SOLUTION: Nursing problem: Acute Pain | My Assignment Tutor

1Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1 NUR251 Assessment 1 S2 2018Assignment template Task 1Firstly, an initial assessment will be completed including – head-to-toe examination, medical historyand vital observations related to gathering comprehensive baseline data (Berman et al., 2018). Withconsent, privacy and ongoing communication, an inspection of the surgery site inclusive of Ruby’sabdomen will be completed. This assessment is necessary to rule out any signs of infection orabnormalities. A wound care chart, observation chart and entry in Ruby’s progress notes and nursingcare plan is necessary.Secondly, a pain assessment will be conducted using the PQRST algorithm (Berman et al., 2018). Thisassessment is necessary, as providing adequate pain relief will assist in Ruby’s comfort bothphysically and emotionally (McCabe, 2017). Negligence of this assessment may result in increasedpain, distress and reluctance of future nursing care (McCabe, 2017). This assessment will berecorded within the patient observation chart, progress notes and depending on the outcome, thepatient medication chart.Thirdly, a neurological assessment is required to assess Ruby’s level of consciousness and mentalstatus post-anaesthesia using the Glasgow Coma Scale (Tollefson & Hillman, 2016). This also includescommunicating with Ruby throughout the initial assessment phases and ensuring adequateresponses to questions such as – orientation to person, time and place (Berman et al., 2018). Thisassessment ensures Ruby is not experiencing any deviations from her normal such as inability torecall recent memory as an adverse post-anaesthesia effect (Berman et al., 2018). A neurologicalassessment chart will be utilised.Lastly, the nurse will use a fluid balance chart to assess Ruby’s current fluid input and output. Aphysical assessment focusing on Ruby’s urine output, skin colour and turgor, peripheral perfusionand mucous membranes will also be completed (Berman et al., 2018). This assessment is necessaryas general anaesthetic reduces bladder muscle mobility and suppresses the urge to void (Berman etal., 2018). If this assessment is not completed accurately there is potential for developing lifethreatening complications relevant to fluid retention or fluid loss (Berman et al., 2018).2Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1Task 2Nursing Care Plan: RUBY SMITH Nursing problem: Acute PainRelated to: Tissue inflammation and trauma associated with subtotal vaginal hysterectomy.Goal of careNursing interventionsRationaleEvaluationMinimise pain and ensureRuby’s comfort ismaintained. Assess Ruby’s pain using PQRSTalgorithm. Monitor Ruby’s verbal and non-verbalcommunication regarding painincluding analgesia requests, facialgrimacing, moaning, wincing andguarding. Regularly assess surgical site for signsof infection or changes in condition. Administer charted analgesia Discuss the importance of notifying The use of a pain intensity scale isa consistent, easy and reliablemethod in determining a person’spain intensity (Berman et al.,2018). Approximately 55-95% of amessage is communicated nonverbally which validates theimportance of face-to-face nursepatient interaction (McElroy,2017). Initial and ongoing woundassessment provides baseline datain which progress can bemonitored and treatment can beamended for optimal woundmanagement (Greatrex-White,2015). Acute pain that is inadequatelymanaged can develop into chronic Ruby appears to be more comfortablethrough less wincing and complaints. Ruby’s number of requests for analgesiahave reduced (from 2hrly to 4hrly). Ruby states that her pain is now a 3/10. 3Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1 nurse of any pain, a change in paintype or severity. Assist Ruby in regular re-positioningwith pillow support to providecomfort.pain which can hinder a patient’shealing and recovery time(McCabe, 2017). Regular re-positioning helps in theprevention of muscle discomfort,pressure injuries and damage tosuperficial nerves and bloodvessels (Berman et al., 2018).Nursing problem: Risk of fluid imbalanceRelated to: A subtotal vaginal hysterectomy has surgery complications such as increased PV loss and risk of swelling/oedema due to trauma and inflammation which maycontribute to a fluid imbalance.Goal of careNursing interventionsRationaleEvaluationMonitor and ensureRuby’s fluid balanceremains at a stable level. Assess skin turgor, mucousmembranes, overall appearance,capillary refill (30ml/hr. Ruby’s vital observations are all withinnormal parameters. Ruby states she has “not been as thirstydue to having regular sips of water” tokeep hydrated as per nurse-patientdiscussion. 4Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1  Monitor fluid input and output via afluid balance chart (ensure output>30ml/hr). Monitor urine consistency/colour/smell for signs of infection.(haematuria, foul smelling). Provide a measured cup and water jugwithin close-proximity to Ruby toensure adequate measurement andhydration. Discuss fluid imbalance and the effectsit can have on the body (dehydrationand associated illness’).hypovalaemia (McGloin, 2015). Determining adequate hydrationin a patient requires timely andaccurate fluid balanceobservations; these observationshelp identify early warning signs ofdeterioration (Pinnington, Ingleby,Hanumapura & Waring, 2016). Achieving adequate hydrationassists in the prevention of illhealth and disease includingstroke, blood glucose control,healthy urinary tract and bowelfunction and fall prevention(Pegram & Bloomfield, 2015).Nursing problem: Reduced mobilityRelated to: History of chronic abdominal pain, acute pain from subtotal vaginal hysterectomy, post anaesthesia lethargy and body healing/recovery.Goal of careNursing interventionsRationaleEvaluationEncourage and assistRuby with gradualmobility. Regularly assess and evaluate level ofmobility through communication andobservation; Assist Ruby with gradualmobility under direction ofmultidisciplinary team. Early mobilisation (within 24hrs) isan essential component ofenhanced post-operation recoveryas it reduces thromboembolismincidence, muscle wasting, jointstiffness, pressure injuries and Ruby’s mobility has been increasingover the shift and she is more confidentin her movement. Ruby states that she feels better whenshe is moving rather than lying in bed. 5Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1  Monitor for signs of any decrease inmobility including changes in walkinggait, speed, coordination anddecreased motivation. Provide TED stockings to reducechances in developingthromboembolism and encourageoptimal blood flow. Educate Ruby on the importance ofmobility to reduce chances of DVT andstimulate recovery by circulating RBCs.depression (Talec, Gaujoux &Samama, 2016). Elastic compression stockingsassist in compensating withvenous return in the calf andplantar of post-operative patientsreducing chances ofthromboembolisms (Talec,Gaujoux & Samama, 2016). Patient education is associatedwith positive health outcomes, anincrease in knowledge, adherenceto treatment plans, involvement incare and perceived control overhealth and illness (Crawford, Roger& Candlin, 2016).Nursing problem: Risk of anxietyRelated to: Chronic pain, acute pain, length of hospital admission, reduced mobility relevant to subtotal vaginal hysterectomy surgery and history of mental health.Goal of careNursing interventionsRationaleEvaluationMinimise Ruby’s risk ofanxiety throughtherapeutic nursing care. Assess Ruby’s mental status throughobservation and communicationincluding her general appearance(speech, hygiene, verbal and non- Mental health assessment is vitalin determining an informedjudgement about an individuals’present mental health status as During 1-2hrly interactions both verbaland non-verbal, Ruby was smiling andrelaxed. 6Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1 verbal expressions, mannerisms,posture and gait). Monitor and repeatwith each encounter. Assess Ruby’s discharge conditions(support network, living conditions). Discuss with Ruby the importance ofhaving a supportive network duringrecovery and discharge for mentalhealth (family and friends). Administer charted medicationsrelevant to Ruby’s mental health(Escitalopram oxalate 20mg daily). Provide Ruby with reassurance(relaxed conversation, comfort,support, distractions).well as possible need forintervention (Tollefson & Hillman,2016). It is essential to ensure a mentalhealth support network is availablewithin the community to reducechances of a decline in mentalhealth condition (Noseworthy,Sevigny, Laizner, Houle & Riccia,2014). Collaboration (including sharedknowledge) between the clientand nurse is the most effectiveapproach to encouragingsuccessful adherence tomedication (Athanasos, 2017). Reducing patient anxiety can beachieved through mind diversion(television, magazines), calm andsupportive patient conversation,establishing a routine and healtheducation (Jiwani, 2016). Ruby is aware of the community healthsupport that is available post dischargeand this has put her mind at ease. Ruby spoke on several occasions of hersupportive family that live close by andtheir willingness to assist her in herrecovery.Nursing problem: Self-care deficitRelated to: Pain and inflammation from subtotal vaginal hysterectomy. This may compromise Ruby’s independence, mental status and hygiene standards which may resultin a delayed recovery. 7Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1 Goal of careNursing interventionsRationaleEvaluationProvide Ruby withassistance in self-carewith ongoing educationand encouragement toregain her independence. Assess Ruby’s self-care activities. Assist and continuously observe Rubywith self-care activities wherenecessary while using encouragingpositive communication. Educate, encourage and demonstratetechniques which will help Ruby regainher independence. Discuss importance of hygiene practiceto reduce chances of infection. Assess Ruby’s skin surfaces whenassisting in activities of daily living. The collection of data relating to aperson’s self-care abilities enablesthe nurse to incorporate theclient’s needs and preferences aswell as nursing interventions toprovide the best possible care(Berman et al., 2018). Effectively displaying andencouraging patient-centred careleads to an increasedpatient/family satisfactionresulting in improved patientoutcomes (Gluyas, 2015). Having in-tact skin and mucousmembranes ensures a significantbarrier to microorganisms at riskof entering the body, ensuringproper hygiene practices enhancesthis barrier (Berman et al., 2018). Inspection of skin surfacesparticularly over pressure-proneareas (sacrum, ischia, greatertrochanters) form a vitalcomponent of reducing pressureinjuries (Borzdynski, McGuinnes &Miller, 2015). Ruby displays eagerness to regain herindependence through self-showeringwhile using the shower chair. Ruby states that she feels comfortableparticipating independently in morethan 60% of her activities of daily living. 8Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1Task 3Firstly, it is vital that Ruby understands why she had the subtotal vaginal hysterectomy(abnormal uterine bleeding & chronic pelvic pain) and what the surgery involved (removal ofthe uterus & fallopian tubes, cervix left intact (Coody, Stutzman & Abraham, 2017)). Thisinformation will give Ruby a good indication of her recovery. Ruby’s recovery should involveregular light exercise eg – light 20minute walk 2-3 times per day for one week in increasingtime intervals while ensuring adequate rest periods are achieved.Awareness of the normal signs and symptoms of Ruby’s surgery is also vital (minimal bloodloss, mild-moderate abdominal pain) and that any abnormal signs (fever, swelling, increasedblood loss, severe abdominal pain) require immediate medical attention to reduce chancesof future illness’/complications (Berman et al., 2018). The nurse should provide a leaflet thatcan be placed on Ruby’s fridge outlining the normal versus abnormal signs and symptoms ofher surgery. Attendance to follow-up appointments is also essential and organisingreminders should be encouraged on Ruby’s calendar/phone with medical details for easyaccess.Thirdly, competent hygiene practice is imperative in reducing risk of infection as well asassisting in the healing process. Ruby can implement daily cleans, both morning and eveningusing soap-free warm water. It would also be advisable to avoid bathing and showering forlong periods, wear loose fitting/breathable clothing, avoid sitting in the same position forprolonged periods, change pads 2-4 hourly and avoid sweating and over-activity (Berman etal., 2018).9Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1Task 410/08/2018 – 2030 – Nursing handover and patient received at 1330.Ruby is alert and orientated to person, place and time. Ruby has positively contributed tonursing care throughout the shift. Ruby’s observations were attended 4/24 – all withinnormal parameters. 1500 – Ruby reported 8/10 pain, pain assessment was initiated and IMIfentanyl 100mcg was administered at 1515, Ruby stated 3/10 pain 1530 with minimalwincing and complaints observed. Pain has been under control with paracetamol 1g QID andIMI ketorolac 30mg TDS. Urine output has been maintained at >30ml/hr with nil signs offluid imbalance/dehydration on 2/24 fluid assessments. FBC is stable. Initial strategy toincrease mobilisation discussed. Ruby demonstrated eagerness through regularindependent repositioning and stated that “I feel better moving rather than lying in bed allday”. Ruby requires x1 assistance with ADL’s. Skin intact. Nil signs of pressure injury oninspection. Guarding, tenderness and minimal swelling present on abdominal examination.Surgical site is clean, nil signs of infection/abnormalities present at 1800. Demonstrationprovided for cleansing of surgical site. Ruby is tolerating food/water. Nil nausea/vomiting.Continent – nil patient complaints. Ruby had family present all day and was activelyparticipating in conversation. Ruby speaks highly of her families ongoing support on severaloccasions – nil signs of anxiety………………………….……………………………………………J.KERR, SRN.10Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1ReferencesAthanasos, P. (2017). Mood disorders. In K. Evans, D. Nizette & A. O’Brien (Eds.), Psychiatricand mental health nursing (4th ed.). Sydney, NSW: Elsevier.Berman, A., Snyder, S. J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., … Stanley, D.(2018). Kozier and Erb’s fundamentals of nursing: Concepts, process and practice (4thed.). Melbourne, Victoria: Pearson Australia.Borzdynski, C., McGuiness, W., & Miller, C. (2016). Comparing visual and objective skinassessment with pressure injury risk. International Wound Journal, 13(4), 512-518.doi: 10.1111.iwj.12468Coody, L., Stutzman, H., Abraham, S., & Duregger, C. (2017). A case for evidence basedpatient education: Differences in short term and long term patient outcomes fortotal vs. subtotal hysterectomy using a systematic review of literature. CogentPsychology, 4(1), 1-8. doi: https://doi.org/10.1080/23311908.2017.1304017Crawford, T., Roger, P., & Candlin, S. (2017). The interactional consequences of ‘empoweringdiscourse’ in intercultural patient education. Patient Education andCounselling, 100(3), 495-500. doi: http://dx.doi.org/10.1016/j.pec.2016.09.017Gluyas, H. (2015). Patient-centred care: Improving healthcare outcomes. NursingStandard, 30(4), 50-59. doi: 10.7748/ns.30.4.50.e10186Greatrex‐White, S., & Moxey, H. (2015). Wound assessment tools and nurses’ needs: Anevaluation study. International Wound Journal, 12(3), 293-301. doi:10.1111/iwj.1210Jiwani, K. (2016). Handling challenging emotions in nursing care. Journal on Nursing, 6(2),12-16. Retrieved from: http://web.b.ebscohost.com.ezproxy.cdu.edu.au /ehost/11Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1pdfviewer/ pdfviewer?vid=5&sid=1ee57a29-7ae2-4e0d-aca7-e9b9a324478a%40sessionmgr103McCabe, C. (2017). Effective pain management in patients in hospital. NursingStandard, 31(29), 42-46. doi: 10.7748/ns.2017.e10736McElroy, C. (2017). Compassionate communication in acute healthcare: Establishing the faceand content validity of a questionnaire. Journal of Research in Nursing, 22(1-2), 72-88. doi: 10.1177/1744987116678903McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British Journalof Nursing, 24(1), 14-18. doi:10.12968/bjon.2015.24.1.14Noseworthy, A., Sevigny, E., Laizner, A.M., Houle, C., & La Riccia, P. (2014). Mental healthcare professionals’ experiences with the discharge planning process and transitioningpatients attending outpatient clinics into community care. Archives of PsychiatricNursing, 28(1), 263-271. Retrieved from https://www-sciencedirectcom.ezproxy.cdu.edu.au/search/advanced?docId=10.1016/j.apnu.2014.05.002Pegram, A., & Bloomfield, J. (2015). Nutrition and fluid management. Nursing Standard,29(31), 38-42. doi: 10.7748/ns.29.31.38.e9126Pinnington, S., Ingleby, S., Hanumapura, P., & Waring, D. (2016). Assessing and documentingfluid balance. Nursing Standard, 31(15), 46-54. doi: 10.7748/ns.2016.e10432Talec, P., Gaujoux, S., & Samama, C. M. (2016). Early ambulation and prevention of postoperative thrombo-embolic risk. Journal of Visceral Surgery, 153(6), S11-S14. doi:10.1016/j.jviscsurg.2016.09.002Tollefson, J., & Hillman, E. (2016). Clinical psychomotor skills: Assessment tools for nurses(6th ed.). Melbourne, VIC: Cengage Learning Australia.12Double click here to fill in this footerKERR__ S301161_NUR251 S2 2018 Assessment 1KEY – Task 4ADLs – Activities of daily livingFBC – Fluid balance chartIMI – Intramuscular InjectionQID – Four times per dayTDS – Three times per day