Question

Jody Foster is a 28-year-old Caucasian woman who presents to the emergency department complaining of right-sided rib pain, neck pain, and headache after being physically assaulted by her husband. Last evening her husband came home intoxicated and became angry when their 12-month-old son began to cry. He punched her in the face, chest, then began to choke her by squeezing her neck for about a minute. She began to feel dizzy, but did not lose consciousness. She admits that this is not the first time she has been assaulted by her husband, but acknowledges that it has gotten worse lately.

Her right cheek is swollen with a large abrasion. She has left lateral neck pain, but no cervical spine tenderness. Her headache is on the left side of her head that has been continuous since she was assaulted. She rates it as a 9/10 and a “throbbing” sensation. She has increased pain in her right chest when she takes a deep breath. She has no other neurologic complaints. The CT of her head is normal, and x-rays revealed no facial or rib fractures.

Jody has no family in the community and no close friends who can assist her. She refuses to press charges against her husband, therefore she does not want the police to be notified. Information regarding shelters for women are given to her but Jody wants to go back home because, “My husband left the house to cool off after I left and said he would go to a friend’s house for the night.” Despite the primary care provider communicating that her life is possibly in danger if she returns home, Jody states that she has no place to go. She relates that she does not want to go to a woman’s shelter with her baby because everything is going to be OK and this time, he is really sorry.

1. What is the nursing PRIORITY? What nursing diagnosis would you use for this priority?

2. What are the PRIORITY nursing interventions?

3. What is the expected response of the patient that indicates nursing interventions were effective?

Answer 1

Since she is complining od pain scoring 9/10 defenitly the nursing priority should be the PAIN

The nursing diagnosis use for this priority is 'Acute pain ,related to injury,as evidenced by pain score of 9/10,throbbing sensation'

The priority nursing interventions include

1. Biological and physiological needs which include respiration,hydration,circulation respiration,nutrition,elimination

So in this patient the first priority is for the pain management.

The nursing inerventions are

1 Assess the pain for its severity and location

2 check the vital signs

3. Provide comfortable position

4 provide calm and quiet environment

5. Use nonpharmacological pain relief measures like reassuring the patient,relaxation excercises,

6 Administer analgesics as per the doctors instruction.

7 Record the drug administarion in the patient flow sheet

8 Document the patient response to pain.

2 Saftey needs which include Environment free from danger,Stable living conditions

3.Love and belongingness needs,includes Relationship friends, family, community.

The expected response from the client includes

verbal response of pain has reduced

Facial expressions denotes the relaxation

Stable vital signs

Patient verbalises regarding her plan after the discharge.