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Medical Diagnoses:Acute Pain related to injury to femur and wrist, constipation, sleep deprivation and decreased kidney function


1.  Acute Pain related to injury to femur and wrist.

 

·         Patient 8/10 on pain scale

·         Patient is guarded

·         Patient grimaces anytime injured limbs are moved.

4.  Constipation related to immobility and pain medication.

 

·         Patient has not had BM in 2 days.

·         Bed rest increases constipation.

·         Pain medications cause constipation.

6.  Risk for Falls as related to injury caused by fall.

 

·         Altered mobility due to femur injury.

·         Pain medications.

·         Obesity and age

2.  Sleep deprivation related to acute pain.

 

·         Patient can’t get comfortable in order to sleep.

·         Patient 8/10 on pain scale.

·         Patient normally belly sleeper and can’t due to injury

78 Caucasian Female 5’7”  250 lbs

BP 117/50 MAP 66  HR 56  RR 18

92% O2 Room Air  Temp 97.6 oral

Chronic Renal Failure, Hypertension, Hemodialysis every other day.

No Known Allergies  Bilateral TKR, Hysterectomy and Appendectomy

Chief Complaint:  Became disoriented and fell pain in R rib cage, R femur and L wrist.

Admit Dx:  R Femur Fx and L Wrist Fx

Patient 8/10 on pain scale, some nausea, vomiting.  Possible Surgery .

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

 

·         Patient on hemodialysis every other day.

·         Patient has abnormal BUN and Cr levels.

3.  Impaired physical mobility related to injury from fall.

 

·         Broken R femur

·         Pain and reported by patient.

·         Pain meds as ordered by physician

5.  Deficient Knowledge related to pain management.

 

·         Patient is reluctant to take prescribed pain medication.

·         Patient is concerned about how she feels while on pain medication.

·         Patient does not want to be addicted.

8.  Risk for peripheral or neurovascular dysfunction.

 

·         Broken femur and wrist.

·         Reduction or interruption of blood flow.

·         Thrombus formation in lower extremity.

·         Confined to bed


NANDA Diagnostic Statement: Acute Pain related to fall with injury to R femur and L wrist AEB patient reports pain 8/10 on pain scale.  Guarding of injured areas and grimacing upon movement.

 

Behavioral Outcome / Goal: Reduce pain level to 5 or by end of 6 hour shift.  Follow pain regimen ordered by physician.  Make patient more comfortable and able to keep food down.


Nursing Interventions:

 

 

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

 

·         Monitor vital signs

 

 

·         Provide medications per physician order

 

·         Elevate leg and arm.  Provide ice pack.

 

 

·         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 and ice help 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:

 

·         Patient states pain is 8/10 on pain scale.

 

·         BP 117/50  HR 56  RR 18            Temp 97.6 oral 92% O2

 

·         After oral pain medication patient states pain is 5/10

 

·         Patient stated she felt much more comfortable with elevation and ice.

 

·         After bath, lotion, massage and clean gown, undergarments and linens she said her pain was 3/10.

 

·         Patient still guarded but appears much more relaxed and was able to eat and keep down breakfast and lunch.

 

Summarize impressions of client progress toward outcomes / problem resolution:  Patient stated pain was 3/10 on pain scale at the end of my shift.  She was relaxed and was very appreciative of all care given to her.  Patient finally agreed to take pain medication.  She was able to eat her breakfast and lunch with minimal nausea.  Patient is concerned about the outcome of her injuries and worried about care once she returns home.  Her husband and daughter are very supportive and I believe they will do whatever is required for her recovery.  She will need to be educated in rehab for her recovery. 


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