Acute pain related inflammation secondary to Diverticulitis m/b pt rating pain a “6” on a scale of 0-10, pt guarding abdomen with movements, and facial grimacing with position change.
Pt will have decreased pain as evidence by pt rating pain a 3 or less on a scale of 0-10, pt able to change position and move without and guarding of the abdomen and facial grimacing by the end of the clinical day. Nursing Interventions
1. Obtain pts assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity. Assess pain on a 0-10 pain scale every hour with rounding. Assess pts description of pain. Acknowledge the pain experience and convey acceptance of pts response to pain.
2. Assess vital signs noting pulse and heart rate q4h. Monitor skin color and temperature, which are usually altered by acute pain.
3. Asses for referred pain, as appropriate.
4. Administer PRN pain medication as per MD order (Hydrocodone/Tylenol 7.5/325 mg PO 3x daily). Assess pain on a 0-10 pain scale, administer medication if pain is 6 or above.
5. Assess pts acceptable level of pain and pain control goals. Teach pt to report pain before it gets severe (8/9 on a scale of 0-10).
6. Provide comfort measures (ie. Touch, repositioning, use of hot or cold packs, nurse’s presence, quiet environment, and calm activities.
7. Evaluate and document pts response to analgesia and assist in transitioning or altering drug regimen, based on individual needs and protocols.
8. Teach the pt ways to lessen pain, including techniques such as therapeutic touch, biofeedback, self-hypnosis, and relaxation skills. Provide individualized physical therapy or exercise program that can be continued by the pt after discharge.
9. Teach patient side effects of the pain medication. (Hydrocodone/Tylenol 7.5/325 mg PO 3x daily).
1. Methods such as visual analog scale or descriptive scales can be used to identify extent of pain. (Elselvierhealth.com) Identifying precipitating factors or aggravating and relieving factors in order to fully understand pts pain symptoms. Experts agree that attempts should always be obtain self-reporting of pain. When that is not possible, credible information can be received from another person who knows the client well. Pain is a subjective experience and cannot be felt by others (Doenges, 660).
2. Some people deny the experience of pain when present. Attention to associated vital signs may help the nurse in evaluating pain
(Elsevlierhealth.com). Heart rate, blood pressure, 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 severe pain (Davis 663). Administer analgesics, as indicated, to maximize dosage, as needed, to maintain “acceptable” level of pain. Notify physician if regimen is in adequate to meet pain control goal. Combinations of medications may be used on prescribed intervals (Doenges, 662).
5. Pts who request pain meds at more frequent intervals than prescribed may actually require higher doses or more potent analgesics (Elselvierhealth.com). One pt may not be 100% pain free but may feel that a “3” is a manageable level of discomfort, while another may require medication for pain at the same level, because the experience is subjective (Doenges, 660).
6. This promotes non pharmacological pain management (Doenges, 661).
7. Increasing or decreasing dosage, stepped program, helps in self-management of pain (Doenges, 662).
8. This promotes active, rather than passive, role and enhances sense of self control (Doenges, 662).
9. By knowing and understanding the possible side effects of this pain med, the pt will be able to report any abnormal changes (S/S) to their PCP to prevent further illness. The following s/s should 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 clinical day. Pt was still rating pain “3 on a scale of 0-10.
No revisions need to be made. Patient’s pain 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.