150k views
1 vote
The nurse is caring for a 3-year-old client following a Fontan

procedure to repair a hypoplastic left heart (above). What
assessment finding(s) by the nurse indicates the child may be in
pain? Select
Focused Assessment 2320: Client at 8 hour post Fontan surgery. Resting in bed with head of bed at 30 degrees, moaning and guarding during assessment. Chest tubes in situ bilaterally with scant serous

1 Answer

4 votes

Final answer:

Signs indicating a child may be in pain following Fontan surgery include moaning and guarding actions during assessment. Caregivers should use pediatric-appropriate pain assessment tools, like the Wong-Baker Faces Scale, and address pain management collaboratively in post-operative care.

Step-by-step explanation:

Signs of Pain in Pediatric Post-Operative Care

When caring for a pediatric patient following a Fontan procedure, such as a 3-year-old with a hypoplastic left heart condition, it is crucial to monitor for signs and symptoms of pain. In a post-operative setting, a child who is moaning and guarding during assessment, while resting with the head of the bed elevated, is likely experiencing pain. These behaviors are common non-verbal pain indicators, especially in young children who may have difficulty expressing their discomfort verbally.

It is essential for caregivers to use appropriate pain assessment tools tailored to children. For example, the Wong-Baker Faces Scale is a recognized pain assessment method for children undergoing venipuncture, as it provides a visual representation of pain levels that a child can easily point to. Although this particular study is not directly addressing surgical pain, it does illustrate the importance of employing age-appropriate and understandable tools for pediatric pain evaluation.

Additionally, clinical teams must review aloud key concerns for patient recovery and care, including pain management strategies. This collaborative approach helps ensure all team members are aware of the patient's condition and comfort level. Immediate interventions for pain after Fontan surgery may include analgesic administration, adjustments in positioning, and providing comfort measures to the child.

User Ziad Halabi
by
8.4k points