Care plan suggestions needed, please

Esme12, ASN, BSN, RN · Jun 18, 2012

does he really understand? is the hand squeezing reflexive? once he squeezes your hand...will he let go on command.

if not his hand grasp my be reflexive and not indicative of a response. utilizing a family member is called surrogate reporting of pain and behavioral/activity changes as they know the patient well.

since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/or unconscious may not be able to provide a self-report. individuals who cannot communicate their pain remain a challenge and are at even greater risk for inadequate pain control.

when patients cannot self-report, other measures need to be used to detect pain. even if they cannot speak for themselves, these patients have the right for pain assessment and management. valid and reliable methods to assess pain in nonverbal patients are clearly needed. the american society for pain management recommends the following multifaceted approach for consideration in detecting pain in this population.

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[td][color=#0079b5]1.

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[td]use the hierarchy of importance of measures of pain intensity for nonverbal patients

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[td][color=#0079b5]a.

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[td]self-report of pain is the most reliable way to assess pain.

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[td][color=#0079b5]i.

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[td]although self-report may be possible with mild to moderate cognitive impairment, as dementia progresses, the ability to self-report decreases and eventually becomes impossible. however, even if patients cannot communicate the experience of pain, they still experience pain sensation.

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[td=width: 67][color=#0079b5]ii.

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[td]obtaining a report of pain from a critically ill patient may be hampered by such conditions as delirium, decreased level of consciousness, presence of an endotracheal tube, sedatives, and neuromuscular blocking agents, for example. in these situations, the patient’s ability to self-report may wax and wane; therefore, serial assessment for the ability to self-report should be conducted.

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[td]search for potential causes of pain.

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[td][color=#0079b5]i.

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[td]assume pain is present and intervene with common problems or procedures known to cause pain (e.g., surgery, wound care, positioning), even in the absence of behavioral indicators of pain.

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[td=width: 67][color=#0079b5]ii.

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[td]rule out or treat other problems that may cause discomfort (e.g., infection, constipation, urinary retention)

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[td=width: 67][color=#0079b5]iii.

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[td]consider chronic pain causes that may have been present before (e.g. history of arthritis or low back pain).

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[td]observe patient behaviors – a valid approach only when self-report is absent. the american geriatrics society identifies the following six main types of pain behaviors: (1) facial expressions (grimacing, e.g.), (2) verbalizations or vocalizations (moaning, e.g.), (3) body movements like tense body posture, (4) changes in interpersonal interactions (aggression or resisting care, e.g.), changes in activity patterns (refusing food or increased wandering, e.g.), and (6) mental status changes like crying or increased confusion.

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[td=width: 35][color=#0079b5]d.

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[td]encourage proxy pain rating by family members or care-givers who know the patient when patients are unable to provide self-reports of pain. inquire about behaviors that may indicate pain or whether preexisting conditions that may cause pain, such as arthritis, are present.

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[td=width: 35][color=#0079b5]e.

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[td]attempt an analgesic trial with procedures or conditions that are likely to cause pain or when pain behaviors continue after attention to basic needs and comfort measures. make appropriate adjustments such as increases in dose or addition of other analgesics if behaviors indicative of pain persist, or additional potentially painful procedures occur.

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[td][color=#0079b5]2.

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[td]establish a procedure for pain assessment

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[td]when patients are unable to self-report pain, other less reliable measures must be used to identify its existence. these assessment measures (described above) form a hierarchy, arranged in order of probable importance. healthcare facilities should institute a procedure for the use of this hierarchy of assessment techniques as a template for the initial assessment and treatment procedure.

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[td=width: 15][color=#0079b5]3.

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[td]use behavioral pain assessment tools, as appropriate

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[td]the number of studies addressing assessment of pain in nonverbal adults who cannot provide a self-report has increased recently. further study is required, though, to demonstrate their reliability, validity, and usefulness in the clinical setting. when utilizing behavioral pain assessment tools, one must keep in mind the following considerations:

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[td]scores obtained when utilizing behavioral pain assessment tools are not equivalent to self-reported intensity ratings and should never be documented as such. only self-reported intensity ratings may be documented as the “5th vital sign”.

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[td=width: 35][color=#0079b5]b.

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[td]pain behaviors may not indicate pain, but another source of distress, such as emotional distress.

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[td=width: 35][color=#0079b5]c.

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[td]it is best to observe a patient during care activities when pain behavior is more likely, rather than at rest.

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[td=width: 35][color=#0079b5]d.

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[td]behavioral assessment tools may be helpful to identify the presence of pain. they also can be used to evaluate attempts to relieve pain by observing for a decrease in pain behaviors following intervention.

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[td]at least 14 behavioral assessment tools have been developed to assess for pain in nonverbal patients with dementia. these tools are in varying stages of development and validation. when selecting a tool, choose one that has been researched for reliability and validity in a similar clinical setting. behavioral assessment tools for the cognitively impaired are of two types: pain behavior scales and pain behavior checklists.

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[td]pain behavior scales are scored by identifying the degree of an observed behavior. this score is not the same as a pain intensity score. an example of a pain behavior scale is the pain assessment in advance dementia scale (painad). it evaluates and scores five categories of behavior: breathing, negative vocalization, facial expression, body language, and consolability. each category may receive a score ranging from 0 to 2. any positive score may indicate that pain is present and the score can be used to evaluate intervention, but cannot be interpreted to mean pain intensity. for a pain behavior scale to be used, the patient needs to be able to respond in all categories of behavior. for example, the painad should not be used with a patient who is a quadriplegic, since body language could not be scored.

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[td=width: 134][color=#0079b5]2.

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[td]behavior checklists differ from pain behavior scales. they do not evaluate the degree of an observed behavior, but just its presence or absence, and do not require a patient to demonstrate all of the behaviors specified. an example of a pain behavior checklist is the pain assessment checklist for seniors with limited ability to communicate (pacslac). this checklist evaluates 60 behaviors such as restlessness, agitation, decreased activity, and appetite changes. the total number of behaviors that a pain exhibits cannot be equated with a pain intensity score. a patient who scores 5 out of 60 behaviors does not necessarily have less pain than a patient who scores 10 out of 60. in an individual patient, though, a change in the total number of behaviors may suggest more or less pain and can be used to evaluate response to interventions.

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[td]tools developed to assess pain with mechanically ventilated and/or unconscious patients are fewer in number. one such tool – the adult nonverbal pain scale (nvps) – was patterned after the faces, legs, activity, cry, consolability observation tool (flacc) used to assess pain in infants and children. when tools are adapted and used in different settings, they need to be tested for reliability and validity in the new patient population. the nvps was tested in the burn trauma unit at strong memorial hospital, rochester, new york. after initial testing, further revision was made to include a respiratory component with ventilator compliance. this revised scale, which scores the categories of facial expression, activity, guarding, physiology (vital signs), and compliance with ventilator, is currently being implemented in several health-care institutions while undergoing further testing.

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[td]minimize emphasis on physiologic indicators

research does not support the use of vital sign changes for identifying pain. absence of an increase in blood pressure, respiratory rate, or heart rate does not indicate absence of pain.

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[td=width: 15][color=#0079b5]5.

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[td]reassess and document

just as with patients who self-report pain, reassessment of pain with non-verbal patients needs to occur after intervention and regularly over time. reassessment should occur utilizing the same initial behavioral pain assessment tool and observing for changes in those behaviors with effective treatment. nonverbal patients – a special population

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hopefully this will help you help you come up with ideas.

nurseprnRN, BSN, RN · Jun 18, 2012

Maybe I missed something, but your nursing dx has to do with decreased oxygenation because he has pneumonia. Where does pain and responsiveness come in here? Is there a separate set of facts supporting a pain dx? What are they?

You don't have ABGs, you have a peripheral O2 sat, btw.

tinyRN72, BSN · Jun 19, 2012

Thank you very much, Esme12, this did give me some great ideas.. he has two huge pressure ulcers and definitely shows guarding, rigidity, and moaned when we did dressing changes. This is great for my second diagnosis, I will have to think for more than two seconds on the first one again.

Thank you for your help.

tinyRN72, BSN · Jun 19, 2012

grntea[color=#1750ff],

[color=#1750ff]the information about pain assessment helped a lot for my other nursing diagnosis (which i had not mentioned). :)

[color=#1750ff]you are correct, i am trying to come up with subjective data for the nursing diagnosis:impaired gas exchange related to decreased ventilation secondary to aspiration pneumonia as evidenced by abgs outside of normal limits.

[color=#1750ff]he has dementia and has suffered a cva, so i don't think i can use decreased mental status. he does seem to be anxious at times, so i put that down. i hate to turn it in with only one thing in that column.

also, i do have the abg levels, i just didn't list them all here. thanks for your response. if you have any ideas which might apply to respiratory distress, please let me know.

as for this poor man. the day after my clinical, he ended up being sent to icu and put on a vent. he progressed to ards. however, i have to write the nursing care plan based on my day with him.

nurseprnRN, BSN, RN · Jun 19, 2012

'*you are correct, i am trying to come up with subjective data for the nursing diagnosis:impaired gas exchange related to decreased ventilation secondary to aspiration pneumonia as evidenced by abgs outside of normal limits.*'

subjective data would be things like when you listen to his chest you hear (or don't hear)..., whether or not he has an effective cough, seems to be aspirating (wet voice/vocalizations, i know he is nonverbal d/t cva), chest xray findings...

poor old guy. pray that his suffering ends soon.

Esme12, ASN, BSN, RN · Jun 19, 2012

Maybe I missed something, but your nursing dx has to do with decreased oxygenation because he has pneumonia. Where does pain and responsiveness come in here? Is there a separate set of facts supporting a pain dx? What are they?
You don't have ABGs, you have a peripheral O2 sat, btw.

Just using this to show how non verbal patient have subjective data

tinyRN72, BSN · Jun 19, 2012

OH, thank you, I was only thinking of things he could directly communicate to me as being subjective.

Esme12, ASN, BSN, RN · Jun 19, 2012

Some other thoughts....

Disturbed thought processes related to brain damage, confusion, or inability to follow instructions

Impaired verbal communication related to brain damage

Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility

Interrupted family processes related to catastrophic illness and caregiving burdens