Desires 0 pain, will accept 1-2 on 0-10 pain scale. Has incision pain of 2-3 between drsg changes, which is controlled by two Percocet, has a 6 during changes. Scenario
K.C. 43 y.o. female 280 lb, I&D of renal abscess 2nd post op day. Being d/c’d home where daughter will do drsg changes.
What is Pain?
According to (Lewis, 2011) The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
Impaired skin integrity r/t I&D
Risk for constipation r/t taking Percocet
Acute pain r/t tissue injury 2o I&D
Evaluate effectiveness of analgesic: pain 1-2, instruct pt to take analgesic at onset of pain: advise to take pain meds 30 mins. to hr prior to drsg changes check willingness to use relaxation techniques demonstrate & teach relaxation techniques, assess pain considering cultural influences, & reduce or eliminate factors that increase the pain: provide quiet disruptive environment
Advise to keep skin clean & dry, wash hands prior to drsg changes, teach pt & daughter s/s of infection: redness, foul purulent drainage, streaks Nursing Interventions
Advise pt to drink plenty of water, increase dietary fiber intake, exercise, or use stool softeners to help in stool passing. Outcomes
Pain control as evidenced by demonstrating ability t use analgesics, use of non-analgesic relief measures, requests analgesics 30 minutes before dressing changes
Pt& daughter will verbalize understanding regarding hand hygiene; I&D site will be free of infection Outcomes
Pt will state understanding of increasing dietary fiber & fluids as evidenced by being free of constipation
Provide relaxing environment, dim the lights, if pt desires distraction,...