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Medical Diagnoses: Acute Pain related to incision on abdomen, Impaired skin integrity and risk for infection


1.Acute Pain related to incision on abdomen and incision on left upper extremity.

·         Pt. rates pain 7 out of 10 on the pain scale before PO pain medication.

·         Physician prescribes PCA of Demerol and PO of Vicodin and Narcan

·         Pain increases during ambulation and repositioning

2.Impaired skin integrity related to incisions

·         12 in incision on abdomen with bandage covering incision with JP x 2

·         Incision on left upper arm covered with gauze dressing

7.Risk for infection related to incisions

·         Pt. had MRSA previously

·         12 in incision on abdomen with bandage covering incision with JP x 2

·         Incision on left upper arm covered with gauze dressing

3.Impaired mobility related to acute pain and incisions

·         Unable to position self comfortably

·         Cannot bend over

·         On fall preventions per hospital policy

·         Does not have left lower arm and hand

·         Pain and medication can have side effects that affect LOC

Chief Complaint: A 42 years old, white female with pain from 2 incision sites.  1st incision on the abdomen from a tram flap removal to the 2nd site on the left upper arm where the tram flap was placed. 

Priority Assessment: Monitor vitals and pain level.  Practice standard precautious to help prevent infection.  Monitor LOC and mobility.  Monitor the volume and appearance of drainage from JP’s. Assist with repositioning and monitor comfort.

8.Risk for falls related to acute pain and impaired mobility

·         On fall preventions per hospital policy

·         Pain and medication can have side effects that affect LOC

·         Does not have left lower arm and hand

4.Constipation related to effects of medications, surgery, and immobility

·         Multiple medications, including anesthesia causing a lack of bowel movement in pt.

·           Decreased mobility and anesthesia contributing to difficulty of bowel movements. 

·         PO for Colace and Dulcolax

5.Self-Care deficit related to musculoskeletal impairment.

·         Unable to carry out ADL’s due to left lower arm amputation.

6.Disturbed body image related to musculoskeletal impairment.

·         Lack of confidence & negative statements


NANDA Diagnostic Statement: Acute Pain related to incision on abdomen and incision on left upper extremity AEB pain being 7 out of 10 on the pain scale

 

Behavioral Outcome / Goal: Pt. will report a decrease in pain from 7 down to 3 on the pain scale by 11/12/xx. Pt. will only rely on PO pain medication for pain relief by 11/11/xx. Pt. will increase physical mobility safely without injury.  Pt. will have a bowel movement before discharge. Pt. will have unimpaired incision healing.


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 of Vicodin and Narcan as prescribed.  Reassess pain level and relief and document the effects.

 

3.      Explain to the  pt. the importance of wearing the  abdominal band during ambulation is to protect the incision on the abdominal and prevent injury

 

4.      Give pt. backrub twice a shift to help stimulate circulation and promote comfort that in turn helps decrease pain.

 

5.      Check bowel elimination at least once per shift._________________________   

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.      Knowledge assists the pt. in feeling like an active participant on the health team. (Cox’s Clinical pg: 488)

 

4.      Helps stimulate circulation, prevent pain from malpractice and enhances comfort. (Cox’s Clinical pg: 488)

 

5.      Immobility caused by pain may decrease the parasympathetic stimulation to the bowel._____________________

Client Response:

 

1.      Pt.’s pain level at 7 while on PCA of Demerol. After PO pain medication of Vicodin, pain level decreased to 5.

2.      Pt. reported pain and asked for PO pain medication when PCA did not reduce pain.

 

3.      Pt. makes a conscience effort to remember to apply the abdominal band on before ambulation.

 

 

4.      After giving the pt. a sponge bath, rubbed her back with lotion and it relieved some pain and made her more comfortable and relaxed.

 

5.      Pt complaining of constipation and the pressure it is putting on the incision located on abd.  She requested a fleet enema because PO medication does not work for her.

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is stable.  Pt. is experiencing pain described as a 7 on the pain scale.  Physician prescribes Demerol through PCA and Vicodin and Narcan orally. Pt. will be weaned from PCA and only depend on PO’s for relief.  Pt. can eat a regular diet with the exception of caffeine prescribed by physician.  Pt. had foley but was removed on 11/10/xx, now voiding on her own with no complications.  Physician did prescribe Bactrium b/c pt. is prone to UTI’s.  Pt. complains that she has not had a BM in 5 days.  Pt. is on aiding medication but pt. said that aiding medication does not work and she requests a fleet enema for relief.  Waiting for physician’s order on fleet enema.  12in red and tender incision on abdomen w/ JPx2 and incision on left upper extremity wrapped in gauze dressing (have not been able to review incision).  Pt. had MRSA previously, Vancomycin was given.  During ambulation pt. must wear waist band to help decrease strain on abdominal incision. Pt. is staying at a good friend’s house that will be helping her recover and with ADL’s after discharge._______________


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