You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 71-year-old man who underwent a surgical repair of a right sided fractured femur.
QUESTION
You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 71-year-old man who underwent a surgical repair of a right sided fractured femur. As you receive report from the postanesthesia recovery unit, you learn that his medical history includes hypertension, 40 year history of smoking (1 pack per day), and COPD. His surgical repair was successful but complicated by excessive bleeding, and he is receiving IV fluids to compensate. His current VS include: BP 92/55, HR 117, RR 20, temperature 100.7 degrees F, SpO2 sat 99% on 2L O2 per nasal cannula. The patient rates his right leg pain at an 8/10 on the pain rating scale. The patient does have morphine and Norco ordered prn for pain. He is widowed, and his three children are scattered throughout the United States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his home clean. The patient was told that he would need to go to acute rehab for about 1-2 weeks following surgery, and the patient is refusing to go.
Write out the patient’s objective & subjective findings that are provided from the case study.
Subjective:
Objective:
Come up with 2 nursing diagnoses for this patient – write out “r/t” and “AEB” statements for each, the best you can.
Determine which nursing diagnosis is your top priority for this patient.
For your top rated nursing diagnosis, come up with 1 patient outcome. Make sure this is written utilizing the SMART acronym.
For your identified patient outcome, write out 3 nursing interventions that you would implement to help the patient achieve their goal.
ANSWER
“Managing Acute Pain Following Surgical Repair: A Comprehensive Nursing Approach”
Subjective
Patient rates right leg pain at 8/10 on the pain rating scale.
Patient is refusing to go to acute rehab.
Objective
Surgical repair of right-sided fractured femur.
Complication of excessive bleeding.
Receiving IV fluids.
Vital signs: BP 92/55, HR 117, RR 20, temperature 100.7 degrees F, SpO2 sat 99% on 2L O2 per nasal cannula.
Medical history includes hypertension, 40-year history of smoking (1 pack per day), and COPD.
Lives alone and receives Meals on Wheels.
Has a cleaning service for his home.
Three children scattered throughout the United States.
Nursing Diagnoses
Acute Pain r/t surgical repair of fractured femur AEB patient’s self-report of right leg pain at 8/10 on the pain rating scale.
Anxiety r/t refusal to go to acute rehab AEB patient’s refusal to comply with healthcare team’s recommendation for post-surgical care.
Priority Nursing Diagnosis: The priority nursing diagnosis for this patient is Acute Pain r/t surgical repair of fractured femur (Momodu, 2023).
Patient Outcome: By the end of the shift, the patient will report a pain rating of 4/10 or lower on the pain rating scale when assessed.
Nursing Interventions
Assess pain level regularly: Monitor the patient’s pain level at regular intervals, using a pain rating scale or numerical rating scale (Wells, 2008). This will help to determine the effectiveness of pain management interventions and ensure timely adjustment of pain medications.
Administer pain medication as prescribed: Administer the prescribed analgesics (morphine and Norco) to manage the patient’s pain (Anekar, 2023). Evaluate the effectiveness of the medication and document the patient’s response.
Implement non-pharmacological pain management techniques: Assist the patient in using non-pharmacological pain management techniques such as guided imagery, deep breathing exercises, or distraction techniques . These interventions can help to reduce pain perception and provide additional pain relief.
By implementing these nursing interventions, the patient’s pain can be effectively managed, promoting comfort and facilitating his recovery. Regular pain assessments and appropriate pain management will contribute to the achievement of the desired outcome of the patient reporting a pain rating of 4/10 or lower.
References
Anekar, A. A. (2023, April 23). WHO Analgesic Ladder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK554435/
Momodu, I. I. (2023, May 31). Osteomyelitis (Nursing). StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568766/
Wells, N. (2008, April 1). Improving the Quality of Care Through Pain Assessment and Management. Patient Safety and Quality – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK2658/
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