Warning:
JavaScript is turned OFF. None of the links on this page will work until it is reactivated.
If you need help turning JavaScript On, click here.
This Concept Map, created with IHMC CmapTools, has information related to: Complexfamilypg2week2, VI. Rationals 1. Maintaining the patient's pain provides comfort and provides for faster healing. 2. Systematic tracking of pain is an important factor in improving pain management. 3. Systematic ongoing assessment and documentation provide directions for the pain treatment plan; adjustments are based on the client's response. Single-item rating of pain intensity are valid and reliable as measure of pain intensity. 4. Pain is a personal experience and the patient is the most reliable indicator of pain. 5. Nonpharamacological interventions should be used to supplement, not replace, pharmocological interventions. They help control the pain. 6. Numerous pathophysiological and psychological morbidity factors may be associated with pain. (Lemone and Burke, 2009) ???? VI. Interventions 1. The nurse will administer supplemental narcotic doses as ordered to keep pain ratings at or below the comfort-function goal q4h or when the patient states a need for pain medication but not before the 4 hour mark starting at 0800 on 11/6/09. 2. The nurse will review the client's flow sheets and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the previous 24 hrs. by 0800 on 11/6/09. 3. The nurse will assess pain in a client by using a self-report such as the 0-10 numerical pain rating scale q2h starting at 0700 on 11/6/09. 4. The nurse will always take the client's report of pain seriously and ensure that the pain is relieved when assessing the patient's pain level q2h starting at 0700 on 11/6/09. 5. The nurse will teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions by 1000 on 11/6/09. 6. The nurse will describe the adverse effects of unrelieved pain by 1000 on 11/6/09 or whenever assessing/relieving the patient's pain on 11/6/09. (Lemone & Burke 2009), V. Expected Outcomes 1. The patient will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects aeb verbally reporting level of pain and any side effect thirty minutes to an hour after pain medication has been given on 11/6/09. 2. The patient will maintain a decrease in pain aeb rating his pain as a 2 or less on a scale of 0-10 by 1300 on 11/6/09. 3. The patient will describe nonpharmacological method that can be used to help control pain by 1300 on 11/6/09 aeb stating different techniques he could use. 4. The patient will maintain a good appetite aeb eating at least 75% of his breakfast and lunch by 1300 on 11/6/09. 5. The patient will understand the importance of proper pain management aeb verbal understanding by 1000 on 11/6/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient was able to report a decrease in pain that was satisfactory to him rating it a 3/10 45 min. after pain medication administration and he was able to report manageable side effects such as making him drowsy on 11/6/09 Goal Met. 2. The patient maintained a decrease in pain aeb rating his pain as a 2/10 at 1300 on 11/6/09 Goal Met 3. The patient described and demonstrated nonpharmacological methods such as ralaxation and distraction by 1300 on 11/6/09 Goal Met. 4.The patient did not eat any of his breakfast and only ate 25% of his lunch by 1300 on 11/6/09 Goal not Met. 5.The patient verbalized the importance of proper pain management by 1000 on 11/6/09 and demonstrated it by reporting any pain he experienced. Goal Met., IV. Secondary Nursing Diagnosis Pain r/t decreased oxygen exchange in right lung aeb grimacing and guarding his RUQ. Define: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predicatable end and a duration of less than 6 months. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects aeb verbally reporting level of pain and any side effect thirty minutes to an hour after pain medication has been given on 11/6/09. 2. The patient will maintain a decrease in pain aeb rating his pain as a 2 or less on a scale of 0-10 by 1300 on 11/6/09. 3. The patient will describe nonpharmacological method that can be used to help control pain by 1300 on 11/6/09 aeb stating different techniques he could use. 4. The patient will maintain a good appetite aeb eating at least 75% of his breakfast and lunch by 1300 on 11/6/09. 5. The patient will understand the importance of proper pain management aeb verbal understanding by 1000 on 11/6/09., III. Focused Assessment 1.VS HR 64, O2 94, Temp 97.7, Resp 22, pulse 65, and B/P 123/69 2. PRN order for Morphine Sulfate 10 mg tablets q4h 3.At 0800 patient rated pain at 3 with pain medication given about 30 min. prior 4. Facial grimaces due to pain in RUQ with movement and at rest 5.At 1200 rated pain at a 9/10 in RUQ asked for pain medication 6. Demonstrated guarding of the RUQ especially when he rated his pain as 9/10 . 7. Breakfast 0%, lunch 25% Generate Nursing Diagnosis IV. Primary Nursing Diagnosis 2. Impaired gas exchange r/t altered blood flow to alveoli aeb O2 stat dropping to 87% with minimal movement. Define: Excess or deficit in oxygenation or carbon dioxide elimination at the alveoli-capillary membrane. Secondary Nursing Diagnosis 3. Activity intolerance r/t acute pain aeb grimacing with movement. Define: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. 4. Ineffective Protection r/t altered clotting function from anticoagulant therapy Define: Decrease in ability to guard self from internal or external threats such as illness or injury. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis D.D. age 62 year old white male Medical Diagnosis: 1. Pulmonary Embolism 2. RUQ Pain assess III. Focused Assessment 1.VS HR 64, O2 94, Temp 97.7, Resp 22, pulse 65, and B/P 123/69 2. PRN order for Morphine Sulfate 10 mg tablets q4h 3.At 0800 patient rated pain at 3 with pain medication given about 30 min. prior 4. Facial grimaces due to pain in RUQ with movement and at rest 5.At 1200 rated pain at a 9/10 in RUQ asked for pain medication 6. Demonstrated guarding of the RUQ especially when he rated his pain as 9/10 . 7. Breakfast 0%, lunch 25%, III. Focused Assessment 1.VS HR 64, O2 94, Temp 97.7, Resp 22, pulse 65, and B/P 123/69 2. PRN order for Morphine Sulfate 10 mg tablets q4h 3.At 0800 patient rated pain at 3 with pain medication given about 30 min. prior 4. Facial grimaces due to pain in RUQ with movement and at rest 5.At 1200 rated pain at a 9/10 in RUQ asked for pain medication 6. Demonstrated guarding of the RUQ especially when he rated his pain as 9/10 . 7. Breakfast 0%, lunch 25% Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis Pain r/t decreased oxygen exchange in right lung aeb grimacing and guarding his RUQ. Define: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predicatable end and a duration of less than 6 months. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis D.D. age 62 year old white male Medical Diagnosis: 1. Pulmonary Embolism 2. RUQ Pain affects II. Pathophysiology 1.Pulmonary Embolismn(PE) is obstruction of blood flow in the pulmonary vascular system by an embolus. 2. PE usually is due do to a thrombus; tumors, fat, amniotic fluid, and debris may also become emboli. 3.PE affects both perfusion and ventilation: 1. Bronchospasm occurs in the affected area of lung. 2. Dead space increases. 3. Alveolar surfactant decreases, increasing the risk for atelectasis. (Lemone & Burke, 2008), V. Expected Outcomes 1. The patient will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects aeb verbally reporting level of pain and any side effect thirty minutes to an hour after pain medication has been given on 11/6/09. 2. The patient will maintain a decrease in pain aeb rating his pain as a 2 or less on a scale of 0-10 by 1300 on 11/6/09. 3. The patient will describe nonpharmacological method that can be used to help control pain by 1300 on 11/6/09 aeb stating different techniques he could use. 4. The patient will maintain a good appetite aeb eating at least 75% of his breakfast and lunch by 1300 on 11/6/09. 5. The patient will understand the importance of proper pain management aeb verbal understanding by 1000 on 11/6/09. Interventions & Rationals VI. Interventions 1. The nurse will administer supplemental narcotic doses as ordered to keep pain ratings at or below the comfort-function goal q4h or when the patient states a need for pain medication but not before the 4 hour mark starting at 0800 on 11/6/09. 2. The nurse will review the client's flow sheets and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the previous 24 hrs. by 0800 on 11/6/09. 3. The nurse will assess pain in a client by using a self-report such as the 0-10 numerical pain rating scale q2h starting at 0700 on 11/6/09. 4. The nurse will always take the client's report of pain seriously and ensure that the pain is relieved when assessing the patient's pain level q2h starting at 0700 on 11/6/09. 5. The nurse will teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions by 1000 on 11/6/09. 6. The nurse will describe the adverse effects of unrelieved pain by 1000 on 11/6/09 or whenever assessing/relieving the patient's pain on 11/6/09. (Lemone & Burke 2009), IV. Primary Nursing Diagnosis 2. Impaired gas exchange r/t altered blood flow to alveoli aeb O2 stat dropping to 87% with minimal movement. Define: Excess or deficit in oxygenation or carbon dioxide elimination at the alveoli-capillary membrane. Secondary Nursing Diagnosis 3. Activity intolerance r/t acute pain aeb grimacing with movement. Define: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. 4. Ineffective Protection r/t altered clotting function from anticoagulant therapy Define: Decrease in ability to guard self from internal or external threats such as illness or injury. (Wilkenson & Ahern 2009) Prioritized to IV. Secondary Nursing Diagnosis Pain r/t decreased oxygen exchange in right lung aeb grimacing and guarding his RUQ. Define: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predicatable end and a duration of less than 6 months. (Wilkenson & Ahern 2009), III. Focused Assessment 1.VS HR 64, O2 94, Temp 97.7, Resp 22, pulse 65, and B/P 123/69 2. PRN order for Morphine Sulfate 10 mg tablets q4h 3.At 0800 patient rated pain at 3 with pain medication given about 30 min. prior 4. Facial grimaces due to pain in RUQ with movement and at rest 5.At 1200 rated pain at a 9/10 in RUQ asked for pain medication 6. Demonstrated guarding of the RUQ especially when he rated his pain as 9/10 . 7. Breakfast 0%, lunch 25% ???? III. Abnormal Assessment Findings 1. RBC 3.94 (Low), HGB 11.8 (Low), HCT 36.1 (Low), 2. Blood Sugar 123 (High) 3. Medications: Lovenox SQ 120 mg, Lasix IV 40 mg, K-Dur ( Potassium Chloride Tablets) 1x10 MEQ PO w/ breakfast 4. History of Cough, Chest Pain, and Thrombi in Leg 5. O2 stat drops to 87% with minimal movement such as being moved up in bed. 6. 2L of oxygen by NC 7. Rapid, shallow breathing ranging about 24 breathes per minutes at rest. 8. Needed bed at 45 degree angle to help him breathe., II. Pathophysiology 1.Pulmonary Embolismn(PE) is obstruction of blood flow in the pulmonary vascular system by an embolus. 2. PE usually is due do to a thrombus; tumors, fat, amniotic fluid, and debris may also become emboli. 3.PE affects both perfusion and ventilation: 1. Bronchospasm occurs in the affected area of lung. 2. Dead space increases. 3. Alveolar surfactant decreases, increasing the risk for atelectasis. (Lemone & Burke, 2008) leads to III. Focused Assessment 1.VS HR 64, O2 94, Temp 97.7, Resp 22, pulse 65, and B/P 123/69 2. PRN order for Morphine Sulfate 10 mg tablets q4h 3.At 0800 patient rated pain at 3 with pain medication given about 30 min. prior 4. Facial grimaces due to pain in RUQ with movement and at rest 5.At 1200 rated pain at a 9/10 in RUQ asked for pain medication 6. Demonstrated guarding of the RUQ especially when he rated his pain as 9/10 . 7. Breakfast 0%, lunch 25%