Nursing Interventions:
1.
Monitor pt. for pain at least every 2 hours using the
numeric pain scale and behavior assessment.
2.
Administer pt.’s pain medication of PO Norcos and IV
Morphine as prescribed. Reassess
pain level and relief and document the effects.
3.
Teach Pt. to report pain as soon as it onsets and 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.
6.
Check bowel elimination at least once per
shift.____________________
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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)
6.
Immobility caused
by pain may decrease the parasympathetic stimulation to the bowel (Cox Clinical
pg:564)__________________________
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Client Response:
1.
Pt.’s pain level
at 8 before IV
Morphine. 30 mins after admin. Pt.’s pain level went down to a 5 on pain
scale.
2.
Pt. reported pain
and asked for the scheduled pain medication that was available at that time. Pt
was relieved once pain meds kicked in.
3.
Pt. reported pain
and asked for IV Morphine when pain was not controlled with Norcos.
4.
Every 2 hours help
pt. shift weight to different positions that does not affect incision site and
does hurt the healing process
5.
Pt. has semi
private room but the no roommate. Pt. is calm, alert and watching t.v. She is
comfortable and not in distress.
6.
Pt. knows that the
physician has ordered some aiding medication for bowel elimination if pt. cannot
go on own and she has to a healthy BM before discharge.________________
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