Acute Pain

Assessment
Subjective:
Patient states: I
feel pain in my
left hip and leg,
and is getting
worst when I
move
Cultural:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:
Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he
requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction

Evaluation Of Goals
Nursing Dx #3
Acute Pain
r/t
left knee
surgical
incision
As Evidence
By
1.verbal reports
of pain
2. grimacing
3.moaning,
4. guarding of
left hip and leg
area when
assessed and
dressing
changes.
5. P:
movements
Q: aching
R: localized
S: 6/10
T: starts when
he moves or
attempts to
move (PT) and
ends when he
rests, stops
from moving or
is given the
prescribed pain

Goals short term

and long term
Given the
prescribed nursing
care, the patient
will have
relieved/controlled
pain
As evidence by/
1. Patient
verbally states
relieved/decrease
d pain within one
hour. Patient
stated his scan
acceptable pain
level is 3/10.

Nursing Interventions6 per goal = 18

1.
Assess patients pain
including: location,
onset/duration,
frequency, quality, and
intensity using a pain
scale of 0-10 every two
hours.

Provide patient with

information to help
increase pain tolerance
(reason for pain, how
long it last)
Perform comfort
measures to promote
relaxation, such as
massage, bathing and
relaxation techniques.
Assess patient verbal
and nonverbal cues.
Ask patient about the

Rationale
1.
Robust pain assessment is imperative to
ensure that patients receive safe and effective
pain management that is tailored to their
needs. Pain assessment is fundamental in
assisting the diagnosis of the cause of the pain
and it should not be assumed that this is selfevident.
Cardiff University. (2010). Pain Community
Centre. Retrieved May 06, 2016.

To educate the patient and to encourage

compliance in trying alternate pain
measurements. (Lippincott, Williams &
Wilkins, pg. 140)

To reduce muscle tension or spasm,

redistribute pressure on body parts and help
patient focus on non -pain related subjects.
(Lippincott, Williams & Wilkins, pg. 140)

Discrepancy between verbal and nonverbal

cues may provide clues to degree of pain,
need for effectiveness of interventions.
(Doenges, pg147)
The use of the rating scale and
characteristics aids patient in assessing level

Goal was met.

1. Goal met patient
verbally reported
decreased pain as
being much better.
2. Goal met,
nonverbal indicators
of pain were absent
upon observation.
3.Goal met, patient
did not guard left
knee incision area
upon assessment and
wound care.

worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house.

medications

pain. Determine pain

characteristics (aching,
stabbing or burning).
Have the patient rate
intensity on a 0-10
scale.
Evaluate
effectiveness of pain
control. Encourage
sufficient medication to
manage pain; change
medication or time span
as appropriate.

Objective:
VS
Temp-98.8
Pulse-108
BP-160/85
RR-26
O2 Sat-97% on
4L NC
Pain Level- 6/10
. P: movements
Q: aching
R: localized
S: 6/10
T: starts when
he moves or
attempts to
move (PT) and
ends when he
rests, stops from

2. Nonverbal
indicators of pain
including
grimacing and
moaning will be
absent/diminishe
d within 30
minutes

2.
Monitor patients
vital signs for signs of
pain including:
increased heart rate,
blood pressure, and
respiratory rate every
two hours.
Observe patient for
nonverbal indicators of
pain including: facial
grimacing, moaning,
guarding, and crying
during assessment of
pain and vital signs.
Encourage
verbalization of

of pain and provides a tool for evaluating

effectiveness of analgesics, enhancing patient
control of pain. (Doenges, pg147)

Pain management is best left to patient

discretion. (Doenges, pg147)

Acute pain activates the sympathetic branch

of the ANS causing responses as increasing
blood pressure, tachycardia and fluctuating
respiratory rates. (Lippincott, Williams &
Wilkins, pg. 362)
Pain is a subjective, multifaceted
experience that varies considerably between
individuals.
Cardiff University. (2010). Pain Community
Centre. Retrieved May 06, 2016.
Fears, concerns can increase muscle tension
and lower threshold of pain perception.
(Doenges, pg148)

moving or is
given the
prescribed pain
medications.
-grimacing
-moaning
-guarding of left
hip and leg area
when assessed
and dressing
changes.
Labs:
Not applicable
Medications:
-Tramadol
(Ultram) 50mg
po Q6hrs
-Celecoxib
(Celebrex)
200mg po
Q12hrs
-Morphine
2mg/ml Q4hr
prn IV (Hold if
RR < 14)
-Oxycodoneacetaminophen
5/325 Q4hr po
prn
-Docusate
Sodium (Colace)
100mg po 2x
Daily

feelings about pain.

Administer
prescribed Morphine
2mg/ml IV Q4hr as
ordered by physician,
monitor the patients
response to pain
medication and reassess
in 30 minutes after
administration.
Provide and teach
caregivers nonpharmacologic comfort
measures including
repositioning and
massage when patient
reports pain prior to
discharge.
Assess the
appropriates of the
patient as a PCA
candidate.

Medicate before an
activity (PT) to increase
patient participation.

Analgesics are helpful in relieving pain and

in aiding the recovery process by promoting
greater ventilator excursion.
(Swearingen, pg. 423)

Non-pharmacologic therapy focuses on

treatment modalities that modify physical or
cognitive aspects of the painful condition.
Non-pharmacologic measures support
analgesia therapy in reducing pain.
Cardiff University. (2010). Pain Community
Centre. Retrieved May 06, 2016.
Maintaining a constant drug level avoids
cyclic periods of pain, aids in muscle healing,
and improves respiratory function and
emotional comfort and coping. (Doenges,
p148)

Turning and ambulation activities will be

enhanced if pain is controlled or tolerable.
(Cooper, p182)

3. Patient will be
able to his basic
ADLs and
activities within 6
weeks.

Teach the patient and

family members the use
of nonpharmacological
techniques.

The use of noninvasive pain relief methods

can increase the release of endorphins and
enhance the therapeutic effect of pain relief
medications. (Carpentino-Moyet, p130)

Instruct the patient to

avoid strenuous
exercise, activities and
heavy lifting (>10 lb)
for 6 weeks.

Avoiding strenuous exercises and activities

will prevent bleeding of the surgical incision.
(Rothrock, p404)

Provide assistance
with mobility while
ambulating with
prescribed cane or
walker.
Assess to what
degree cultural,
environmental,
intrapersonal, and
intrapsychic factors
may contribute to pain
or pain relief.
Instruct the patient to
evaluate and report the
effectiveness of
measures used.

Patient will be unsteady while attempting to

walk with his injury. A support person is
needed to promote safety and to prevent any
further injuries to this patient. (Vincent, p139)
This may modify patients expression of his
experience. HCP should not stereotype any
patient response but to evaluate the unique
response of each patient. (Gulanick, p145)
Pain reliefs strategies can be modified to
promote more satisfactory comfort levels.
(Gulanick, p148)

Infective
Breathing
Pattern
Assessment

Subjective
Pt stated: I
started to have
difficulty
breathing after
my surgical
procedure 4/28.
Patient states:
After my
surgery I feel
like a pressure
on my chest
when I breath
Cultural/
Psychosocial
Background:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:

Nursing Dx #1

Ineffective
Breathing
Pattern
r/t
decrease rate
and depth of
respirations
associated with
the effect of
anesthesia
As evidence
by
1.Patient states:
After my
surgery I feel
like a pressure
on my chest
when I breath
2.Tachypnea
3Ddyspnea
4.Elevated B/P
5.Observed
physical
discomfort
6.Use of
accessory

Goals Short and

Long Term

Giving the
prescribed nursing
care the patient
will have a
controlled baseline
respiration rate
and a normal O2
saturation level.
As evidence by:
1.Establish a
normal/effective
respiratory
pattern

Nursing Interventions
6 per goal=18

Rationale

Assess respiratory
rate and depth by
listening to lung
sounds. Place a
monitor on patient

Respiratory rate and rhythm changes are

early warning signs of impending respiratory
difficulties. (Gulanick, p35)

Assess accessory
muscles used for
breathing
(sternocleidomastoid,
scalene) and
retractions/flaring of
nostrils

This muscles increase chest excursion to

facilitate effective breathing. (Gulanick, p35)
(Gulanick, p440)

position client with

proper body alignment
(semi-fowlers
position)

This is for good lung excursion and chest

expansion (Gulanick, p440)

Ensure that oxygen

delivery system is
applied to the patient,
the appropriate amount
of oxygen is delivered
-4L NC
Pace and schedule
activities providing

this provides adequate oxygenation to

prevent patient from desaturation (Comer,
p185)

Goals
Evaluation

Short Term:
Goal met, the
patient has
demonstrated
appropriate coping
behaviors and
methods to improve
breathing pattern.
Long term:

This prevents dyspnea resulting from

fatigue (Gulanick, 383)

Goal partially met,

the patient shall have
applied techniques
that improved
breathing pattern and
be free from signs
and symptoms of
respiratory distress
AEB respiratory rate
within normal range,
absence of cyanosis,
effective breathing
and minimal use of
accessory muscles
during breathing

Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he
requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction
worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house.
Objective:
-Tachypnea- RR
26

Muscle noted
7.Nasal Flaring
8.O2 Sat of
97% with O2
4L via Nasal
cannula
9.hypoxia

adequate rest periods

Encourage sustained
deep breaths by
emphasizing slow
inhalation, holding end
inspiration)

2.Patient will
demonstrate
appropriate
coping behaviors
like proper
breathing and
coughing

these techniques promote deep inspiration

(Gulanick, p32)

Teach client
appropriate deep
breathing and coughing
techniques
Teach patient side
effects of medications
that he is taking
(morphine, Oxycodone)

these facilitate adequate clearance of

secretions (Gulanick, p36)

Refer the client to a

dietician and or support
groups.

for proper counseling and intake of caloric

needs. (Herrin, p135)

For management of underlying pulmonary

condition and respiratory distress. (McLuckie,
p73)

Maximize respiratory
effort with good
posture and effective
use if accessory
muscles.

For the pharmacological management of

the patients condition (Ford, p747)

Assess and record

respiratory rate and
depth at least every 4
hours

to limit fatigue (Ralph, p42)

-dyspnea
-elevated B/P
160/85
-Observed
physical
discomfort
- Use of
accessory
Muscle noted
-Nasal Flaring
- O2 Sat of 97%
with O2 4L via
Nasal cannula
-hypoxia
Labs:
-BUN-34
-Creatinine3.010
-HhA1c- 7.2
-Glucose- 398
-ABGs
pH-7.26
PaCO2-56
HCO3-24
[Respiratory
Acidosis/ Acute
Ventilation
Failure-Respiratory
Depression
(Anesthesia)]
Medications:
Not applicable

Reassess ABG
levels, according to
facility policy, to
monitor oxygenation
and ventilation status.
Auscultate breath
sounds at least every 4
hours to detect
decreased or
adventitious breath
sounds; report any
changes.

3.Patient would
be able to apply
techniques that
would improve
breathing pattern
and be free from
signs and
symptoms of
respiratory
distress.

Assist patient to a
comfortable position,
such as by supporting
upper extremities with
pillows, providing
over- bed table with a
pillow to lean on, and
elevating head of bed.

to detect early signs of respiratory

compromise. (Ralph, p47)

to monitor oxygenation and ventilation

status (Ralph, p42)

These measures promote comfort, chest

expansion, and ventilation of basilar lung
elds. (Ralph, p42)

Help patient with

ADLs, as needed
Administer oxygen
4l NC as ordered.
Schedule necessary
activities to provide

to conserve energy and avoid overexertion

and fatigue. (Ralph, p42)
Supplemental oxygen helps reduce

periods of rest

Teach patient about:

pursed-lip breathing
abdominal breathing
performing relaxation
techniques taking
prescribed medications
(ensuring accuracy of
dose and frequency and
monitoring adverse
effects) scheduling
activities to avoid
fatigue and provide for
rest periods.

hypoxemia and relieve respiratory distress.

(Ralph, p43)
This prevents fatigue and reduces oxygen
demands. (Ralph, p43)

These measures allow patient to participate

in maintaining health status and improve
ventilation. (Ralph, p43)

Refer patient for

evaluation of exercise
potential and
development of
individualized exercise
program.

Exercise promotes conditioning of

respiratory muscles and patients sense of
well-being. (Ralph, p43)

Assessment
Activity
Intolerance
(SOB)
Subjective:
Patient state: I
feel weak and
fatigued every
time I try to do
any exercise or
activity, during
physical therapy
my leg really
hurt and I feel
Short of Breath
Cultural/
Psychosocial
Background:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:
Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he

Dx#2

Interventions

Rationale

Evaluation of Goals

Establish Rapport

To gain patient participation and cooperation

in the nurse patient interaction (miller, p191)

1.After 2 days of
nursing
interventions the
client exhibited a
normal range of
respiratory pattern
of 20, cardiac rate of
79 bpm and has no
shortness of breath
and fatigue during
any activity

Goals
Activity
intolerance
r/t
-the presence
of surgical
incision
-imbalance
between
oxygen demand
as manifested
by
1.limited
mobility on the
lower
extremities
2. Shortness of
breath
3.Elevated
Heart Rate
-108
4.Fatigue
5.Obesity 151.3
Kg
6. Patient
States: Pain
6/10
7. Patient states
I fell fatigued
and week every

1.After 2 days of
nursing
interventions the
client will be able
to maintain
activity level
within
capabilities, as
evidenced by
normal heart rate
during activity,
as well as absence
of shortness of
breath, weakness,
and fatigue.

Monitor and record

Vital Signs
Adjust clients daily
activities and reduce
intensity of level.
Discontinue activities
that cause undesired
psychological changes
Instruct client in
unfamiliar activities
and in alternate ways of
conserve energy

To obtain baseline data and to help

determine patients current health status and
evaluate
To prevent strain and overexertion

Short Term:

To conserve energy and promote safety

The patient shall have

used identified
techniques to
improve activity
intolerance
Long Term:

Encourage patient to
have adequate bed rest
and sleep
Assist the client in
ambulation

to relax the body

The patient shall have
reported measurable
increase in activity
intolerance
to prevent risk for falls that could lead to
injury

requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction
worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house. Patient
state multiple
times that he
will love to
return home to
play baseball
with his
grandson.
Objective:
-Facial grimace

time I have to
do any
activities
8. Increase of
baseline B/P
with activities168/90- 164/88
9. Elevated
Respiration
Rate - >26

Note presence of
factors that could
contribute to fatigue
Ascertain clients
ability to stand and
move about and degree
of assistance needed or
use of equipment
Give client information
that provides evidence
of daily or weekly
progress
Encourage the client to
maintain a positive
attitude
Assist the client in a
semi-fowlers position

fatigue affects both the clients actual and

perceived ability to participate in activities
to determine current status and needs
associated with participation in needed or
desired activities

to sustain motivation of client

to enhance sense of well being

to promote easy breathing

Elevate the head of the

bed
to maintain an open airway
Assist the client in
learning and
demonstrating
appropriate safety
measures

to prevent injuries

when moved
VS:
-T: 98.8
-P: 108
-RR: >26
-BP: 168/90
-164/88
Pain scale of 8
out of 10 with
movement or
exercise
-Burning
sensation on
incision site
-Guarded
movement
-Limited
mobility in
lower
extremities
Morse Fall
Scale= 85 High
risk -Risk fall
prevention
interventions
Braden Scale=
20 Low risk of
developing
pressure ulcers.
Physical
therapy 4xDaily

Instruct the SO not to

leave the client
unattended
Provide client with a
positive atmosphere
Instruct the SO to
monitor response of
patient to an activity
and recognize the signs
and symptoms

Establish rapport
Monitor vital signs

Establish guidelines
and goals of activity
with the patient and
caregiver.
Encourage adequate
rest periods, especially
before meals, other
ADLs, exercise

to avoid risk for falls

to help minimize frustration and rechannel

energy
to indicate need to alter activity level

Rapport is important to gain patients

cooperation and reduce anxiety.
Baseline data is important to help determine
patients current health status and evaluate
effectiveness of nursing intervention rendered.
Motivation is enhanced if the patient
participates in goal setting.

Rest between activities provides time for

energy conservation and recovery.

sessions, and
ambulation.
Encourage
verbalization of
feelings regarding
limitations

Maintain a quiet,
comfortable
environment
Teach
patient/caregivers to
recognize signs of
physical over activity.
Teach energy
conservation
techniques.

Acknowledgment t that living with activity

intolerance is both physically and emotionally
difficult, aids coping.
Promotes rest and sleep and prevents anxiety
thereby decreasing the patients oxygen
demands
This promotes awareness of when to reduce
activity.
To conserve energy and decrease the need
for oxygen supply.