S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time, place, and person). S.E has no known drug allergy and he is NPO except for medicine.
Problem: LLQ abdominal pain
Acute pain |
Assessment| Planning/Nursing Goals| Intervention/Implementation| * Physiological variables, such as age and pain tolerance * Descriptive characteristics of pain, including location, quality, intensity on a scale of 1 to 10, temporal factors, and sources of relief. * Environmental variables, such as setting and time.| * Patient will rate pain on scale of 1-10 and Verbalizes reduced pain level * Patient will report more than 4 hours of sleep nightly. * Patient will express feeling of comfort and relief from pain| * Administer prescribed analgesic * Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. * Reassess pain frequently using pain scale.| Risk for bleeding related to colonoscopy|
Assessment| Planning/Nursing Goals| Intervention/Implementation| * Cardiovascular status, including blood pressure, cardiac output, Vital signs, patient and family history of Cardiovascular disease, peripheral pulses and smoking history. * Presence of health condition that may interfere with bleeding, such as coagulopathies * History of GI problems,disease, or surgery; bowel sound| * Patient will receive adequate screening/monitoring to alert clinicians of existing risk factor for bleeding. * Patient vital signs and tissue perfusion will remain within expected ranges during episodes of risk.| * Screen each patient for risk factor for bleeding. * Obtain clinical laboratory test and point of care tests (urine...