Acute Pain NCP

Nursing Diagnoses:

·         Acute pain related to disruption of skin, tissue, and muscle integrity; musculoskeletal or bone trauma

·         Acute pain related to presence of tubes and drains

Cause Analysis:

ASSESSMENT	OBJECTIVES	INTERVENTIONS	RATIONALE
Objective Cues: Reports of pain (PQRST) Subjective Cues: ·         Alteration in muscle tone ·         facial mask of pain ·         Distraction, guarding, or protective behaviors ·         Self-focusing, narrowed focus	Short-term: Within 4 hours of providing nursing interventions, the patient will be report reduced pain to a tolerable level. Long-term: Within 3 days of providing nursing interventions, the patient will be able to participate in activities appropriately.	Independent: ·         Note client’s age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course, including size and location of incision, drain placement, and anesthetic agents used. ·         Review intraoperative and recovery room record for type of anesthesia and medications previously administered. ·         Evaluate pain frequently in immediate postoperative phase and regularly (e.g., hourly per protocol) following transfer, noting characteristics, location, and intensity (0–10 scale). Emphasize client’s responsibility for reporting pain and relief of pain completely. ·         Note presence of anxiety or fear, and relate with nature of and preparation for procedure. ·         Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if client denies pain. ·         Assess causes of possible discomfort other than operative procedure. ·         Provide information about transitory nature of discomfort, as appropriate. ·         Reposition as indicated, such as semi-Fowler’s or lateral Sims’. ·         Provide additional comfort measures such as backrub and heat or cold applications. ·         Encourage use of relaxation techniques such as deep-breathing exercises, guided imagery, visualization, or music. ·         Provide regular oral care, occasional ice chips or sips of fluids as tolerated. ·         Document effectiveness and side or adverse effects of analgesia. Collaborative: ·         Administer medications, as indicated, for example: IV analgesics after reviewing anesthesia record for contraindications and/or presence of agents that may potentiate analgesia ·         Around-the-clock analgesia via patient-controlled analgesia (PCA) or epidural analgesia (PCEA) with intermittent rescue doses, as needed ·         Local anesthetics, such as epidural block or infusion ·         NSAIDs, such as ketorolate (Toradol), diflunisal (Dolobid), or naproxen (Anaprox) ·         Monitor use and effectiveness of transcutaneous electrical nerve stimulation (TENS) unit when used.	·         Approach to postoperative pain management is based on multiple variable factors. Note: Administration of the anticonvulsant lamotrigine (Lamictal) before spinal anesthesia reduces analgesic use and lowers pain scale ratings in the postoperative client. ·         Presence of opioids and droperidol in system potentiates opioid analgesia, whereas inhalation anesthetics have no analgesic effects. In addition, intraoperative local and regional blocks have varying duration based on drug choice and dose. ·         Provides information about need for, and effectiveness of, interventions. Note: It may not always be possible to eliminate pain; however, analgesics should reduce pain to a tolerable level. A frontal and/or occipital headache may develop 24 to 72 hours following spinal anesthesia, necessitating recumbent position, increased fluid intake, and notification of the anesthesiologist for alternative pain relief plan. ·         Concern about the unknown, such as outcome of a biopsy and/or inadequate preparation due to emergent procedure, can heighten client’s perception of pain. ·         Changes in these vital signs often indicate acute pain and discomfort. Note: Some clients may have a slightly lowered BP, which returns to normal range after pain relief is achieved. ·         Discomfort can be caused or aggravated by presence of nonpatent indwelling catheters causing bladder pain, NG tube resulting in gastric fluid and gas accumulation, or parenteral lines that have infiltrated IV fluids or medications. ·         Understanding the cause of the transitory discomfort, such as sore muscles from administration of succinylcholine, which may persist up to 48 hours postoperatively; sinus headache, which may be associated with nitrous oxide; or sore throat, which may be due to intubation, provides emotional reassurance. Note: Paresthesia of body parts suggests nerve injury. Symptoms may last hours or months and require additional evaluation. ·         May relieve pain and enhance circulation. Semi-Fowler’s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims’ will relieve dorsal pressures. ·         Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being. ·         Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities. ·         Reduces discomfort associated with dry mucous membranes due to anesthetic agents and oral restrictions. ·         Respirations may decrease on administration of opioid, or synergistic effects with anesthetic agents may occur. Note: Migration of epidural analgesia toward head may cause respiratory depression or excessive sedation. ·         Analgesics given IV reach the pain centers immediately, providing more effective relief with smaller doses of medication. Note: Initial opioid dosage should be reduced by onefourth to one-third after use of fentanyl (Innovar) or droperidol (Inapsine) to prevent respiratory depressant effects (Deglin & Valler, 2005). ·         Research supports need to administer analgesics around the clock initially to prevent rather than merely treat pain. Use of PCA necessitates detailed client instruction. PCA is considered very effective in managing acute postoperative pain with smaller amounts of opioid and increased client satisfaction. Note: Continuous epidural infusions may be used for 1 to 5 days following procedures that are known to cause severe pain such as certain types of thoracic or abdominal procedures. ·         Analgesics may be injected into the operative site, or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain. Note: Continuous epidural infusions may be used for 1 to 5 days following procedures that are known to cause severe pain such as certain types of thoracic or abdominal surgeries. ·         Useful for mild to moderate pain or as adjuncts to opioid therapy in moderate to severe pain. Allows for a lower dosage of opioids, reducing potential for side effects. Use alternating schedule with NSAIDs administered between opioid doses so peak effect occurs at a different time. ·         TENS may be useful in reducing pain and amount of medication required postoperatively.

 Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 796-798)

Risk for Infection NCP

Problem Identified: Risk for Infection

Nursing Diagnosis: 

• Risk for Infection related to inadequate primary defenses
• Risk for Infection related to invasive procedures
• Risk for Infection related to surgical incision

Cause Analysis:

ASSESSMENT	OBJECTIVES	INTERVENTION	RATIONALE
Subjective Cues: Objective Cues:	Short Term: After 8 hours of giving nursing interventions and health teachings, the client will be able to identify behaviors and practices to prevent and reduce the risk for infection. Long Term: After 3 days of giving nursing interventions, the client will achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.	Independent: Stress and model proper hand-washing technique to client and caregivers.  Maintain aseptic technique with any procedures. Provide routine site care/wound care, as appropriate. Inspect dressings and wound; note characteristics of drainage.  Encourage frequent position changes and being out of bed or ambulation, as tolerated.  Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible. Monitor vital signs.  Collaborative: Obtain drainage specimens, if indicated.  Administer antibiotics, as indicated.	Reduces risk of cross-contamination/bacterial colonization. Prevents entry of bacteria, reducing risk of nosocomial infections.  Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications. Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.  Reduces bacterial colonization and risk of ascending UTI.  Temperature elevation and tachycardia may reflect developing sepsis.  Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy. Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.

Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 346-347, 651-652)

Hyperthermia NCP

SYSTEMIC INFECTION 

Nursing Diagnosis: 

• Hyperthermia related to increased metabolic rate, illness.
• Hyperthermia related to dehydration.
• Hyperthermia related to direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation. 

Cause Analysis:

ASSESSMENT	OBJECTIVE	INTERVENTION	RATIONALE
Subjective:  "I feel warm" as verbalized by the patient Objective:   Increase in body temperature higher than normal range   Flushed skin, warm to touch  Increased respiratory rate  Tachycardia  Increased Neutrophil level  Increased platelet level	Short Term Objective:      After 4 hours of giving nursing interventions, the client will be able to demonstrate temperature within normal range and be free of chills. Long Term Objective:      After 3 days of giving nursing interventions, the client will experience no associated complications.	Independent Monitor client temperature—degree and pattern. Note shaking, chills or profuse diaphoresis.    Monitor environmental temperature. Limit or add bed linens, as indicated. Provide tepid sponge baths. Avoid use of alcohol. Collaborative Administer antipyretics, such   as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol). Provide cooling blanket, or hypothermia therapy, as indicated.	Temperature of 102_F to106_F (38.9_C–41.1_C) suggests acute infectious disease process. Fever pattern may aid in diagnosis: sustained or continuous fever curves lasting more than 24 hours suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever varying only a few degrees in either direction reflects pulmonary infections; and intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher than 102_F (38.9_C).    Room temperature and linens should be altered to maintain near-normal body temperature. Tepid sponge baths may help reduce fever. Note: Use of ice water or alcohol may cause chills, actually elevating temperature. Alcohol can also cause skin dehydration. Antipyretics reduce fever by its central action on the hypothalamus; fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells. Used to reduce fever, especially when higher than 104_F to 105_F (39.5_C–40_C), and when seizures or brain damage are likely to occur.

Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8^th ed. (p. 691-692)