Care Case Study (1)-Pain
During RN’s intiial interview, Wrenda shares information about her home, career, and family. The RN evaluates the info to determine psychosocial factors that may impact pain management. Which info obtained by RN is most likely to influence Wrenda’s perception of her pain?
Wrenda’s younger child is an infant who feeds every 3 hours-feeding infant every 3 hrs interrupts sleep and results in fatigue. Fatigue often heightens perception of pain and impairs coping skills.
To assess the quality of Wrenda’s pain, the RN asks which question?
“What word best describes the pain are you experiencing?”- The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching or stabbing
Which behavior that Wrenda exhibits supports her subjective report of acute pain?
Frequent guarding-Guarding or protecting painful area is common behavioral response to pain
After completing the pain assessment, the RN develops of care. RN identifies pain and anxiety as the priority problems. To determine the etiology of Wrenda’s anxiety, what is the priority nursing intervention?
Continue interview with client-further assessment by RN is needed to determine cause of client’s anxiety
What is the best goal for the RN to include in the plan of care related to the problem statement “Acute pain related to strain on muscles with movement?”
Client reports pain 1 on a 0-10 scale–goal is a broad statemetn that reflects a positive direction for the client’s problem, in this case, acute pain
RN considers interventions to include in plan of care. Before implementing any interventions, what action is most important for RN to take?
Discuss plan of care with client-after considering interventions to implement, the nurse should review the plan of care w/ client and seek client input
The RN consults with the clinic director, a pain management physician, who recommends the use of NSAIDs and alternating heat & cold applications, as well as back exercises. RN provides client teaching about these treatments. Wrenda tells RN she will take acetaminophen that she already has at home. What instruction should RN provide?
Acetominophen does not have an antiinflammatory effect-it’s an effective analgesic and antipyretic, but NO inflammatory effect
Wrenda decides to purchase buffered aspirin and asks if this meds is also safe to give her 4yo son since he occassionally experiences viral infections & becomes feverish.
All aspirin products should be avoided in children unless specifically prescribed-aspirin products seem to be associated with Reye’s Syndrome in children and should be avoided unless specifically prescribed
Wrenda tells RN that she has an electric heating pad at home that she used when she sprained her ankle. How should nurse respond?
“Dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation”–heat, dry or moist, promotes muscle relaxation and relief of pain caused by stiffness or spasm
Wrenda states she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible. Which instruction is most important for RN to provide?
Excessive exposure to cold can damage skin-educate pt on safe application. Other info can then be included. RN explain that the cold should only be applied as prescribed: 20-30 minutes at a time. RN tell Wrenda to remove the cold pack if her skin appears red before the prescribed time period has elapsed
How should RN explain mechanism that causes skin to become reddened from prolonged exposure to cold?
Reflex vasodilation occurs following intial vasoconstriction effects of cold-to restore adequate blood supply to tissues
Wrenda returns to the pain clinic in a week and reports that her pain has worsened. Pain management physician recommends use of transcutaneous electrical nerve stimulator (TENS) unit and prescribes a schedule IV opioid analgesic. Wrenda states to RN she is familiar with the TENS unit, calling it a biofeedback treatment. What is best response by RN?
“Pain relief is actually provided by delivery of small electrical currents to the skin”-TENS considered type of cutaneous stimulation in which electrodes attached to a battery-operated unit stimulate the skin and underlying tissues near the are of localized pain
RN explains use of the TENS unit and demonstrates how to apply it. Which instruction(s) should RN include?
-Be sure to use conduction gel/pads when applying electrodes to skin (for safe, effective conduction of the electrical current and to reduce possibility of injury to pt
-clean the where the electrodes will be placed and dry thoroughly
In addition to the TENS unit, Wrenda has Schedule IV analgesic. RN sees specific protocols for controlled meds. What characyeristics of scheduled drugs results in need for protocols?
High potential for abuse
clinic stocks small number of meds. RN counts remaining meds w/oncoming RN and notes count isnt accurate. What action should rn implement
Review Rx for any scheduled drugs w/all nurses w/access to meds to determine why innacurrate
5 days later pt returns to pain clinic reporting Rx, TENS unit, and other care measures haven’t been successful in reducting her pain, and that, in fact, the pain seems to be worse. Wrenda is admitted to med center via ED for diagnostic tests and pain management. While Wrenda is in the ED, HCP prescribes IM injection of 60mg of ketoralac, a NSAI agent. if 30mg/mL? How many mL administer?
B/c thin, what site is best?
Ventrogluteal-2mL Rx can be safely administered
where rn place palm to locate injection site?
greater trochanter-on pt hip, index point anterior iliac spine and middle finger toward iliac crest
Once needle inserted in skin, what intervention should RN perform?
-pull back on syringe plunger and observe for blood (aspiration reduce risk of injecting med into capillary. if blood isobserved, need should be withdrawn and a new dose of meds prepared)
-Slowly inject med into the muscle mass (CDC recommends slow injection without aspiration for IM injections of vaccines and immunizations)
-Follow facility policy re aspiration of IM injection
After completing Wrenda’s admission to med unit, the staff RN offers to guide her through series of relaxation exercises. RN first plans to assist her with guided imagery exercise. Pt states she would like to sit in armchair in room and identify image of watching a mountain sunset as being relaxing to her. To ensure that the exercise is most effective, what action should the RN implement?
Include as many sensory images as possible in the experience-promoting use of all senses diminishes pain
Pt states guided imagery exercise was helpful, and she is interested in learning add’l exercises. RN guides ehr in a progressive relaxation activity. After 1t establishing regular breathing pattern, the RN tells pt to locate area where she can feel muscle tension. What instruction should RN provide next?
Tense muscle fully
Further assessment and testing indicates that Wrenda has back problem that requires surgery, which is scheduled for the next day
Further assessment and testing indicates that Wrenda has a back problem that requires surgery, which is scheduled for the next day. RN knows that a pt-controlled analgesia (PCA) pump will be prescribed as part of pt’s post-op care. When is the best time to teach Wrenda about use of PCA?
The day before surgery is scheduled-teaching is best before surgery while client is awake and alert and not experiencing post-op pain
Following surgery, pt returns to nursing unit with IV infusion and PCA pump. The prescription states, “Morphine sulfate 0.5mg/hr infusion with add’l demand dose of 1mg every 6 minutes. Hourly limit of 10mg.” Prior to giving report to oncoming RN, Rn reviews pt’s use of PCA pump and determines pt received 4 demand doses of morphine for each hour for the last 4 hours. What is the total dosage of morphine that Wrenda has received in the last 4 hours?
On the second post-op day, RN observes that pt is no longer self-administering demand doses of morphine. What is the most likely reason for this change?
She is receiving adequate pain control without add’l doses-her pain has decreased or is controlled effectively by other measures
RN assesses pt’s pain and determines that the evaluation of her use of PCA pump is correct. Pt pain has lessened, and she no longer needs any demand doses of morphine. The RN consults the surgeon, and the morphine is discontinued. Pt’s new Rx is for hydrocodone/acetaminophen. What is the rationale for combining these two ingredients?
The synergistic effect of the two meds improves pain control-non-opioids like acetaminophen are used in combination so that a lower dose of opioid can be used while still providing analgesic effect
Wrenda has also been receiving docusate sodium, a stool softener. She asks the RN if this needs to be continued. How should RN respond?
“You may need to continue the docusate sodium because most opioid analgesics, including hydrocodone/acetaminophen, cause constipation”
RN overhears two other nurses discussing pt’s pain management in the hallway. One nurse states pt is exhibiting drug-seeking behavior and is probably already addicted to her pain meds. What is the priority nursing intervention?
Arrange to continue the conversation in a more private location-RN must act as pt advocate, protecting her privacy. Discussing in hallway violates pt’s right to privacy
Wrenda’s RN believes other nurses are incorrect in their understanding of her pain management. RN explains this to the other nurses, providing nurses with accurate info about pain management and addiction. The RN’s response demonstrates what ethical principle?