For Review
Nursing Assessment
Mr. C. is a 57-year-old businessman who was admitted to the surgical unit for treatment of a possible strangulated inguinal hernia.Two days ago he had a partial bowel resection. Postoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/in her left arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is complaining of abdominal pain (7 on a scale of 0–10)
Physical Examination
Height: 188 cm (6′3′′)
Weight: 90.0 kg (200 lbs) Temperature: 37°C (98.6°F)Pulse: 90 BPM Respirations: 24/minute Blood pressure: 158/82 mm Hg Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact.
Diagnostic Data
Chest x-ray and urinalysis negative, WBC 12,000
Nursing Dx
Acute Pain related to tissue in- jury secondary to surgical intervention (as evidenced by restlessness; pallor; elevated pulse, respirations, and systolic blood pressure; dilated pupils; and report of 7/10 abdominal pain.
Pain Control
[1605] as evidenced by often demonstrating ability to
■Use analgesics appropriately
■Use non analgesic relief measures
■Report uncontrolled symptoms to health care professional
Pain Level
As evidenced by mild to no
■Reported pain
■Protective body positioning
■Restlessness
■Pupil dilation
■Perspiration
■Change in BP, HR, R from normal baseline data
Nursing Interventions
1. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.
2. Consider cultural influences on pain response (e.g., cultural beliefs about pain may result in a stoic attitude).
3. Reduce or eliminate factors that precipitate or increase Mr. C.’s pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)
4. Teach the use of non pharmacologic techniques (e.g., relaxation, guided imagery,
Mr. C. is a 57-year-old businessman who was admitted to the surgical unit for treatment of a possible strangulated inguinal hernia.Two days ago he had a partial bowel resection. Postoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/in her left arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is complaining of abdominal pain (7 on a scale of 0–10)
Physical Examination
Height: 188 cm (6′3′′)
Weight: 90.0 kg (200 lbs) Temperature: 37°C (98.6°F)Pulse: 90 BPM Respirations: 24/minute Blood pressure: 158/82 mm Hg Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact.
Diagnostic Data
Chest x-ray and urinalysis negative, WBC 12,000
Nursing Dx
Acute Pain related to tissue in- jury secondary to surgical intervention (as evidenced by restlessness; pallor; elevated pulse, respirations, and systolic blood pressure; dilated pupils; and report of 7/10 abdominal pain.
Pain Control
[1605] as evidenced by often demonstrating ability to
■Use analgesics appropriately
■Use non analgesic relief measures
■Report uncontrolled symptoms to health care professional
Pain Level
As evidenced by mild to no
■Reported pain
■Protective body positioning
■Restlessness
■Pupil dilation
■Perspiration
■Change in BP, HR, R from normal baseline data
Nursing Interventions
1. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.
2. Consider cultural influences on pain response (e.g., cultural beliefs about pain may result in a stoic attitude).
3. Reduce or eliminate factors that precipitate or increase Mr. C.’s pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)
4. Teach the use of non pharmacologic techniques (e.g., relaxation, guided imagery,