Rationales for Interventions

Esme12, ASN, BSN, RN · Sep 30, 2012

Welcome to AN! The largest online community!

http://www.bhj.org/journal/2000_4202_apr00/sp_359.htm

Well refer to a pain assessment tool for the facial grimace.......

http://www.southwestspineandpain.com/how-accurate-is-the-1-to-10-pain-scale/

CT Pixie, BSN, RN · Sep 30, 2012

#1 Acute pain. I have two interventions - assess for abdominal guarding during movement/transfer... and assess for facial grimace during movement/transfer. I can't for the life of me find a rationale in my book for this. Any suggestions on which section to look?
#2. Impaired skin integrity - Intervention - Assess colostomy site for patency and signs of infection. I have looked all over ( I think..its a blurr right now) and can't find a rationale. I have looked in the surgical chapter, GI disorders chapter. I know we talked about checking for that and why.. and why to check for wet skin and how it causes breakdown but I can not find it.
Again, thank you again for any advice.
Good night. Will be checking this tomorrow!

For the acute pain, I don't think that's really TWO interventions Facial grimacing and guarding are both non-verbal cues to pain. The rationale for assessing for non-verbal cues to pain....well, some people are very stoic and will not verbally indicate pain for fear of looking weak, needy, etc. But they very well could be in a great deal of pain. Generally people verbalizing no pain would not grimace, guard the painful site. The people verbally denying pain may show non-verbal cues that you can observe.

For the skin integrity..not only is the colostomy skin area possibly having moist skin..but think about the caustic actions of what is causing that skin to be moist..what is coming out of that stoma? *wink*

comrlg · Sep 30, 2012

For the acute pain, I don't think that's really TWO interventions Facial grimacing and guarding are both non-verbal cues to pain. The rationale for assessing for non-verbal cues to pain....well, some people are very stoic and will not verbally indicate pain for fear of looking weak, needy, etc. But they very well could be in a great deal of pain. Generally people verbalizing no pain would not grimace, guard the painful site. The people verbally denying pain may show non-verbal cues that you can observe.
For the skin integrity..not only is the colostomy skin area possibly having moist skin..but think about the caustic actions of what is causing that skin to be moist..what is coming out of that stoma? *wink*

I appreciate the feedback. I myself know the reasons for these interventions..and I have those two separate because I have no other evidences :) The problem I am having though, is that I MUST cite our textbook for the rationales, and I can't find it anywhere. I can find plenty that tell me that I need to do those interventions, but nothing explaining why. I was just hoping for some direction as to WHERE to possibly look in my book..i.e. Integumentary system (which i have done) , the Gi chapter, etc.....

CT Pixie, BSN, RN · Sep 30, 2012

I would say the GI chapter should have colostomy info and possible the rational for skin integrity issues with a colostomy. Can you site a NANDA book? They have rationales for the interventions.

comrlg · Sep 30, 2012

I would say the GI chapter should have colostomy info and possible the rational for skin integrity issues with a colostomy. Can you site a NANDA book? They have rationales for the interventions.

No, can't site nanda book only our text. I have looked in both chapters and more, just at a loss right now. That's the only thing i am missing..aaarrgghh

CT Pixie, BSN, RN · Sep 30, 2012

Well thats no bueno! Sorry, other than GI and Integ I don't know where you'd find the rationale in your book.

Esme12, ASN, BSN, RN · Sep 30, 2012

Again look for using the pain scales as your evidence like the FLACC scale my care plan book give a ton of references

NANDA-Definition Ackley: Nursing Diagnosis Handbook, 9th Edition
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 1979); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.
Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968; APS, 2008)
Defining Characteristics
Subjective
Pain is a subjective experience, and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity (APS, 2008). A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain level and establish a comfort-function goal (Pasero, 2009a; Puntillo et al, 2009).
Objective:
Pain is a subjective experience, and objective measurement is impossible (APS, 2008; Breivik et al, 2008). If a client cannot provide a self-report, there is no pain intensity level (Pasero & McCaffery, 2005). Behavioral or physiological responses should never serve as the basis for pain management decisions if self-report is possible (Pasero & McCaffery, 2005; Herr et al, 2006; Erstad et al, 2009). However, observation of these responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report (Herr et al, 2006; Bjoro & Herr, 2008). 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 (Puntillo et al, 2009). Acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate (Dunwoody et al, 2008; Polomano, Rathmell et al, 2008). 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 medications (Herr et al, 2006). Behavioral or physiologic indicators may be used to confirm other findings; however, the absence of these indicators does not indicate the absence of pain.

Look in your surgical reference book for your colostomy.