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Medical Diagnoses:Acute Pain related to cervical incision AEB patient reports pain at 7/10 on pain scale.


1. Acute pain related to surgical incision.

 

·         Patient 7 on pain scale

·         Patient unable to achieve comfort

·         Surgical incision on anterior portion of neck.

·         JP drain just below incision.

·         Pain meds given q 4 per physician order.

4. Anxiety related to overall health.

 

·         Patient has insomnia.

·         Patient HIV positive.

·         Patient has had breast/ovarian/thyroid cancer.

·         Educated patient on relaxation techniques.

·         Gave patient bath & back massage.

6. Impaired skin integrity related to surgical incision and JP drain.

 

·         Anterior neck incision @ C5-C6.

·         Steri strips & Wound Dressing.

JP drain removed – wound cleaned

2. Sleep deprivation related to acute pain and anxiety.

 

·         Patient having difficulty sleeping.

·         Patient misses her dog.

·         Patient wants to be home.

Patient has pain 7/10

61 African American Female  5’11” 

237 lbs.  BP 118/74  O2 97% Room Air

Temp 97.7 Oral   HR 56  RR 18

HIV, COPD, CAD, GERD, Anxiety, Asthma, (L) Breast, Ovarian & Thyroid Cancer.  Allery:  SULFA

Chief Complaint:  Pain and numbness in neck since thyroid surgery.

Admit Diagnosis:  C5-C6 Anterior cervical discectomy. 

Patient 7 on pain scale post op.  JP drain removed w/o complication.  Patient eating, drinking, and mobile.  Voiding toilet no BM at this time.

7. Deficit Knowledge related to pain management. 

 

·         Patient is afraid of becoming addicted to pain pills.

·         Patient on several medications due to other diseases/illness.

·         Educated patient on importance of pain control for healing vs. addiction wanting to be high.

3. Constipation related to surgery and decreased mobility.

 

·         Anesthesia can cause constipation.

·         Bed rest increases difficulty of BM.

·         Pain meds cause constipation.

·         Colace given to soften stool.

5. Stress overload related to chronic health issues.

 

·         Patient has HIV

·         Patient has COPD & CAD

·         Patient has history of cancer.

8. Impaired Physical Mobility related to disc surgery.

 

·         Surgical incision anterior neck @ C5-C6.

·         C5-C6 Spinal Fusion.

·         Pain as reported by patient,.

·         Pain meds q4 as ordered by physician.



NANDA Diagnostic Statement: Acute Pain related to cervical incision AEB patient reports pain at 7/10 on pain scale.

Behavioral Outcome / Goal: Patient will have pain level of 4 or less by end of shift and follow medication regimen ordered by physician.

Nursing Interventions:

 

·        Assess pain severity on scale of 1-10 every hour by asking patient.

 

·        Monitor vital signs.

 

·        Offer and encourage pain medications per physician order.

 

·        Give client a bath and provide fresh linens to help her relax and relieve anxiety.

 

·        Observe non- verbal cues to assess pain and anxiety level.

 

·        Educate and have patient demonstrate relaxation techniques.

Rationale:

 

·         Initial assessment provides baseline & comparison.

 

·         Usually altered in acute pain.

 

·        Meds will help alleviate pain and provide comfort.

 

·        Bathing and gentle massage can help pain mgt. provide relaxation & reduce anxiety.

·        How patient sits, holds body or facial expression can reveal a lot about how a patient feels.

·        Will help to relieve tension, reduce anxiety and pain level.


Client Response:

·         States pain is 7.

 

·         97.7 temp, HR 56, RR 18 BP118/74, O2 97% room air.

 

·        After pain meds patient stated pain was 5.

 

·        After bath, lotion, clean pj’s and clean bed linen patient stated pain level was 3-4 and felt great.

 

·        After bath patient appeared much happier and more relaxed.

·        Patient listened about relaxation & watched TV, made phone calls for distraction.

Summarize impressions of client progress toward outcomes / problem resolution:  Patient states that pain level was a 4 at the end of my shift at 2.  She was doing so well Dr. discharged her 1 day early.  JP drain removed and assisted MD with dressing change.  Client ate breakfast and lunch and was mobile and alert and oriented x3.  Patient was in much better spirits after her bath and conversing with her for a time, 2 doses of pain medicine and a visit from her grand child.  Client was extremely grateful for her care and was discharged home with prescription for pain medication, incision care instructions and follow up appointment with Dr.

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