SOLUTION: Nursing problem: Acute Pain | My Assignment Tutor

Catherine Dent S3009901Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 NUR251 Assessment 1 S2 2018 Assignment template Task 1Following a positive patient identification, a neurological assessment using the Glasgow Coma Scalewould assess Ruby’s mental status and level of consciousness, thereby detecting changes ordeterioration in her status. Assessment includes vital observations such as respiration rate andtemperature to detect brain dysfunction. Undetected changes in consciousness may result indecreased oxygenation, decreasing LOC and undetected adverse reactions from anaesthetic (Karcz,& Papadakos, 2013).Hydration assessment would be achieved using a fluid balance chart to document input and outputof all fluids such as intravenous-therapy, urine or blood loss, to maintain hydration, detectcardiovascular and renal complications, and manage electrolyte imbalances. Skin turgor and mucousmembranes would be assessed (LeMone et al., 2017). Undetected hypovolaemia or hypervolaemiamay result in pulmonary oedema, hyponatraemia or hypovolaemic shock (Leech, & Nesbitt, 2012).The PQRST method would assess Ruby’s pain and identify requirements of analgesia and/or adjuncttherapy thereby achieving and maintaining management of her pain. Ruby’s pain rating out of ten,facial grimacing, guarding, and physiological effects such as tachycardia and hypertension would benoted. Poorly managed pain negatively impacts on mobility, slows recovery and reduces well-being.Surgical pain may cause reduced gastric motility and increased likelihood of an ileus developing(LeMone et al., 2017).Holistic, head-to-toe physical assessment including base-line vital observations is compared to preoperative data, providing an up-to-date flow-chart of Ruby’s status. Assessment would also includeRuby’s appearance, emotional state and PV bleeding. Without this information, respiratory andcardiovascular complications such as pneumonia, atelectasis, DVT and haemorrhage may not bedetected and lead to life-threatening events. A work-place observations form would be used todocument vitals (LeMone et al., 2017).Catherine Dent S3009902Last name DENT student number S300990 NUR251 S2 2018 Assessment 1Task 2Nursing Care Plan: RUBY SMITH Nursing problem: Acute PainRelated to: Subtotal Vaginal HysterectomyGoal of careNursing interventionsRationaleEvaluationMinimise Ruby’s painAssess pain using PQRST formula, /10 numericscale, non-verbal cues such as facialexpressions, guarding, altered appetite, pallorand diaphoresis.Assess vital observations due to pain such astachycardia, tachypnoea and hypertension.Administer regular analgesia relevant to levelof reported pain. Assess and monitor efficacyand side-effects/adverse reactions.A comprehensive pain assessment usingthe PQRST formula allows for subject dataresulting in adequate and appropriatetreatment (Gregory, 2014)Hypertension, tachycardia, tachypnoea,dilated pupils are physiological responsesto pain (Lemone, et al., 2017)Monitoring post administration ofmedication detects efficacy orineffectiveness of drug and any adversereactions (Lemone, et al., 2017)Ruby states her pain is now 0/10Ruby has a relaxed appearance, appearshappier and there is no diaphoresis or guardingVital observations are within normal ranges,pulse 6-100, BP 80/120, RR 12-20 andtemperature 36.2Ruby experienced no adverse reactions andanalgesia was effective Catherine Dent S3009903Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Educate Ruby on side effects of analgesia suchas constipation, how to use pain scale and theimportance of conveying her pain level or sideeffects, to allow for adequate painmanagement and aperients.Provide adjunct therapy such as heat packs forabdominal discomfort, repositioning with apillow as directed by Ruby’s preference. PlayRuby’s favourite music as a distraction.Empowering Ruby to make decisionsregarding her treatment ensuresparticipation. Education enables less timespent in pain and greater pain relief(Ingadóttir, & Zoëga, 2017)Non –pharmaceutical therapy have thepotential to decrease pain and reduce theassociated distress (Fouladbakhsh,Jenuwine, Szczesny, & Vallerand, 2011).Ruby is empowered in decision making andstates she feels more in control of her painRuby states the heat pack has resulted indecreased abdominal discomfort and that she isenjoying the music Catherine Dent S3009904Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Nursing problem: Risk of fluid imbalanceRelated to: IVT, risk of urine retention and reduced fluid intakeGoal of careNursing interventionsRationaleEvaluationMaintain Ruby’snormovolaemic statusOrganise cannula insertionMonitor and administer IVT, intake of fluid,monitor urine/vomit/blood output anddocument on fluid balance chartMonitor for symptoms and signs of fluidimbalance such as tachycardia, venousdistention, SOB, tachypnoea, cough/crackles,postural hypotension, headache, and level ofconsciousnessEducate Ruby on the importance ofmaintaining adequate fluid intakeTo facilitate IVTObservations, fluid balance charts anddaily weighing, can detect hypervolaemiaor hypovolaemia and facilitates timelyprevention such as fluid restrictions orrapid infusion (Waterhouse, & Farmery,2012).The evidence of any symptoms or signs offluid deficit are detected by regularobservations and assessments (LeMone etal., 2017)Education reduces the risk of fluid deficit(LeMone et al., 2017)Cannula is inserted and IVT administeredNo hypervolaemia or hypovolaemia is evidenton all observationsUrine output is straw coloured and >30ml p/hrNo symptoms or signs of fluid/electrolyteimbalances present and patient remainsnormovolaemicRuby is drinking adequate amounts of fluid Catherine Dent S3009905Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Daily weighAssess skin turgor and mucous membranes forsigns of dehydrationRapid weight can detect fluid imbalance(Lemone, et al., 2017)Dehydration causes diminished skin turgorand dry mucous membranes (Lemone, etal., 2017)Ruby’s weight remains unchangedNo dehydration is noted on assessment Catherine Dent S3009906Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Nursing problem: Reduced mobilityRelated to: pain and reduced consciousness following anaesthetics administered during surgeryGoal of careNursing interventionsRationaleEvaluationIncrease Ruby’s mobilityto achieve independenceRefer for physiotherapy and observe to assessmobility, and provide assistance whenmobilising to ensure safetyPerform falls risk assessmentAssess and administer analgesia prior tomobilisingGather equipment required for mobilising asper physiotherapist recommendations, such ascommode, supply non-slip socksPhysiotherapy assessment post-surgeryencourages early mobilisation and reducesrisk of respiratory complications and DVT’s(Burgess, Immins, & Wainwright, 2018).Falls risk assessments detect risk factorswhich enable appropriate interventions toprevent falls (Boynton, Kelly, & Perez,2014).Adequate pain management enablesincreased patient involvement (Lemone,et al., 2017)Providing a safe environment usingmobility aids encourages early mobilisation(LeMone et al., 2017)Ruby is mobilising independently, safely andwith confidenceRisk assessment completed – no adverse eventshave occurredRuby states there is no pain when mobilisingRuby feels safe and states she has moreconfidence to mobilise more frequently Catherine Dent S3009907Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Encourage and promote Ruby’s safeindependent mobilisation by building atherapeutic relationship with goodcommunicationTherapeutic relationships reduceperception of pain, improve mood andwell-being (Hughes, Percy, & Richardson,2015).Ruby is mobilising independently after atrusting relationship was developed Catherine Dent S3009908Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Nursing problem: Risk of anxietyRelated to: pain, knowledge deficit, loss of power and history of depressionGoal of careNursing interventionsRationaleEvaluationReduce risk of anxietyGive usual antidepressant medication, assessfor adverse reaction and efficacyDevelop a trusting relationship and discussRuby’s fears to establish a plan to alleviatethem. Educate Ruby on her recovery, what toexpect and provide reassurance.Educate Ruby on relaxation techniques, slowbreathing, muscle relaxation, playing herfavourite musicEscitalopram is an SSRI, which increasesserotonin in the brain resulting in animproved mood, they are best takenregularly, as prescribed for optimal effect(Cobb, Haswell, Hodgman, Martini, &Nacca, 2015).Therapeutic interpersonal relationshipsbetween a nurse and the patient arerelated to improved levels of anxiety anddepression (Duff, Kornhaber, Walker, &Walsh, 2016).Relaxation techniques reduces stress bylowering RR and BP resulting in reducedanxiety and improved mood (Crooks,2013).Ruby states she is feeling better since taking hermedicationRuby’s states that following education on whatto expect during recovery, she feels her anxietylevel is reduced and she is looking forward toher visitors this afternoon.Ruby is visibly enjoying a visit with her familyand friends.Ruby’s facial expressions and demeanourappear less anxious, and she states she isenjoying her music whist practicing controlledbreathing. Catherine Dent S3009909Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Nursing problem: Self-care deficitRelated to: Impaired mobility, pain and reduced consciousness following surgeryGoal of careNursing interventionsRationaleEvaluationIncrease Ruby’s ability toperform self-careindependentlyAssess level of capability including Ruby’sinput, provide education re temporary deficitAdminister analgesia prior to ADL’s, toiletingAccess equipment required to perform ADL’sand toiletingRefer to physiotherapist for mobilisingassessment, breathing techniques and pelvicfloor exercises following surgeryAssessing capability and education deficitcan improve nurses to identify and achieveRuby’s self-care needs (Akhond, Alami,Khosravan, Mohammadpour, and Sharghi,2015).Adequate pain management enablesgreater participation (Lemone, et al.,2017)Promotes safe practice and confidence forpatients (Lemone, et al., 2017)Physiotherapy assessment post-surgeryencourages early mobilisation and reducesrisk of respiratory complications and DVT’s(Burgess, Immins, & Wainwright, 2018).Ruby is showering and toileting independentlyRuby states pain reduction allowed her toperform self-caring independentlyRuby states commode was useful in achievinggoals of self-carePhysiotherapist assessment completed Catherine Dent S30099010Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 Provide privacy for all hygiene/toiletingRegularly re-assess level of capabilityEnsuring patients right to privacy anddignity is paramount in providing qualitynursing care (Lemone, et al., 2017)To acknowledge improved condition andaltering levels of independence (Lemone,et al., 2017)Providing privacy for Ruby allowed her toshower and toilet with dignityRuby is now able to toilet and showerindependently Catherine Dent S30099011Last name DENT student number S300990 NUR251 S2 2018 Assessment 1Task 3Verbal education should be supported in written form to prompt memory (LeMone et al., 2017).Ruby will need education on mobility and life-style factors such as resting for first few days,continued gentle walking to aid in healing, no heavy lifting above 10kgs, no sport or sex for sixweeks and that she is able to drive after a few weeks. Light duties at work and home are acceptablebut she should enlist daily help from family and take some leave from work (InternationalUrogynecological Association, 2018).It would be important for Ruby to be aware of the risk of infection, and education would includesigns and symptoms such as unpleasant vaginal odour and discharge, not including a normalcream/brown or bloody discharge, which should gradually reduce after six weeks post-surgery.Education on risk of UTI and awareness of symptoms such as burning on urination, pain and a raisedtemperature. Teach Ruby method to check her own temperature daily for early detection. See GP ifany of these symptoms develop, to obtain antibiotics (International Urogynecological Association,2018).Ruby it at increased risk of emboli due to her surgery and age, and should have education on signsand symptoms such as localised calf pain, redness, tenderness or lower leg swelling, chest pain orany breathing difficulties, and seek medical attention immediately if they occur (Dongo, Irekpita,Jebbin, Kesieme, & Kesieme, 2011). Ruby can implement prevention by regular ambulationthroughout the day, practice ankle flexion and extension whilst sitting, avoid crossing legs and takeprophylactic anticoagulant medication if prescribed (LeMone et al., 2017)Catherine Dent S30099012Last name DENT student number S300990 NUR251 S2 2018 Assessment 1Task 48/8/2018 1500 under Dr Smith. Day 5 post subtotal vaginal hysterectomy. Bowels open today,patient stated she is voiding good amounts of straw coloured urine this shift. Pain managed wellwith regular Panadol, Ruby reports 0/10 pain this shift. Minimal PV blood loss since surgery, patientstates nil blood loss this shift. Ruby states she is feeling well and ready to go home tomorrow. Rubystates no nausea this shift. Currently on light diet but has requested normal diet as appetite hasincreased, kitchen notified. Early ambulation encouraged post-surgery, now independentlymobilising around room without assistance. Self caring with ADL’s. FBC no longer required asdrinking and voiding good amounts as per FBC. TED stockings removed. Care as per clinical pathway.IVT and cannula removed, patient eating and drinking well, mucous membranes moist, skin turgornormal, no sign of dehydration. Medications administered apc. Alert and oriented to time and place,GCS normal at 15. Vitally stable, afebrile and within normal ranges, O2 removed, sats 99% on RA. HRregular 80. Remains on antihypertensive with good effect, BP 130/80. RR 18. Temp 36.2. Abdomennon tender to touch and no evidence of urine retention. Skin intact and well perfused. Respirationclear. Family and husband visited this shift, pt in good spirits and looking forward to going hometomorrow. Dr has given permission for D/C in the morning, husband to collect at 1000. Educationprovided to patient. F/U appointment with Dr Smith in 2 weeks’ time. Continue to monitor bloodloss. Vitals 4/24 as per chart. D/C paperwork completed. Contact doctor re prophylacticanticoagulant for discharge if required. Signed. C. Dent, student nurse…………………………… C. DENTKey (if required) ADL’sTEDactivities of daily livingthrombo-embolic-deterrent (socks)GCSGlasgow coma scoreUTIurinary tract infectionLOClevel of consciousnessRRrespiratory rateFBCfluid balance chartIVTintravenous therapyPQRSTprovocation/palliation, quality/quantity, region/radiation, severity scale, timing Catherine Dent S30099013Last name DENT student number S300990 NUR251 S2 2018 Assessment 1 PVper vaginalDVTdeep vein thrombolismSOBshortness of breathBPblood pressureKGSkilogramsGPgeneral practitionerAPCas per chartO2oxygenSATSsaturationRAroom airHRheart rateRRrespiratory rateTEMPtemperaturePTpatientDRD/CF/Udoctordischargefollow-up Catherine Dent S30099014Last name DENT student number S300990 NUR251 S2 2018 Assessment 1ReferencesAkhond, M., Alami, A., Khosravan, S., Mohammadpour, A., and Sharghi, N. (2015). The effect of asupportive educational intervention developed based on the Orem’s self‐care theory on theself‐care ability of patients with myocardial infarction: A randomised controlled trial. Journalof Clinical Nursing, 24(11-12), 1686-1692. Retrieved fromhttps://onlinelibrary-wiley-com.ezproxy.cdu.edu.au/doi/epdf/10.1111/jocn.12775Boynton, T., Kelly, L., & Perez, A. (2014). Implementing a mobility assessment tool for nurses: Anurse-driven assessment tool reveals the patient’s mobility level and guides SPHMtechnology choices. American Nurse Today, 9(9), S13. Retrieved fromhttp://go.galegroup.com.ezproxy.cdu.edu.au/ps/i.do?&id=GALE|A411015313&v=2.1&u=ntu&it=r&p=AONE&sw=wBurgess, L., Immins, T., & Wainwright, T. (2018). What is the role of post-operative physiotherapy ingeneral surgical Enhanced Recovery after Surgery pathways? European Journal ofPhysiotherapy, 1-6. doi/abs/10.1080/21679169.2018.1468813Cobb, T., Haswell, D., Hodgman, M., Martini, D., & Nacca, N. (2015). Serotonin syndrome followingmetaxalone overdose and therapeutic use of a selective serotonin reuptake inhibitor.Clinical Toxicology, 53(3), 185-187. Retrieved fromhttp://web.b.ebscohost.com.ezproxy.cdu.edu.au/ehost/pdfviewer/pdfviewer?vid=1&sid=95e81142-f956-41cc-8d61-11bc3fc0b24c%40pdc-v-sessmgr01Crooks, L. (2013). Manage stress before it manages you. American Jails, 27(1), 8-10,13-16. Retrievedfromhttp://web.b.ebscohost.com.ezproxy.cdu.edu.au/ehost/pdfviewer/pdfviewer?vid=1&sid=0660f312-265a-4789-8f84-dd9477da0c1a%40sessionmgr104Catherine Dent S30099015Last name DENT student number S300990 NUR251 S2 2018 Assessment 1Dongo, A., Jebbin, N., Irekpita, E., Kesieme, C., & Kesieme, E. (2011). Deep vein thrombosis: A clinicalreview. Journal of Blood Medicine, 2011, 59-69. Retrieved fromhttps://www.dovepress.com/deep-vein-thrombosis-a-clinical-review-a7291Duff, J., Kornhaber, R., Walker, K., & Walsh, K. (2016). Enhancing adult therapeutic interpersonalrelationships in the acute health care setting: An integrative review. Journal ofMultidisciplinary Healthcare, 9(1), 537-546. Retrieved fromhttp://go.galegroup.com.ezproxy.cdu.edu.au/ps/i.do?ty=as&v=2.1&u=ntu&it=DIourl&s=RELEVANCE&p=AONE&qt=SP~537~~IU~1~~SN~1178-2390~~VO~9&lm=DA~120160000&sw=wFouladbakhsh, J., Jenuwine, E., Szczesny, S., & Vallerand, A. (2011). Nondrug Therapies for PainManagement Among Rural Older Adults. Pain Management Nursing, 12(2), 70-81. Retrievedfromhttps://www-sciencedirectcom.ezproxy.cdu.edu.au/search/advanced?docId=10.1016/j.pmn.2010.08.005Gregory, J. (2014). Dealing with acute and chronic pain: Part one – assessment. Journal of CommunityNursing, 28(4), 83-84,86. Retrieved fromhttp://web.b.ebscohost.com.ezproxy.cdu.edu.au/ehost/pdfviewer/pdfviewer?vid=1&sid=a7d4a17e-9600-422e-bf4d-85c3394ed598%40pdc-v-sessmgr06Hughes, J., Percy, M., & Richardson, C. (2015). Nursing therapeutics: Teaching student nurses care,compassion and empathy. Nurse Education Today, 35(5), E1-E5. Retrieved fromhttps://www-sciencedirectcom.ezproxy.cdu.edu.au/search/advanced?docId=10.1016/j.nedt.2015.01.016Catherine Dent S30099016Last name DENT student number S300990 NUR251 S2 2018 Assessment 1Ingadóttir, B., & Zoëga, S. (2017). Role of patient education in postoperative pain management.Nursing Standard (2014), 32(2), 50-63. doi/full/10.7748/ns.2017.e10939International Urogynecological Association. (2018). Vaginal Hysterectomy. Retrieved fromhttps://www.yourpelvicfloor.org/conditions/vaginal-hysterectomy-forprolapse/#what%20will%20happen%20to%me%20after%20the%20operation?Karcz, M., & Papadakos, P. (2013). Respiratory complications in the postanesthesia care unit: Areview of pathophysiological mechanisms. Canadian Journal of Respiratory Therapy: CJRT =Revue Canadienne De La Thérapie Respiratoire : RCTR, 49(4), 21-29. Reviewed fromhttp://web.a.ebscohost.com.ezproxy.cdu.edu.au/ehost/pdfviewer/pdfviewer?vid=1&sid=a8442ab6-5d29-4def-823e-cedb7f2dd618%40sessionmgr4009Leech, C., & Nesbitt, I. (2012). Fluid management. Surgery (Oxford), 31(2), 54-58. Retrieved fromhttps://www-sciencedirectcom.ezproxy.cdu.edu.au/search/advanced?docId=10.1016/j.mpsur.2012.12.005LeMone, P., Burke, K. M., Bauldoff, G., Gubrud, P., Levett-Jones, T., Hales, M…(2017). MedicalSurgical Nursing Critical Thinking for Person Centered Care. Melbourne, Australia: PearsonWaterhouse, B., & Farmery, A. (2012). The organization and composition of body fluids. Anaesthesia& Intensive Care Medicine, 13(12), 603-608. Retrieved from https://www-sciencedirectcom.ezproxy.cdu.edu.au/search/advanced?docId=10.1016/j.mpaic.2012.09.007