Problem: 21 years old Emma had MVA 2days ago, she sustained multiple rib Fx (R: 3-8, L: 4-8), she is complaining a lot of pain and she is very anxious and agitated Phx; Nil, no allergy Uni student-studying Law You just completed your nursing assessment@1000hrs GCS-15 Vital sign: BP 140/85, HR 98, RR 24, Sats 95% on NP 4L, Temp 37 Pain score: 8/10 Medical staff ordered PCA: Fentanyl 500mg in N/Saline 50mls in total Bolus dose:10mcg/ml, 5 mins lockout ---You educated Emma, and commenced Fentanyl PCA at 1100hrs She has been using 12 times per hour. 13:00hrs-Nurisng handover@ bedside ---GCS 13, very drowsy Vital signs: BP 95/60, HR 60, RR7, Sats 92% NP 2L Q1.
What is your nursing intervention for Emma? Please provide a rationale for each nursing intervention.