Acute pain related irritation secondary to Diverticulitis m/b pt score pain a “6” on a scale of 0-10, pt guarding abdomen with movements, and facial grimacing with place change.
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Pt will have decreased ache as evidence by pt score pain a 3 or less on a scale of 0-10, pt able to change position and transfer without and guarding of the stomach and facial grimacing by the end of the scientific day. Nursing Interventions
1. Obtain pts evaluation of ache to include location, traits, onset, length, frequency, high quality, depth.
Assess ache on a 0-10 pain scale every hour with rounding. Assess pts description of pain. Acknowledge the ache expertise and convey acceptance of pts response to pain.
2. Assess very important signs noting pulse and heart rate q4h. Monitor skin color and temperature, which are normally altered by acute pain.
3. Asses for referred ache, as appropriate.
4. Administer PRN pain treatment as per MD order (Hydrocodone/Tylenol 7.5/325 mg PO 3x daily). Assess ache on a 0-10 ache scale, administer medication if ache is 6 or above.
5. Assess pts acceptable stage of pain and pain management objectives. Teach pt to report pain earlier than it gets extreme (8/9 on a scale of 0-10).
6. Provide comfort measures (ie. Touch, repositioning, use of scorching or cold packs, nurse’s presence, quiet surroundings, and calm actions.
7. Evaluate and doc pts response to analgesia and help in transitioning or altering drug regimen, based on particular person needs and protocols.
8. Teach the pt ways to reduce ache, together with methods corresponding to therapeutic contact, biofeedback, self-hypnosis, and leisure abilities.
Provide individualized bodily therapy or train program that might be continued by the pt after discharge.
9. Teach affected person unwanted effects of the pain medication. (Hydrocodone/Tylenol 7.5/325 mg PO 3x daily).
1. Methods similar to visual analog scale or descriptive scales can be utilized to establish extent of ache. (Elselvierhealth.com) Identifying precipitating elements or aggravating and relieving components so as to totally understand pts pain signs. Experts agree that attempts ought to always be obtain self-reporting of pain. When that isn’t potential, credible info may be obtained from one other one that knows the consumer properly. Pain is a subjective expertise and cannot be felt by others (Doenges, 660).
2. Some individuals deny the expertise of ache when present. Attention to related important indicators could assist the nurse in evaluating pain
(Elsevlierhealth.com). Heart price, blood stress, and respirations are usually altered with acute pain (Doenges, 660).
3. Helps determine possibility of underlying condition or organ dysfunction requiring treatment (Doenges, 659).
4. Produces analgesia. Norco (Hydrocodone and acetaminophen) is indicated for the relief of moderate to moderately extreme ache (Davis 663). Administer analgesics, as indicated, to maximize dosage, as wanted, to take care of “acceptable” level of pain. Notify physician if routine is in adequate to meet pain management aim. Combinations of medicines could also be used on prescribed intervals (Doenges, 662).
5. Pts who request pain meds at more frequent intervals than prescribed may very well require larger doses or stronger analgesics (Elselvierhealth.com). One pt is in all probability not 100 percent ache free however might feel that a “3” is a manageable degree of discomfort, while one other may require treatment for pain on the identical degree, as a end result of the expertise is subjective (Doenges, 660).
6. This promotes non pharmacological ache management (Doenges, 661).
7. Increasing or lowering dosage, stepped program, helps in self-management of ache (Doenges, 662).
8. This promotes lively, somewhat than passive, role and enhances sense of self control (Doenges, 662).
9. By knowing and understanding the attainable side effects of this ache med, the pt will be ready to report any abnormal changes (S/S) to their PCP to forestall further illness. The following s/s must be addressed: confusion, dizziness, sedation, euphoria, hallucinations, headache, blurred vision, respiratory depression, hypotension, bradycardia, constipation, nausea, vomiting, sweating, urinary retention (Davis, 664).
Outcome was met by the end of medical day. Pt was still ranking ache “3 on a scale of 0-10.
No revisions must be made. Patient’s ache was relieved and tolerable.
Doenges, M (1992). Nurse’s Pocket Guide: diagnoses, prioritized interventions, and rationales, (13th ed.). Philadelphia: P.A. Davis Company.
Pain. November 5, 2013. Elselvier. Retrieved from http://www.us.elselvierhealth.com.
Vallerand, A. (2013). Davis’s drug guide for nurses, (13th ed.) Philiadelphia:P.A. Davis Company.