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 and state a priority nursing diagnosis label for your assigned client related to pain.

Develop and state three (3) nursing interventions for this nursing diagnosis label or patient problem. When planning individualized nursing interventions, consider the patient’s type of pain and cultural perspective.

Provide your rationale or reasoning for each intervention chosen. Identify another interdisciplinary team member and an action they could take to help resolve the chosen client problem or nursing diagnosis.

Answer 1

1. Acute pain related to surgery as evidenced by evidence of pain, physical changes and verbal reports of pain.

Intervention: 1) Take complete assessment of pain ,its severity, frequency, intensity , quality and precipitating factors.

Rationale: For better guidance to manage the type of pain experienced. And also avoiding factors that can trigger pain sensation.

Intervention 2)Administer analgesics as per doctors order when required.

Rationale: As it is his first day of surgery he is likely to experience pain more so it is important to provide comfort to the patient so that he can take adequate rest.

Intervention 3) Reduce and eliminate the factors that cause pain and provide diversional therapy .

Rationale: To reduce pain perception.

2)Impaired mobility related to pain as evidenced by difficulty in ambulating or moving.

Intervention 1) Assess the ability of the patient to move or transfer.

Rationale: 1) It is necessary to turn the patient at least every two hours to prevent pressure sores.

Intervention 2) Use correct methods to position the patient.

Rationale: To prevent increase in pain perception.

Intervention 3)Encourage and teach the importance of positioning ie. for better blood circulation and good recovery to the patient and his family.

3) Impaired skin integrity related to prolonged state of rest and less ambulation.

Intervention 1) Assess for signs of infection or changes in the integrity of the skin.

Rationale 1) To detect abnormalities as early as possible.

Intervention 2) Observe and maintain pressure points

Rationale: To prevent pressure ulcers.

Intervention 3 ) Provide regular skin care , remove wet or soiled linen, provide a wrinkle free bed.

Rationale: To maintain skin integrity.