Nursing Interventions:
1.
Monitor pt. for pain at least every 2 hours using the
numeric pain scale and behavior assessment.
2.
Administer pt.’s PO pain medication (Oxycodone and
Narcan) as prescribed. Reassess pain
level and relief and document the effects.
3.
Teach pt. how to use the PCA for pain as much as it
allows and report pain as soon as it is not being relieved by PCA. Also the description of pain and its
contributing factors.
4.
Reposition pt. at least every 2 hours. Maintain
alignment with pillows and monitor positioning around lumbar area. Prevent skin breakdown
5.
Provide pt. a peaceful and quiet environment for resting
and healing.________________________
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Rationale:
1.
Pain is subjective in nature and only the client can
fully describe it (Cox’s Clinical pg: 487)
2.
Response to pain and pain medication is unique to each
client (Cox’s Clinical pg:488
3.
Pain is more readily controlled when it is treated early
(Cox’s Clinical pg:487)
4.
Help stimulate circulation. Alignment helps prevent pain
malpractice and enhances comfort.
(Cox’s Clinical pg:488)
5.
Promotes action and effect of medication by providing
decreased stimuli (Cox’s Clinical pg: 488)_______________________
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Client Response:
1.
Pt.’s pain level at 8 while on PCA of morphine, after PO
pain medication of Oxycodone pain level decreased to a 6.
2.
Pt. reported pain and asked for PO pain medication when
PCA did not reduce pain.
3.
Pt. reported pain as soon as PCA medication wore off. Pt. describes the pain is located in
her neck and shoulders.
4.
Every 2 hours help pt. shift weight to different
positions that do not affect incision site. Pt. hesitates during reposition,
cautious around incision.
5.
Pt. has private room and on isolation precautious. Television on but volume is down low. Lights are dim and pt. calm. Pt. rests after pain medication is
given. Pt. is stable._==============
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