Question

A 25-year-old Arab American man is one day post-operative following vascular surgery. There have been no post-surgical complications. He tells his family that he is “in terrible pain,” and he reports ratings of 2 to 3 on 0-10 numeric rating scale to the nursing staff. He requests pain medication every two to three hours, and will not get out of bed or ambulate.

Identify the actual and potential physiological and psychological responses to the pain/discomfort, for your assigned client.

Answer 1

Nursing Diagnosis: Acute pain related to surgical incision

Outcomes: The client verbalizes and demonstrates an increased level of comfort as evidenced by reporting less severe pain on a 1 to 10 scale, using less analgesia and ambulating increasing distances.

Interventions and rationale:

1. Assess the clients level of pain: type, duration and location - Baseline data to evaluate the effectiveness of treatment and a guide to choice of analgesia provided.

2. Medicate with prescribed analgesics based on level of pain and prior effectiveness - Analgesia is provided to obtain comfort, using the previous response to analgesia and current level of pain to guide the decision.

3. Evaluate the effectiveness of pain medication affter each administration - Determines the adequacy of analgesias.

4. Teach the client how the pain will be controlled - Clients can participate in pain management by notifying the nurse prior to intense pain and by using patient controlled analgesia devices.

5. Position the leg to promote blood circulation and keep the leg warm - Arterial inflow is aided by supine position and warmth.

Evaluation: Acute pain should subside over 48 to 72 hours.