Need help with first nursing care plan - (pain)

firefly101 · Oct 16, 2012

i have Ackley's 9th ed NANDA book. in the acute pain section, under r/t is states injury and agents but does not include infection. and even though it is pretty obvious that he has an infection, he has not been diagnosed with one, and i cannot diagnose him with one or include it in a nursing diagnosis, though i could put "risk for infection" ..

what about:

risk for infection r/t ineffective health maintenance (i could teach the pt how to recognize signs of infection, how to take better care of himself (i could include diet and fluid intake here), teach why its important not to wait until he is in agonizing pain before coming into the doctors office) but then i can't tackle the pain issue that is going on NOW

OR

acute pain r/t pathological process (im not sure if i can use that..this is actually stated in an alphabetized listing in the beginning of the book (but when i go to the full section on acute pain it is not listed), but what can i do for him here if he doesn't have a medical diagnosis? i feel like there are few things i can do for him if i focus on pain since i dont know the direct cause)

am i getting any closer?

i can only pick 1 diagnosis ...

firefly101 · Oct 17, 2012

Mr. Jason Jackson is an 80 y.o. male widower who was admitted into your medical-surgical unit this morning. He has been complaining of pain in his right lower quadrant of his abdomen. Mr. Jackson states to you, "I have a sharp pain in my side that doesn't seem to go away. When I walked up the stairs, it really hurt me." When you asked how he rated his pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing and he hunches over while he walks around the room. He also guards his right side with his hands. You note that his general appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." You auscultate his lungs and they were clear throughout bilaterally. You took his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. He told you he doesn't normally run that high with his pulse, BP, and temperature. During his last void, he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself. He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance with his Medicare plan. Mr. Jackson said he has two children, but they live far away. His daughter Gloria lives in Florida and his son Chuck lives in Washington D.C.

acute pain r/t inflammation of tissues

- is that an appropriate diagnosis for this case?

and then AEB: increased TPR, increased BP, complaints and signs of pain

Esme12, ASN, BSN, RN · Oct 17, 2012

Mr. Jason Jackson is an 80 y.o. male widower who was admitted into your medical-surgical unit this morning. He has been complaining of pain in his right lower quadrant of his abdomen. Mr. Jackson states to you, "I have a sharp pain in my side that doesn't seem to go away. When I walked up the stairs, it really hurt me." When you asked how he rated his pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing and he hunches over while he walks around the room. He also guards his right side with his hands. You note that his general appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." You auscultate his lungs and they were clear throughout bilaterally. You took his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. He told you he doesn't normally run that high with his pulse, BP, and temperature. During his last void, he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself. He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance with his Medicare plan. Mr. Jackson said he has two children, but they live far away. His daughter Gloria lives in Florida and his son Chuck lives in Washington D.C.

acute pain r/t inflammation of tissues

- is that an appropriate diagnosis for this case?

and then AEB: increased TPR, increased BP, complaints and signs of pain

Yes it does......Related Factors (r/t): Injury, agents (biological, chemical, physical, psychological)

Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs; demonstrate pain-related behaviors such as guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity.

Acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate.

However, physiological responses are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathologic conditions, hemostatic changes, or medication, .

Behavioral or physiologic indicators may be used to confirm other findings; however, the absence of these indicators does not indicate the absence of pain.

The patient has .....

acute pain R/T severe RLQ abdominal pain AEB facial grimacing, guarding of right side, B/P 155/96; P-105; R-24, patient states complaints of pain "was a 9/10"

The temp is an indicator of infection...not the pain.

firefly101 · Oct 17, 2012

for a nursing diagnosis could we put: acute pain r/t stimulation of pain receptors in the LRQ of the abdomen ?? (my group insists on wording it this way because its how our dx was worded in the example we did in class last week).

ive been hearing other students share what their diagnoses for this case.... like acute pain r/t malnutrition, (or even labeling it chronic pain, saying that the malnutrition and poor diet are causing his pain. and then their interventions involve changing his lifestyle and somehow getting family support). hearing all of these diagnoses are really throwing me off. . . for my interventions and goals for this dx, i cannot use changing lifestyle/ educating pt about dietary choices/ ect because it is not relevant to the diagnosis, correct? also, the reason i cannot put acute pain r/t inflammation is because that is assuming infection, which i cannot do, right? (i'm trying to get a full understanding of why these other diagnoses don't work...)

i need 1 long term and 2 short term goals. for short term, i would want the patient to express that his pain is a 2/10 by time of discharge (or since pain perception differs from person to person, should i word it "patient expresses that pain no longer interferes with ADLs" - such as walking up the stairs). i could also have the patient identify the adverse effects of unrelieved pain by the time of discharge.

so my interventions (need 2 per goal) would be

1. nurse will aid in non-pharmacological interventions to manage pain, such as re-positioning & teach relaxation techniques

(could i also put: nurse will inquire about pharmacological interventions with health care provider? or nurse will obtain a prescription to administer opioid analgesic?)

(or, nurse will frequently reassess pain lvls?)

2. describe the adverse effects of unrelieved pain (EBN: unrelieved acute pain can have physiological and psychological consequences that facilitate negative client outcomes ...)

(unsure about a second at the moment... my goal is very specific... but i'm sure i could find something in the NANDA or my textbook...)

for a long term goal could i want to get family involvement (like have his children check up on him once a week or something, or even refer him to a service/ social worker that could check up on him, to make sure he doesn't allow himself to get this sick again before going into the doctor's office...) though i'm not sure how to word it or cite it. i'm not finding much relevance in my NANDA book...

Esme12, ASN, BSN, RN · Oct 17, 2012

As a nurse there are certain symptoms that you can surmise are something specific. I am not in your class, nor your instructor.......but in the case of this scenario this patient has an acute process (abd pain, guarding, grimacing).....complicated by infection. There are certain hallmark features of this scenario that would make the assumption that an infectious process in acute and current......the Temp of 102. Pain does not cause a temperature nor does dehydration cause a temperature of 102.

This patient has not been eating because he is sick with an infectious process located in the abdomen that will kill him with sepsis if left untreated and if there is no intervention. The mentioning of the canned/frozen food may be a symptom of depression/isolation but is important in this scenario because it has added to his dehydration/fluid balance/intake.

This patient did not "allow" himself to get sick......but he does need social service intervention to educate him and obtain for him financial services to assist him with his bills and the nurse to educate him that fear of bills should not delay his seeking health care....something that can be assisted by his family checking on him.

Your goals can be pain relief and return to independent living to pre-illness level. Use of alternative pain techniques are good, administration of analgesics are good, to self report relief, etc.

I would not allow other students to influence your line of thinking for they may not be right. This patient scenario, vital signs, and complaints are an acute process. Patient symptoms can allow the nurse to make certain assumptions about a disease process so she can anticipate care and advocate the patients well being.....you don't need a medical diagnosis to make these assumptions.

The patient assessment drives the care plan "LOOK" at this patient. He is flushed diaphoretic doubled over in pain he states the pain is 9/10. He is hypertensive (pain fever) tachycardic (pain, fever) and febrile his appetite is poor from the pain , illness.

firefly101 · Oct 18, 2012

just wanted to say thank you again for helping me! hopefully i won't struggle as much with the next care plan, haha

Esme12, ASN, BSN, RN · Oct 18, 2012

You are welcome.....I am to help!