NUR250 Medical Surgical Nursing 1

1 Acute Pain

• Nursing Interventions

Assess the pain characteristics which include pain quality such sharp and burning pain, the severity of pain on a scale of 0to 10, location, onset, and duration plus relieving and precipitating factors.

Get rid of stressors and all sources of discomfort if possible as they are the aggravating factors of pain, that is, stressors increases pain.

Provide rest period for the purpose of promoting sleep, relief, and relaxation.

Determine appropriate pain relief method.

• Rationale

The pain assessment is the first nursing intervention in pain management that helps in planning. The appropriate source of information about the extent of pain is from the patient. The scales such as 0 to 10 pain scale and others like visual analogues are one of the most appropriate methods to distinguish different degrees of pain. Different degrees of pain are treated using different analgesics. Nonopioid treats mild pain and opioids treats severe pain.

Getting rid of additional stressors is crucial in pain management. The degree of pain may be increased or decreased if the patient is unable to cope with additional painful stimuli from the environment, intrapersonal and other psychological factors that add additional stress 

Pain may be increased due to exhaustion. Fatigue and discomfort normally exaggerate pain experience. A quiet and peaceful environment usually facilitates rest .

Patients experiencing acute pain should be given a nonopioid analgesic unless they are contraindications. Nonopioids work in peripheral tissues blocking the synthesis of prostagradins that normally stimulate nociceptors. 

• Expected Outcomes

The patient describes that she is experiencing less pain at a less scale level of 3 or 4 on a pain rating scale of 0 t 10 .

Sally will demonstrate and display improvement on parameters such as improved pulse rate, blood pressure and relaxed body posture or comfort .

2 Other clinical manifestations that can be assessed on Frank

Loss of skin elasticity due to hydration

Cold and clammy skin that is pale

Dry mucous membranes and anxiety

3. Items assessed using the PQRST pneumonic

P-Provokes- what causes the pain, makes it better or what worsen

Q-Quality- Is the pain sharp, dull, stabbing, burning, crushing or how does it feel like. It si important to let the patient describe the pain without pressure so as he or she can give the correct information.

R-Radiates- is the pain in one place, does it radiate or not?

S-Severity- what is the severity or degree of the pain on a scale of 0-10

T-Time- when did the pain start and what duration has it taken.

4.

• Conclusion from signs and symptoms

Frank is in hypovolemic shock and need immediate interventions

• Two highest priority nursing diagnosis

Acute pain related to the disease process as evidenced by patient reporting an increased in severity of the pain 

Ineffective breathing patterns related to the disease process as evidenced by patient becoming more dyspnoeic and increased anxiety .  

• Four immediate nursing interventions

Administer opioid analgesics. Opioids can be administered orally but in this case, the intravenous infusion should be considered as its effect is fast. Opioids are normally indicated for severe pain cases.

Administer oxygen using oxygen mask or nasal prongs at around six liters per hour. Patient with difficulty in breathing have low oxygen saturation and immediate care should be done.

Position the patient at the supine position. Supine position enhances comfort and proper breathing. In addition, supine position is the best for patients on oxygen.

Remove excess clothing the patient has and allow proper ventilation. This is to prevent excess sweating. Reassure the patient will be alright to relieve excess anxiety .

• Five priority nursing assessments

Assess and monitor oxygen respiratory rate and oxygen saturation. The respiratory rate should be 10 -28 breaths per minutes and oxygen saturation should not be less than 90.

Monitor and record vital signs after every two hours. Vital signs include blood pressure, heart rate, and pulse plus respiration rate. Vital signs normally provide the basic parameters used to describe the wellbeing of an individual.  Any deviation from the normal will indicate if the progress in management is towards the positive outcomes or negative outcomes.

Assess the fluid balance and the level of dehydration. This is to enable one to determine the appropriate amount of fluids per hour the patient should be put on.

Assess and evaluate the levels of anxiety. The increase in anxiety will worsen the condition. Nurses should evaluate whether the levels of anxiety are decreasing or not.

Assess the levels of comfort and relaxation. Nurses should assess if the patient is comfort and position accordingly. Comfort relieves anxiety and promotes healing. Turning of the patient after every two hours is essential.

• Two potential complications

Kidney damage

Brain damage

Heart attack 

 5.

• Priority nursing actions

Assess the level of anxiety. Anxiety may result and increase the problems of the client not be able to breathe properly due to struggle.

Administer short acting beta 2 adrenergic agonist like albuterol. Patients collapsing due to a cold shower and have difficulty in breathing are probably asthmatic since cold shower can complicate the condition. Short-acting beta 2 agonists are bronchodilators which normally act by relaxing the muscles lining of the airways that carry air to the lungs thus it is usually best for the acute asthmatic attack.

Assess breath sounds and other adventitious sounds such as stridor and wheezes. Wheezing is usually as a result of bronchospasm. When the wheezing is diminishing, these are some of the suggestive signs of respiratory failure. Other sounds may due to complications such as pneumonia .

• The most appropriate position and why

The most appropriate position is high fowler’s tripod position where the patient sits while leaning forward with hands on his knees.  This is the best position that usually promotes oxygenation since it allows maximum chest expansion .

  6.

• Phase of the burn

Emergency phase of burns management- The emergency phase of burns management is always under the first 48 hours where the top nursing priorities are always considered.

• Five Priority Nursing Problems

Impaired gaseous exchange

Acute pain

Fluid volume deficit

Hypothermia

Anxiety 

• What the above priority are related to and why they are the key priority.

Impaired gaseous exchange is related to smoke inhalation, carbon monoxide poisoning and obstruction of the upper airway. Other possible related factors include edema and additional effects of smoke inhalation. This is a key nursing priority in emergent burn management in order to promote gas exchange and airway clearance. Certain nursing interventions such as the provision of humidified oxygen, pulse oximetry monitoring and assessment of breath sounds and respiratory rate are crucial.

Fluid volume deficit is related to factors such as evaporation losses from the wounds and injuries of blood vessels that increase the capillary permeability. This is a crucial nursing priority so that to restore fluid and electrolyte loss by the burn would through evaporation and capillary injury. Regular fluids infusions, monitoring electrolytes levels and monitoring input and output are the major nursing interventions.

Hypothermia is due to factors such as the presence of open wounds and loss of microcirculation around the skin. This is to maintain adequate body temperature. Less body temperature inactivate body enzymes thus inhibiting proper metabolic activities.

Acute pain is related to nerve and tissue injuries from the burn. This is to control pain and promote comfort.

Anxiety is related to factors such as fear and psychological impacts of the burn injury. Minimizing patient and family anxiety help to promote comfort and reduce stress factors.

  7.

• conclusions

The patient is suffering from small bowel obstruction. Possible intestinal loop shows obstruction, abdominal fullness, and possible fluid level are signs brought by obstructive intestine.

• Five specific assessment, why to do them and what they will tell you

Inspection- This includes visualization of the whole abdomen. The patient should be in supine position. Inspection helps to check any visible abnormality such as distention, breathing patterns and abnormal colorations. In small bowel obstruction, there could an increase in abdominal girth due to distention, dry skin, and bulges.

Auscultation- This is always done before percussion and palpation to prevent alterations of the bowel sounds. The bowel sounds are listened using the stethoscope in all four quadrants of the abdomen. In bowel obstruction there may be high pitched ticking sounds indicating normal bowel obstruction, hyperactive bowel sounds indicating an early intestinal obstruction or absent of bowel sounds showing late bowel obstruction.

Percussion-  The percussion is normally used to demonstrate sounds that give clues to the underlying problems. The results of percussion in intestinal obstruction is that there normally a resonance sound indicating the presence of fluids and gasses. Note the condition and movements of the patient during percussion to check for pain .

Palpation- Palpation allows one to assess for tenderness, moisture, texture masses, and temperatures.  In abdominal obstruction, the skin is dry with no moisture, there are palpable masses due to obstruction and tenderness can be experienced at the extended site or obstructed area.

Assess any signs of dehydration such as poor peripheral perfusion, hypotension and increase tachycardia. Dehydration is due to the fact that there is water unabsorbed in the bowel and vomiting. The patient is also unable to replace the lost water orally.  Pyrexia may indicate there is perforation of the bowel.

• Why max need a nasogastric tube

A nasogastric tube is inserted in patients with intestinal obstruction for initial decompression and suctioning of the gastrointestinal content and also for the purpose of preventing aspiration.  A continued nasogastric tube depresses chances of intraoperative compressions and also provides symptomatic relief thus benefiting the patient .  

• How to confirm the tube is in the correct place

To check if the tube is in place, one needs to attach a syringe to the free end. After attaching ensure no air is inserted. Aspirate a sample of gastric content. Test the pH of the aspirated content so that to ensure that the content is acidic. The pH should be tested using litmus paper of which it should be below a pH of 6. Obtain an x-ray to verify if the placement is in the correct placement before aspirating further.

• If this the aspirate to expect from nasogastric tube and why

This is the aspirate that is expected from the nasogastric tube. The gastric content visualizations and colors should be in most cases cloudy and green, tan, bloody or blown.  Intestinal fluids are normally yellowish due to the presence of bile.  In most frequently respiratory aspirate contains blood and thus the above fit to be gastric aspirate.

• parameters need to be monitored when the nasogastrictube is free on drainage and why

If one does not obtain the drainage or aspirates, the patient should be positioned to the left in order to move the gastric content to the greater curvature and then the aspiration should be repeated. If still the drainage cannot be seen, the tube should be advanced up to five centimeters, inject a 10cc air and auscultate air sounds with the stethoscope. In additional to that, an X-ray should be performed to ensure and confirm the tube is properly placed.

• medical orders for

Nutrition and hydration

Nil per oral until the obstruction is eradicated or treated.

Infusion of intravenous fluids like normal saline for hydration and 5% dextrose for nutritional purposes 

Administration of intravenous nutritional supplements such as vitamins and mineral elements

Elimination

The elimination of gastric content is through the nasogastric tube as the oral anal route cannot function. The nurse is to aspirate gastric content after a given period of time.

Monitor and record fluid input and output.

  8.When it is appropriate for focus assessment.

A focus assessment usually involves data collection of the problem that has already been identified. This type of nursing assessment normally covers a much less wide scope and takes a shorter time than the initial assessment. Nurses perform this type of assessment to determine whether the problem still exists and whether the problem status has changed. This includes checking for improvements, resolving the problems and checking if the problems are worsening or no. In addition to that, this assessment also checks appraisal of any new concern, overlook and check any misdiagnosis. Some clinical areas like intensive care units normally perform focus assessment from time to time. Focus assessment is usually performed when checking problems relating to one or two body systems where any presenting or current problem or concerns need to be addressed.