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Topics: Hypertension, Blood pressure, Pain Pages: 5 (981 words) Published: March 18, 2013
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
■Pupil dilation
■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, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. 5. Provide Mr. C. optimal pain relief with prescribed analgesics.

1. Pain is a subjective experience and must be described by the client in order to plan effective treatment.

2. Each person experiences and expresses pain in an individual  manner using a variety of sociocultural adaptation techniques

3. Personal factors can influence pain and pain tolerance. Factors that may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management program

4. The use of noninvasive pain relief measures can increase the re- lease of endorphins and enhance the therapeutic effects of pain relief medications.

5. Each client has a right to expect maximum pain relief. Optimal  pain relief using analgesics includes determining the preferred  route, drug, dosage, and frequency for each individual. Medications ordered on a prn basis should be offered to the client at the interval when the next dose is available.

Learning Objective| Learning Content| Method/ Strategy| Rationale| Time Venue/ Resources| Evaluation| After 6 minutes of discussion, the family can define proper nutrition within 2 minutes. After 15 min. of discussion, the family will be able to understand and state 10 out of 14 importance of proper nutrition, within 5minutes.After 7 min. of discussion, the family will be able to enumerate the six types of nutrients within 2 minutes. After 10 minutes of discussion, the family will be able to jot 5 out of 7Dietary Guidelines within 4 minutes.| Introduction:•Definitions•Enumerations•IllustrationsLifestyle Change:•Cost•Benefits•Meal PlanFamily Participation:•Questions•Clarifications•OpinionsWrap Up| DiscussionDiscussionDiscussionDiscussion| Discussions- are highly imaginative and idealistic. They consider things...
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