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.

	Erstellt von D R vor fast 11 Jahre

2 2NN3 Notiz am PAIN - PBL, erstellt von D R am 17/01/2016.