Question

Ms. X has type 2 diabetes mellitus and peripheral arterial occlusive disease with neuropathy. Ms. X is disabled because of limited mobility and chronic pain associated with lower extremity claudication and neuropathic pain. She has been admitted for an elective right femoral to distal tibial bypass. Ms. X’s chronic pain has been effectively managed with gabapentin (600 mg three times daily) and a 75-mcg fentanyl patch every third day. Ms. X reports that her pain patch is due to be changed the next day. Her diabetes mellitus has been effectively managed with diet and a combination of oral agents. Postoperatively, orders for pain management include her home regimen of gabapentin and fentanyl patch and an order for morphine for breakthrough pain.

Clinical Assessment

Ms. X is admitted to the critical care unit from the perianesthesia recovery room after an 8-hour surgical revascularization of the right lower extremity. She is awake; alert; and oriented to person, time, place, and situation. Ms. X is breathing through her mouth and taking shallow breaths. She complains of right lower extremity and bilateral foot pain. Her skin is warm and dry. Ms. X is able to move her toes on command, and lower 134extremity sensation to touch is intact; however, she is complaining of severe burning in both feet.

Diagnostic Procedures

Ms. X reports that her pain is a 10 on the Numeric Rating Scale. The Riker Agitation Sedation Scale score is 5.

Medical Diagnosis

The diagnosis is acute postoperative incisional pain superimposed on chronic neuropathic pain involving both lower extremities. Neuropathic pain is likely worsened because of missed doses of gabapentin.

Questions

1. What major outcomes do you expect to achieve for this patient?

2. What problems or risks must be managed to achieve these outcomes?

3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

5. What possible learning needs do you anticipate for this patient?

6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Answer 1

Solutions:

1. The major outcomes to be achieved for this patient

• Reduction of pain to the satisfactory level.
• The patient should be calm and comfortable.
• To improve the mobility of lower extremities and to increase the muscle tone.
• Safe and correct administration of medication.
• Control of diabetes.

2. The problems/risks that should be managed for this patient include

• Inadequate assessment of pain as the patient is affected with neuropathy.
• Need for long-term use of pain medication.
• The patient may experience side effects or addiction due to prolonged use of opioids.
• patient's lack of tolerant to pain.
• Altered hemodynamic status.

3. The nursing interventions for the identified problem should include

• Proper assessment and observation of pain at rest.
• Assess the patient pain tolerant level.
• Use of pain medication effectively.
• Use of non-pharmacological methods such as cold application, relaxation techniques.
• Monitor respiratory and cardiac status.

4. The pain can be controlled by using Patient-controlled Analgesia. The PCA is administered through an infusion pump. The patient is allowed to self-administer of pain medication to a certain level. The patient has to be monitored for respiratory effects. If the patient is still experienced pain, then intraspinal anesthesia is used which inhibit the pain-transmitting agent in the spinal cord.

5. The patient has a deficit in knowledge regarding pain, pain management, use of opioids, and side effects of pain medication. The patient and the family members should be taught about pain management, use of a sufficient amount of opioids, side effects of opioids, an alternative method in pain management to get adequate knowledge.

6. When assessing the pain level, the patient's cultural values, beliefs, tolerant, the opinion, the aging factor should be concerned. Language is one of the foremost barriers in a culturally diverse patient. Use of patient language is effective in identifying the patient intensity of pain on the pain scale. The nurse should respect the patient's values and opinions before taking a clinical decision. Pain management of plan should be developed based on age and cultural factors.