If he has an itch, it is okay to use a knitting needle to scratch under the cast.”11. What additional information should be included in your discharge teaching? Cast care, positioning.