1.  Acute Pain related to surgical incision.

·         Patient 10 on pain scale.

·         Patient unable to achieve comfort.

·         Surgical incision on lumbar spine.

·         Pain meds given q4 per physician order.

4.  Impaired physical mobility related to lumbar surgery.

·         Surgical incision L4-L5.

·         Pain as reported by patient.

·         Pain meds q4 as ordered by physician.

6.  Risk for imbalanced fluid volume related to decreased kidney function.

·         Patient on hemodialysis every other day.

·         Patient has abnormal BUN and Cr levels.

2.  Sleep deprivation related to acute pain.

·         Patient having difficulty sleeping.

·         Patient has pain 10/10.

·         Patient restless.

56 African American Female 173 cm 83.9 kg  BP 140/81  O2 98% Room Air

Temp 96.8 Oral  HR 63  RR 20

End Stage Renal Disease, GERD, COPD, Hypertension, Chronic Anemia, Sinus Bradycardia  Allergy:  LATEX

Chief Complaint:  All over pain and numbness in lower extremities.

Admit Diagnosis:  I&D L4-L5 and Back Pain.

Patient 10 on pain scale.  Incision healing well with no sign of infection.  Patient eating, drinking, urination/BM in bed pan

7.  Risk for infection related to surgical incision.

·         Lumbar spine incision L4-L5.

·         Patient has been in hospital for 4 weeks.

·         Patient confined to bed.

3.  Impaired skin integrity related to surgical incision.

·         Lumbar spine incision L4-L5.

·         Steri strips

5.  Noncompliance related to patient unwillingness to cooperate with care.

·         Will not allow MD requested testing.

·         Will not follow instructions for pain management.

8.  Risk for falls related to surgery and lower extremity weakness.

·         Lumbar spine incision L4-L5.

·         Patients lower extremities weak and painful.

·         Patient can’t walk without assistance.

Nursing Interventions:

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

·         Monitor vital signs

·         Provide medications per physician order

·         Reposition and elevate leg to help provide comfort.

·         Give patient a bath and provide fresh linens to help her relax and provide comfort.

·         Observe non-verbal cues to assess pain.

Rationale:

·         Initial assessment provides baseline & comparison.

·         Usually altered in acute pain.

·         Meds will help alleviate pain and provide comfort.

·         Elevation helps with swelling and provides pain relief.

·         Bathing can help pain mgt and provide relaxation.

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

Client Response:

·         Client states pain is 10.

·         BP 140/81, Temp 96.8, HR 63, 98% O2 on Room air, RR 20

·         After pain meds patient states pain was an 8.

·         After repositioning and elevation patient stated she felt better.

·         After bath patient stated pain was 7

·          

·          After bath patient appeared happier and was more compliant and thanked me for helping her.

Summarize impressions of client progress toward outcomes / problem resolution:  Patient stated that pain was 7 at the end of shift but did not appear to be in severe pain.  She had good ROM and when husband came to visit never complained of pain.  Patient is definitely ill and has a lot going on that can cause pain therefore monitoring her closely is going to be key as she complains so much that real problems may be missed.  Her incision appears free of infection and is healing well.  She appears to be weak in both lower extremities and I would request PT evaluation to help with mobility issues.