Five Nursing Diagnosis
Acute pain related to lobectomy procedure and rib removal as evidenced by patient whimpering when moving at rating her pain eight to ten out of ten throughout the day. I chose this as a high priority, number one nursing diagnosis because of how high the patient rated her pain. Whether she was just lying in bed, or moving around, she was in pain. The only thing that could somewhat decrease her pain was pain medications, and even then, her pain only went down from a ten to and eight (Ackley & Ladwig, 2014).
Risk for infection related to surgical wound on her left upper back and drainage tube in left lung. I chose this as the second nursing diagnosis and would also rate this high priority. The patient did not have a
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This is the fifth nursing diagnosis and is a low priority. This is only low priority because the patient is still able to get up and move, she just takes more time than usual and requires minimal assistance (Ackley & Ladwig, 2014).
Nursing Care Plan and Evaluation Acute pain related to lobectomy and rib removal as evidenced by patient whimpering when she moved and rating her pain eight to ten out of ten throughout the day. The predicted behavioral outcome is the patients pain will decrease from eight out of ten down to five out of ten by noon on the day of care. Interventions to meet this goal include:
1. Administering the patient’s pain medications as often as allowed. This is important to help maintain the patient’s pain at an acceptable level (Unbound Medicine, 2014).
2. Assist the patient in movement. This helps to decrease the patient’s pain by taking some of the weight off her (Unbound Medicine, 2014).
3. Position the patient in the most comfortable position. Positioning has a large effect one pain. The patient preferred to be sitting upright in her chair.
4. Provide or promote nonpharmacological pain management for the patient. Things such as a cool, calm, therapeutic environment (Unbound Medicine, 2014).
5. Continuously ask the patient to rate her pain. Providing the rating, location and type of pain. This is useful in determining if pain reduction measures are effective Unbound Medicine, 2014).
The
| This is important because we need to look at the relevant data and realize that she seems to be in distress and first take care of that. Also realize that she seems to have an infection. With this information we are able to prioritize
However, other resources, such as mobile doctors may be available to prevent the patient from requiring hospital admission (17). Furthermore, certain approaches to pain relief, such as warm running water and cold packs, are not always readily available to paramedics. Thus implementing these procedures as a necessary part of paramedic practice would not prove practical. However, paramedics should be aware of the different approaches to relieving pain for these patients and be further aware that if the resources are available, they should be utilised in order to provide as much relief as possible to the suffering
Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a
The nurse will assist Mrs. Thomas in achieving optimal pain control. The nurse will interact with Mrs. Thomas more than any other practitioner. The nurse will have to continuously assess Mrs. Thomas pain control. Due to Mrs. Thomas’s advance stage in her illness her pain control needs will vary depending on her level of conscious and the disease process. Keeping Mrs. Thomas’s level of pain to a level where Mrs. Thomas can still maintain her functional ability will be an ongoing struggle. Too little or too much pain medicine will prevent Mrs. Thomas in participating in activities.
Devote effort to focus on patient’s need for help with toileting, pain level, and positioning.
Pain is the most commonly reported reason for coming to the hospital in America. It’s causes have a massive variance, and in many chronic cases the root source of pain can not be articulated at all. When a patient reports pain, the role of the nurse, and the whole healthcare staff, is to aim to reduce that pain. In many cases pain reduction can be attained through nonpharmacologic, complementary and alternative methods (CAM). Using CAM to reduce pain is an ideal scenario for both the patient and the healthcare staff as these alternative methods have fewer negative consequential effects.
Such as in the S for Sleeping Disorders, the nurse found out that patient is having difficulty sleeping, with the assist of pain medication. The nurse requested that she will refer a sleep regiment, and make sure the environment has less distractions. Next was P for Problem with eating, the nurse found out that the patient must eat her food in small pieces, and prefer a soft consistency, and has issue using her eating utensils, due to weakness in her fingers. The nurse recommended the RNA to assist her with that at dinner time. Next, the I for Incontinence, the nurse found out that patient has issue with getting to the bathroom in time before she has an accident. The nurse recommended for patient to have a bathroom regiment and bed side commode. In C for Confusion the nurse found out that due to patient being on pain medication, she is sleeping so much, and she is confused as to where she is, along with the date and time. In E for Evidence of Falls, she assesses history of fall within 6 months and the use of assisted devices, then recommended physical therapy consult due to weakness and strength. In S for Skin Breakdown, the nurse recommended soft care mattress, heel lift boot and frequent skin assessment due to patient concern with her skin easily can
Because severe pain is more difficult to control, Mrs R may become anxious and fatigued, and may also withdraw again from the regimen if there is no success in achieving pain relief; therefore, the preventive approach needs to be considered. (Wells, 2014). For an effective pain control pain, Mrs R should also keep a daily record of her pain. Writing a diary can help empower the patient in her own care, give her confidence and increase self-efficacy (Bastable, 2014). Also, a strategy of pain management is to combine opiods with non-narcotics, such as Tylenol, in order to enhance pain relief and to slowly decrease the use of narcotics overtime (Lewis, 2014). Mrs R was explained to always follow the right dosage of medication to optimize the narcotic results. A complete assessment of pain should be performed: PQRST. Pain is a subjective concept and the patient must describe the pain in order to provide an effective care plan (Jarvis, 2013). Responses to pain medication should be documented to facilitate communication between health care providers, therefore to maximise effective pain management strategies (Lewis, 2014). The use of non-pharmacological therapy for pain is also recommended to Mrs R because it helps reduce the dose of an analgesic/opiod required to control pain and helps to minimize analgesic side effects, and also promote the release of endorphins which inhibit pain signals (NCBI, 2010). Mrs R is encouraged to use distraction such as watching TV, listening to the radio/music, which redirect the attention on something and away of the pain. Imagery can also be proposed to divert the focus away from the pain by stimulating the client’s imagination to develop sensory images. Relaxation strategies can also be used to help Mrs R to be free of her anxiety and stress, and to reduce muscle tension (Lewis,
Pain that is undertreated can limit her post-op mobility and ability to participate actively in rehabilitation program. Mrs. M had pain at a level 5-8 during the night which indicates a moderate to intense pain that apparently interferes her sleep and probably limits her ability to perform normal daily activities.
After it is determined the patients are in recovery from serious illnesses and surgical episodes the potential for complications is still present, and those patients still require a higher level of nursing intervention than is typically offered in a skilled nursing
In the planning phase, the health care team had a discussion about priorities on one hand, the patient’s pain level is eight out of
Non-pharmacological adjuvants are non-medicinal elements which could include music, relaxation, breathing techniques, imagery, distraction, and massage (Sylvia, Carol, LeeAnn & MSN, 2011). Assessments of pain and side effects refer to the examination of a patient at regular intervals of time. Intervention and reassessment is based on changes related to previous pain and side effect assessments. Patient education is training individuals on how to manage or prevent pain with medication and activity. Goal setting is designed to aid in maintaining and reducing pain by allowing the patient, nurse, and doctor to work together in order to form a plan of pain management. All concepts work together to promote a balance between analgesia and side effects.
-use a self-report pain tool to identify current pain intensity level and establish a comfort-functioning goal by the end of the shift.
Medical environments can create anxiety, high levels of anticipation and fear. These emotions will not help the patient during their health crisis. It is the responsibility of the healthcare provider and staff to find ways to alleviate these feeling. The hospital employees must put themselves in the patient’s shoes and attempt to imagine how the patient is feeling. Discovering different approaches to help patients find effect methods of pain control can create challenges. Medication is not always the answer to eliminating pain. Side effects and inadequate relief often occurs when pharmacological relief is sought.
The patient may also have the option to control her own pain through a pump that is connected to