Site Loader

This case study will help you apply the nursing process to a patient who is in pain from multiple injuries and requires pain management from the nurse.

Nursing Case Study on Pain

Anthony is a 59-year-old male who suffered a severe femur fracture, multiple pelvic fractures, and a lower lumbar fracture after a motorcycle accident. He underwent surgery and will be discharged to a rehab facility for further treatment in two days. Sarah, the nurse, plans to visit Anthony in his room first thing this morning. Sarah will use the nursing process of assessment, diagnosis, planning, implementation, and evaluation.

Best services for writing your paper according to Trustpilot

Premium Partner
From $18.00 per page
4,8 / 5
4,80
Writers Experience
4,80
Delivery
4,90
Support
4,70
Price
Recommended Service
From $13.90 per page
4,6 / 5
4,70
Writers Experience
4,70
Delivery
4,60
Support
4,60
Price
From $20.00 per page
4,5 / 5
4,80
Writers Experience
4,50
Delivery
4,40
Support
4,10
Price
* All Partners were chosen among 50+ writing services by our Customer Satisfaction Team

Assessment & Diagnosis

Sarah begins her process with assessment.

As she enters the room, she finds Anthony lying very still in bed. He is breathing fast and does not wish to move or participate in the assessment. He grimaces from time to time. He states his pain is 4 out of 10 on a 0 to 10 pain scale. His vital signs are: heartrate 98, respirations 26, temperature 98.

6, and blood pressure 140/87. Sarah reviews Anthony’s documentation from other days to find his vital signs have been running high, like what she found this morning. Anthony has Percocet and ibuprofen ordered, but has only taken the ibuprofen three times in the last two days.It is important to be aware of subjective and objective signs of pain. Subjective signs are indications of pain that may be personal or unique from patient to patient. How pain is perceived and rated can be influenced by a patient’s personal background and culture, as well as previous experiences with pain and pain management.

Subjective signs may not be measurable but may be observed by a practitioner or reported by the patient. Anthony reports a pain of 4 out of 10, but the nurse Sarah observes his stoic posture, his unwillingness to move or participate in care, and the grimacing on his face when as she assesses him. These are all subjective measures of his pain.Objective signs refer to indications of pain that can be measured. For example, vital signs can be measured and compared to normal vital sign standards. In Anthony’s case, his respirations, heartrate, and blood pressure are all higher than the normal standard and should indicate to the nurse that he is in pain. In addition, Anthony’s refusal to participate in care is objective as it is measurable; he does not participate.

These are Anthony’s objective signs of pain.Sarah makes a diagnosis. She believes that, even though he is rating his pain as a 4, he is in moderate to severe pain.

Planning ; Implementation

Now Sarah moves into the planning part of her process. She knows that her plans should include both invasive and non-invasive pain management measures to help Anthony. Her first priority is to get Anthony’s pain managed and under control before educating and teaching him about techniques he can use throughout his day.

Sarah offers Anthony pain medicine. He is reluctant and then finally agrees to take the ibuprofen. Sarah attempts to discuss with Anthony the benefit of taking the Percocet for such severe injuries.

Sarah is patient and listens to Anthony as they discuss his pain options. Anthony finally expresses that he is concerned with becoming addicted to the Percocet, and that is why he has not taken it. After a long discussion, Sarah and Anthony decide that he should take the Percocet, and then she will teach him additional pain management techniques that he can use to cope with the pain.

Sarah continues to work with Anthony in the implementation part of the nursing process. She administers two Percocet per the physician order to Anthony and helps him sit up in bed and eat breakfast so to upset his stomach less. About 30 minutes after breakfast, Sarah explains to Anthony that now that the medication has had to time to be absorbed by the body, it would be a good time to get up and sit in the chair. With her assistance, Anthony is able to transfer to the chair, brush his teeth, and watch TV. The process takes about 40 minutes.Sarah decides that Anthony is tired and offers to come back and teach him about non-invasive pain management techniques after he has had time to rest. This will allow for optimal response when she is teaching Anthony.

After about an hour nap, Sarah rates Anthony’s pain and determines that it is tolerable at a 3 out of 10. Sarah and Anthony discuss taking ibuprofen to help keep the pain down. Anthony agrees to take the medication to prevent the pain from increasing suddenly.In addition, Sarah goes over the use of deep breathing and meditation techniques that can be used throughout the day. Deep breathing is the process of taking slow, deep, and repetitive breaths to help reduce some pain and help the patient focus on the breathing rather than the pain. Often when patients are experiencing pain, they may hold their breath or take shallow breaths. The lack of oxygenation does not help the pain exacerbation.

Meditation refers to the practice of spending quiet time reflecting or thinking. For patients dealing with pain, reducing stimulation can help the patient calm down and reduce feelings of pain. Sarah explains to Anthony that meditation can also occur with the use of soft, light music.Finally, Sarah turns on the guided imagery channel provided by the hospital and teaches Anthony how he can use guided imagery to channel his pain and retreat to a nice, inviting place in his mind when he is battling a painful experience.

After some discussion, Anthony talks about a cabin in the mountains he enjoys, and he determines he will think about that place when he is stressed or in pain.

Evaluation

Finally, Sarah moves into the evaluation part of the nursing process. After the education, she re-evaluates Anthony’s pain and he states it is about a 2 out of 10.

He appears more relaxed in his posture and face. His vital signs are heartrate 86, respirations 20, temperature 98.6, and blood pressure 130/84. Anthony is able to verbalize several non-invasive pain management techniques he can utilize throughout his day. He also verbalizes when it would be appropriate to take ibuprofen, when to take Percocet, and the chance of addiction. Sarah documents under the Education tab that the patient was educated about pain management, medication usage, when to take his medication, and side effects.

Lesson Summary

This lesson was a case study regarding pain and pain management in a 59-year-old male, Anthony, who had multiple, painful fractures due to a motorcycle accident.

Using the nursing process of assessment, diagnosis, planning, implementation, and evaluation, Sarah made a diagnosis that Anthony was in moderate to severe pain by using subjective data and objective data found in the assessment phase. She made a plan with Anthony to manage the pain he was presently in and then teach him how to deal with future pain occurrences.Sarah then implemented the plan by first administering medication to reduce the pain Anthony was experiencing, taking time for it to work, and then helping him perform his morning care and rest before she educated him.

When she educated Anthony, she taught him about meditation, guided imagery, and deep breathing techniques and when to use them.During the evaluation phase of the nursing process, Sarah evaluated the effectiveness of the medication administered by asking Anthony to re-rate his pain. She then evaluated her teaching by asking Anthony to verbalize what he learned back to her. Finally, she documented the education and teaching she provided to Anthony, as well as his response in the computer.Medical Disclaimer: The information on this site is for your information only and is not a substitute for professional medical advice.

Post Author: admin

x

Hi!
I'm Eric!

Would you like to get a custom essay? How about receiving a customized one?

Check it out