PAIN - PBL

Seite 1

Care Scenario 1

From Mosby's NCLEX - RN

Acute pain: mild to severe lasting < 6 months, usually associated with specific injury, involve sympathetic nervous system response.

Leads to increased pulse rate and volume, rate, and depth of respirations, blood pressure, and glucose level; ruin production and peristalsis decrease.

Chronic pain: mild to sever pain lasting > 6 months; associated with parasympathetic nervous system; client may not exhibit signs and symptoms associated with acute pain; may lead to depression and decreased functional status.

Referred pain: pain experienced in an area different from site of tissue trauma.

Intractable pain: pain not relieved by conventional treatment.

Neuropathic pain: pain caused by neurologic disturbance; may not be associated with tissue damage

Phantom pain: pain experienced in missing body part

Radiating pain: pain experienced at source and extending to other areas.

Assessment/Analysis 1. Client's description of pain: location, intensity as measured by numeric rating scale of 0-10, character, onsite, duration and aggravating and alleviating factors

PQRST (Provoke, Quality/Quantity, Radiating, Scale, Timing)

2. Associated signs and symptoms: increased vital signs (may be decreased with visceral pain), nausea, vomiting, diarrhea, diaphoresis

3. Nonverbal cues: distraught facial expression, rigid or self-splinting body posture

4. Contributing factors: age (older adults may expect pain or may fear addiction, so they may not complain), culture, past experience, anxiety, fear, uncertainty (lack of information), fatigue

5. Effect of pain on ability to perform activities of daily living (ADLs)

Planning/Implementation 1. Individual pain management based on client's needs and not on own personal experiences, biases, or cultural beliefs regarding pain

2. Monitor and document client pain, associated symptoms, in response to pain management interventions

3. use non pharmacological techniques

4. administer prescribed analgesics and local anesthetics

5. Institute measures to counteract Side effects of medications (e.g., increase finer and fluids to prevent constipation associated with opioids)

6. provide preoperative and postoperative care for clients requiring surgical intervention for pain management

Evaluation/ outcomes 1. reports a reduction in pain of Equal or less then four a numeric rating scale

2. participate actively in ADLs

Obstruction in small intestine From Medsurg

* onset: rapid

* vomiting is frequent and copious

* Pain: colicky, cramplike, intermitent

* dehydration and electrolyte imbalance occur rapidly

* Feces for a short time

* Ab distension may occur dependent upon location of obstruction

Obstruction below proximal colon

most GI fluids have been absorbed and just solid fecal matter accumulate and symptoms of discomfort appear, greater chance of metabolic acidosis

* Onset: gradual

* Pain: low-grade, cramping ab pain

* Absolute constipation

* Greatly increased ab distension

* At end stages, may vomit fecal matter

* Paralytic Ileus: generalized sense of discomfort

* Emergency surgery is performed if the bowel is strangulated, but many bowel obstructions resolve with conservative treatment.

Nursing Management: Intestinal Obstruction

Assessment:

* Get detailed hx: type and location of obstruction with characteristic symptoms

Ab pain

* Ab tenderness or rigidity

* Onset, frequency, colour, odour and amount of vomitus

* Bowel function: passage of flatus

* Auscultate bowel sounds: will be more high pitched before obstruction

* Inspect ab for scars, palpable masses and distension and observe muscles for guarding and tenderness

Planning

* Overall goal is to relief the obstruction and return to normal bowel function

* Minimal to no discomfort

* Normal fluid and electrolyte status

* Maintain adequate nutrition

Implementation

* Monitor for I & O

* IV admin if ordered

* Serum electrolyte levels should be monitored

* pt is often restless to try and relieve pain with position adjustments – try to promote restful enviro

RNAO: BPG Assessing Pain Practice Recommendations for Pain

Assessment:

* Screen for the presence or risk of any type of pain

* Perform pain assessment

* Use a validated tool if person unable to self report

* Explore person’s beliefs, knowledge and level of understanding about pain and pain management

* Document

Planning:

* Collaborate with person to identify goals for pain management and suitable strategies to ensure comprehensive approach

* Establish plan to incorporate goals and make sure to address:

o Assessment findings

o Persons belief and knowledge and level of understanding

o Person’s attributes and pain characteristics

Implementation

* Implement plan while trying to minimize adverse effects of pharm interventions including:

o Multimodal analgesic approach

o Changing opioids (dose or routes0

o Prevention, assessment and management of adverse effects during the administration of opioid analgesics

o Prevention , assessment and management of opioid risk

* Evaluate any non pharm interventions for effectiveness

* Teach caregiver about pain management strategies in their plan of care

Evaluation

* Reassess person’s response to pain management interventions consistently using the same re-evaluation tool. Frequency of reassessment is determined by:

o Presence of pain

o Pain intensity

o Stability of person’s medical condition

o Type of pain: eg. Acute vs persistant

o Practice setting

* Communicate and document person’s response to pain management

SBAR

S –

Situation

- Briefly describe the current

situation

- Give a clear, succinct overview of

pertinent issues

B –

background

- Briefly state the pertinent

history

- What got us to this point?

A

–Assessment

- Summarize the fact and give your

best assessment

- What is going on? Use your best

judgement

R –

Recommendation

- What actions are you asking for?

- What do you want to happen next?

SBAR

technique provides a standardized framework for communication between members

of the healthcare team about a patient’s condition. SBAR is an easy-to-remember

mechanism useful for framing conversations, especially critical ones, requiring

immediate attention and action.

Using the

SBAR model allows for an easy and focused way to set expectations for what will

be communicated between members of the team, which is essential for developing

effective teamwork and fostering a culture of patient safety.

http://www.nursingcenter.com/journalarticle?Article_ID=715155

NG Tubes

- Candidates include patients who

have adequate digestion and absorption but cannot ingest, chew, or swallow food

safely or in adequate amounts

- A feeding tube is administered

into the stomach or small intestine

- For short term feeding nasal or

oral feeding tubes are appropriate

- NG feeding tubes are often

inserted at the bedside without technological assistance

- Most serious complication is

inadvertent pulmonary intubation – enter the airway undetected and can lead to

serious pulmonary injury

- Feeding tubes are positioned into

the small bowel to reduce the incidence of pulmonary aspiration of stomach

contents

- Variation in colour and pH of

fluid withdrawn from feeding tube can help indicate tubes positioned in the

stomach from those in the small intestine but the best measure is an X-ray

- Carbon dioxide detectors can help

locate the position of tubes during insertion by changing the colour of the

sensor but X-ray is still more reliable

- Maintaining and monitoring tube

location during feeding and keeping the head-of-bed elevation at a minimum of

30 degrees effectively reduces aspiration and subsequent pneumonia

- Measurement of gastric residual

volumes is done routinely to identify risk for regurgitation and pulmonary

aspiration of gastric contents; involves withdrawing and measuring the contents

of the stomach at regular intervals

- Oral hygiene and care of the nasal

passage or tube insertion site promote patient comfort during tube feeding and

can reduce complications

Lewis,

S.L., Heitkemper, M.M., Dirksen, S.R. (2014). Medical-surgical nursing in Canada: Assessment and management of

clinical problems (3rd Canadian Ed.). Toronto, ON: Elsevier/Mosby.