Need help with nursing interventions.

[duytschaver2010]

I am a first year nursing student struggling with nursing plans.

I have a patient who had a colon resection. We have to come up with 2 nursing diagnoses, 2 outcomes for each nursing diagnosis and 4 interventions for each outcome. The first one I have is Nursing Diagnosis:

1. Acute pain r/t tissue trauma associated with surgery AEB pt. states pain of 7 on 0-10 scale.
   

Goal: Pt. will be comfortable

Outcome #1

1. Patient will state pain of 2 or less on scale of 0-10 within 30 minutes of administering an analgesi.
   

Interventions for Outcome #1:

1. Administer analgesic with pain level of 2 or above on 0-10 scale.
   

R. Moderate to sever pain; extended release product for opioid-tolderant patients requiring around the clock management of persistent pain. (Vallenard, Sanoski, 2013)

2. Reassess pain within 30 minutes of administering analgesic.

R. to check if analgesic is working (Pasero et al, 2011b)

3. Assess patient overall level on 0-10 scale

R. to check if patient is having pain higher then stated comfort level ona valid and reliable self report pain tool. (McCaffery, Heir, and Pasero, 2011)

4. apply ice pack as needed.

R. The history will provide an understanding of what medications have been tried and were or were not effective in treating the patient's pain. (APS, 2008; Pasero et al, 2011b)

Evaluations:

1. Pt. states pain of 2 on 0-10 scale
   
2. pt. states pain level is 2 on 0-10 scale
   
3. Pt. states pain is 2 on 0-10 scake
   
4. Pt. gives list of home medications on admission
   

Outcome #2

2. Pt. will notify the nurse when pain level is 2 or higher on a scale of 0-10 on an ongoing basis.

Interventions for outcome #2:

1. Assess pain level on 0-10 scale ambulating or getting out of bed

R. Relationship between pain level and functional goals is a major focus on an individualized pain management. (McCaffery, Heir, and Psero, 2011)

2. Instruct pt of non-pharmacological relief including relaxing, distraction, and imagery.

R. Cognitive strategies can restore the client's sense of control, personal efficacy, and active participation in own care. (APS 2008, Bruckenthal, 2010)

3. Perform daily activities at the peak time the analgesic is considered.

R. Peak time is 15-30 minutes for IV nonopioids and opioids (Pasero et al, 2011b)

4. Ask pt. to report side effects such as nausea and pruritus, and to describe bowel elimination and ability to rest and sleep.

R. Opioids cause constipation by decresasing intestinal motility and reducing muscoal secretions. (Pachal, Muller-Schwefe & Wurzelmanm, 2007)

Evaluations:

1. Pt. states pain level of 2 when getting out of bed

2. Pt. states deep breathing and imagery help keep pain level at a 2.

3. Pt. states getting out of bed 15-30 minutes after receiving analgesic helped keep pain level at a 2.

4. Pt. states side effects of nausea from analgesic administration

Outcome # 1 was met: Pt. stated pain level of 2 on a 0-10 scale.

Outcome # 2 was met: Pt. notified nurse when pain level was a 7 and requested administration of pain medication.

The 2nd one has to be pscho-social. So I came up with this:

1. Knowledge deficit r/t patients lack of postoperative education AEB pt. not ambulating and not using incentive spirometer
   

Outcome #2:

1. Patient will use incentive spirometer Q2H while awake.
   

Interventions for outcome #2:

1. Teach pt. how to use incentive spirometer.

R. Teaching the use of the spirometer will decrease the likelihood of infectin. Mainintg a check on this will allow one to notice if his oxygen in the blood is decreased which could increase his risk for infection.

2. Evaluate patient's understanding through demonstrations and verbalizations.

R. Watch patient demonstrate use of spirometer to make sure she has the right understanding and know the correct way of using it. A demonstration back is more successful than providing information alone.

I am having trouble coming up with 2 more interventions. Can someone please help.

Thanks

[Kuriin, BSN, RN]

Try and think of something else for psychosocial. Your patient just had a resection of his or her colon. How would that make you feel? What makes you think this is knowledge deficit?

[Bedside_Life RN]

Try and think of something else for psychosocial. Your patient just had a resection of his or her colon. How would that make you feel? What makes you think this is knowledge deficit?

Although there are other critiques to your plan of care that could be worked on I wish I could like kuriin's comment x100. This can have huge impacts on the psychosocial aspects of this patient. This may be the biggest miss that nurses do not take into consideration. A good way to think about this is you don't realize the impact of having shob until you have experienced it. Kuriin has pointed you in a great direction that new nurses often do not take into consideration.

LIKE x1,000

[SeattleJess]

Hey, duytschaver2010, great question and kudos to you for the footwork.

I'm going to be starting nursing school in two weeks and I've been lurking around this pocket of AllNurses to learn. When I first read about "nursing diagnosis" in the text I bought as soon as my school gave us a book list, my head just reeled. I don't have any answer, just thanks for your question... and the answers that those who know are providing. I'll have my own question soon, I know.

[Esme12, ASN, BSN, RN]

YOu have done well! I agree what about the emotional side....why did the patient have a colon resection? How will this affect thier daily life? If it was a cancer diagnosis....how does this make them feel? All hospitalizations have impacts on a patients family and finances....think in that direction

[kbrn2002, ADN, RN]

You are off to a good start! As others have said, definitely look into the psycho-social aspects further. Fear on multiple fronts, worry about future health, worry about possible lifestyle changes, financial concerns are just a few you could delve into.

Also just something else to consider. Take a longer look at you pain interventions; there are many available besides use of pain medications. As a matter of fact medications are not always the preferred first response.

[chiandre]

You are off to a good start! As others have said, definitely look into the psycho-social aspects further. Fear on multiple fronts, worry about future health, worry about possible lifestyle changes, financial concerns are just a few you could delve into.

Also just something else to consider. Take a longer look at you pain interventions; there are many available besides use of pain medications. As a matter of fact medications are not always the preferred first response.

I agree with kbrn2002. Incorporate more Nurse-initiated interventions with the MD-Initiated interventions. You mentioned that the patient is not ambulating. As a nurse, how can you help the patient with ambulation? Think of resources available to you to help the patient with this problem.

[duytschaver2010]

Thank you everyone for your feedback. It really has opened up a new way to thinking about this!

[Esme12, ASN, BSN, RN]

You are welcome!