Pain Assessment in John
John should be assessed for different medical conditions like pain, anxiety and blood pressure.
Pain assessment need to be performed in John due to wound. Pain assessment can be performed by measuring pain on pain scale from 0 to 10. Physical response to the pain and non-verbal ques for pain need to be assessed in John.
Anxiety need to be assessed in John because his past history indicates he was associated with anxiety. Anxiety can be assessed by using Hamilton Anxiety Rating Scale (HAM-A). This scale can differentiate pain severity in different grades like not present, mild, moderate, severe and very severe.
Stress due to pain and anxiety can increase blood pressure in John. Blood pressure can be measured by using device called sphygmomanometer (Dewit et al., 2016).
Assessment and management of pain is necessary in John because pain can disturb physical and psychological wellbeing of John.
Anxiety assessment is important in case of John because he has long history of anxiety. Anxiety assessment in John can be helpful in providing intervention for different conditions like fear, insomnia, tension and mood.
Increase in blood pressure can lead multiple health problems in the future. Hence, blood pressure assessment in important in John.
It is necessary to assess pain, anxiety and blood pressure collectively in John because these conditions can exaggerate each other. Nurse should asses these conditions in John because it can affect his physical, physiological and psychological wellbeing (Dewit et al., 2016).
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Nursing problem: Risk of infection |
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Related to: John got cut in his foot on Oyster shell. Hence, he became injurious and consequently he got infected. |
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Goal of care |
Nursing interventions |
Rationale |
Evaluation |
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Spread of infection should be stopped. Infection should be stopped or prevented. |
Antiseptic solution should be used to clean the wound and sterile dressing should be changed on regular basis. Antibiotic like gentamicin should be administered through parenteral route. Assess and monitor nutritional status and body weight. Monitor signs of infection like redness, swelling, pain and discharge from site of infection. |
Application of antiseptic solution for cleaning wound can produce bactericidal or bacteriostatic action (Ridley, 2015; Harrington, 2014). Initially antibiotic should be administered through oral route. If it is not exhibiting desired effect through oral route, it should administer through parenteral route because parenteral route can exhibit fast response as compared to the oral route. In case of John, it was evident that oral antibiotic administration is not exhibiting desired effect Hence, parenteral route was used for gentamicin administration (Ridley, 2015; Harrington, 2014). Increased WBC count indicate body’s defence against infecting pathogens (Ridley, 2015; Harrington, 2014 Poor nutritional status can lead to underdeveloped immune system and increased susceptibility to infection (Ridley, 2015; Harrington, 2014 These are classical signs of infection (Ridley, 2015; Harrington, 2014) |
Infection can be evaluated by counting white blood cell count. Wound specimens should be assessed for infection. |
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Nursing problem: Risk of injury |
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Related to: John got cut in his foot on Oyster shell. Hence, he became injurious. |
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Goal of care |
Nursing interventions |
Rationale |
Evaluation |
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Complete healing of injury. Injury not developed in wound. No occurrence of pain sensation due to injury. |
Area around injury should be monitored for color, temperature, edema, moisture and appearance of the skin. Injured skin should be monitored for its integrity and consequently development of wound and infection. John should be assessed for sensitivity to pain. Wound care practices and requirements need to be monitored. It includes checking of type of cleansing agent and water temperature used for cleaning. Wound area should be kept moist. Foot elevation |
Careful inspection can be helpful in identifying extent of injury and potential problems due to injury. Early interventions can be provided for injury (Atkin et al., 2014). Sensitivity of injured skin differs on individual basis. Hence, cleaning of injured skin need to be optimized (Chou et al., 2014). Dressing should be applied in such a way that wound area remains moist which can be useful in absorbing exudate and filling dead space (Romero-Collado et al., 2015; Berg et al., 2012). Foot elevation is useful in reducing edema. By using gravity, swelling can be lowered down (Martin and Nunan, 2015 ). |
Injured skin remains intact and there is no inflammation. Injured area is devoid of infection. John is aware of the cleaning procedure and importance of cleaning of injured area. John can clean his injured area on his own. Skin area remains intact. |
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Nursing problem: Pain |
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Related to: Pain due to injury and wound. |
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Goal of care |
Nursing interventions |
Rationale |
Evaluation |
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There should be reduced pain sensation in John. There should not be restlessness and anxiety in John. |
In John, pain sensation should be assessed for quality, severity, location, onset and duration of pain. Signs and symptoms exhibited by John should be assessed. Cultural, environmental and intrapersonal attributes of John towards pain should be assessed. John’s anticipation towards pain management should be assessed. John’s request to consider different methods for pain relief should be assessed. Nurse should recognize pain in John and plan probable plan for pain management. Painkiller like ibuprofen which is a NSAID should be administered to John. |
Careful assessment of pain in John can be helpful in providing early intervention to John. Pain scales can differentiate severity and sensitivity of pain (Gulanick and Myers, 2016). Pain is subjective assessment. Few patients might not agree existence of pain. In such patients, pain related symptoms like blood pressure, heart rate and temperature should be recorded. Due to pain, Johns skin might become pale and cool to touch. Some patients might become restless and anxious (Woo et al., 2013). Cultural, environmental and intrapersonal play significant role in verbalising and expression of pain (Grondin et al., 2015). Different patients have varied anticipation for pain. Few of the patients take it seriously however others do not bother about it. Treatment method can be changed on the patient’s anticipation about pain (Malec and Shega, 2015). Different medical and non-medical interventions are available for the management of pain. Based on John’s comfort level treatment and management method should be changed (Raviv et al., 2015). Painkillers are associated with various side effects. Early recognition and management of pain can be helpful in lessening dose of painkiller and reducing its duration of treatment. NSAIDs like ibuprofen exhibits its action by blocking prostaglandin release and by producing effect on the peripheral tissues. Hence, ibuprofen can relieve pain in John (Buer, 2014). |
There is significant reduction in pain sensation in John. Physical and psychological alterations not observed in John. There is no cultural, environmental and intrapersonal hindrance for evaluation and treatment of pain in John. John anticipated mild to moderate pain and exhibited tolerance to it. John can avail any type of pain management therapy. Pain sensitivity lessened in John. John relieved form the pain. |
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Nursing problem: Nutrition and hydration |
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Related to: Due to inadequate consumption of food in the form of liquid and solid. |
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Goal of care |
Nursing interventions |
Rationale |
Evaluation |
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John received adequate amount of nutritious food. |
Dietician should be incorporated in John’s, hence dietician can provide diet plan for John. He should consume food both in solid and liquid form. Record body weight on regular basis. Observe physical signs for poor nutritional intake. Provide pleasant environment for food intake. |
Adequate amount food need to be provided to John which can be helpful to control injury and lesion. Less food consumption lead to less perfusion and reduced supply of oxygen to the injured tissues (Dimaria-Ghalili and Nicolo, 2014; Stiles, 2013). Can be used as caloric and nutrient requirement (Dimaria-Ghalili and Nicolo, 2014; Stiles, 2013 ). Poor nutrition can result in fatigue and sluggishness (Dimaria-Ghalili and Nicolo, 2014; Stiles, 2013). It can reduce stress and can produce favourable environment for food intake (Dimaria-Ghalili and Nicolo, 2014; Stiles, 2013). |
John consumed adequate amount food. |
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Nursing problem: Anxiety. |
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Related to: Injury and associated pain can lead to development of anxiety in John. |
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Goal of care |
Nursing interventions |
Rationale |
Evaluation |
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John should define his anxiety and coping method. |
Assess anxiety level. Assess of physical reactions to anxiety. Define type of anxiety whether long duration or short duration. Psychological counselling for management of anxiety. |
Anxiety level assessment can be helpful in providing appropriate management (Gulanick and Myers, 2016). Physical symptoms like nausea, weakness, or dizziness can be evident irrespective of physical cause (Gulanick and Myers, 2016). Based on the type of anxiety nursing intervention can be implemented (Gulanick and Myers, 2016). To protect John fear due to anxiety ( Gulanick and Myers, 2016). |
Improvement in functional thinking. John can recognise signs and symptoms of anxiety. Improved activity level in John. John expresses feelings related to anxiety. |
Gentamicin is an antibiotic and it is being administered to John because he is having cellulitis. Cellulitis is caused by bacterial infection like Streptococci and Staphylococci. These are gram positive bacteria and gentamicin is active against these gram-positive bacteria. It is mandatory to perform renal function test in John prior to gentamicin administration because gentamicin is prone to cause nephrotoxicity. Gentamicin can exhibit toxicity in the dose dependent manner, hence nurse need to assess dose of gentamicin in John in relation to its efficacy and toxicity (Becker and Cooper, 2013). Gentamicin should not be administered along with nonsteroidal anti-inflammatory drug (NSAID). In combination, gentamicin and NASID drugs can exaggerate nephrotoxicity. However, ibuprofen is being administered to John which is a NSAID. Hence, nurse need to monitor effect of combined administration of gentamicin and ibuprofen in John. Nurse should monitor efficacy outcome of gentamicin in John because if it is not producing desired effect in 3 – 5 days, nurse should reconsider administration of gentamicin (Chen et al., 2014).
Anxiety Assessment in John
Ibuprofen is a NSAID which can exhibit its effect in conditions like pain, fever and inflammation. Ibuprofen is being administered in John because he is having pain due to wound. In case of John, ibuprofen is administered because he is experiencing pain. Pain in John need to be monitored by nurse after its administration. Nurse need to monitor hypertension in John because ibuprofen can increase blood pressure. Moreover, John is having hypertension hence nurse need to consult with doctor prior to its administration. Overdose of ibuprofen can lead to occurrence of abdominal pain and gastrointestinal bleeding. Nurse need to educate him for consumption of ibuprofen as self-medication and instruct him not take it in overdose. Allergic reactions of ibuprofen in John need to be assessed because ibuprofen has potential to produce allergic reactions. Nurse need to assess nausea, dyspepsia, diarrhea, constipation, headache, dizziness, rash and fluid retention in John because ibuprofen can produce all these adverse reactions (Moore et al., 2014).
Chest X – ray can be the choice of method for John to assess his further health condition and deterioration. His signs, symptoms and reports indicate that John might be having pulmonary edema.
John is exhibiting symptoms like hypertension and raised respiratory rate with coarse crackles in base of lungs bilaterally on auscultation. In case of pulmonary edema patients there can be fluid accumulation in the alveolar wall and this can be seen in the chest X- ray.
Hypertension and breathing insufficiency in John can be managed by asking him to relax and be in the high flower’s position which can be helpful in the expansion of lung and augmentation of oxygenation. Electrolyte balance and vital signs need to be monitored in John because fluid consumption is reduced in him. ABG need to be monitored in him and based on the data obtained for oxygen saturation, artificial oxygen need to be provided to him (Tabuchi et al., 2013). John should be administered with diuretics. Diuretics can be useful in reducing fluid in the arteries and veins which enables movement from lungs to the blood circulation. In patients with pulmonary edema, fluid need to be removed from the air sacs (Platz et al., 2015). This fluid can be removed from the air sacs by opening these sacs by using Bipap machine. Gaseous exchange can also be improved at capillary and alveolar interface by opening these sacs (Tabuchi et al., 2013).
Blood Pressure Assessment in John
John’s deterioration can be prevented by monitoring and maintenance of blood pressure and immediate supply of artificial oxygen. Maintenance of normal blood pressure can be helpful to supply optimum amount of blood to the vital organs. It can be helpful in preventing further deterioration of these vital organs and maintenance of their normal functioning (Tabuchi et al., 2013; Platz et al., 2015).
John should adhere to the prescribed schedule for medication consumption. John is consuming antibiotic gentamicin and he need to complete prescribed schedule for its consumption. Otherwise, stopping medication consumption prior to its schedule can lead to resistance development for their antibiotic in John. It is proved that anxiety can develop non-adherence to medication consumption. Moreover, John is being suffering through anxiety since long time (Dewit et al., 2016).
John is having multiple health problems like hypertension and breathing problem. These health-related complications can develop depressive behaviour in John. John can effectively manage depressive behaviour and anxiety by using relaxation techniques. Due to pain after injury, John might be feeling stressful. However, John need to divert his attention from this painful condition because stress can exaggerate hypertension and breathing problem in John (Dewit et al., 2016).
John need to clean his wound regularly and keep area around the wound hygienic. It can be useful foe John to get fast wound healing and prevent spread of infection (Dewit et al., 2016).
John need to access numerous websites to get more insight about his condition. These websites include medicine information centre, drug information centre, and medicine and therapeutic information centre. John need to establish effective communication with healthcare professionals to understand his condition.
References:
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Berg, A., Fleischer, S., Kuss, O., Unverzagt, S., and Langer, G. (2012). Timing of dressing removal in the healing of surgical wounds by primary intention: quantitative systematic review protocol. Journal of Advanced Nursing, 68(2), 264-70.
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Chou, P.L., Chien, C.S., Lee, B.O., Bai, Y.L., and Hung, C.C. (2014). Early recovery experience of patients with injury in Taiwan. Journal of nursing scholarship, 46(4), 245-52.
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Martin, P., and Nunan, R. (2015). Cellular and molecular mechanisms of repair in acute and chronic wound healing. British Journal of Dermatology, 173(2), 370-8.
Moore, R.A., Derry, S., Straube, S., Ireson-Paine, J., and Wiffen, P.J. (2014). Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain. Pain, 155(1), 14-21.
Platz, E., Jhund, P.S., Campbell, R.T., and McMurray, J.J. (2015). Assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. European Journal of Heart Failure, 17(9), 906-16.
Raviv, O., Delbar, V., Arad, J., and Grinstein-Cohen, O. (2015). The effect of supportive emergency department nursing care on pain reduction of patients with Red Sea marine wildlife injuries. International Emergency Nursing, 23(4), 281-5.
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Romero-Collado, A., Raurell-Torreda, M., Zabaleta-del-Olmo, E., Homs-Romero, E., and Bertran-Noguer, C. (2015). Course content related to chronic wounds in nursing degree programs in Spain. Journal of nursing scholarship, 47(1), 51-61.
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Tabuchi, A., Styp-Rekowska, B., Slutsky, A.S., Wagner, P.D., Pries, A.R., and Kuebler, W.M. (2013). Precapillary oxygenation contributes relevantly to gas exchange in the intact lung. American Journal of Respiratory and Critical Care Medicine, 188(4), 474-81.
Woo, K.Y., Abbott, L.K., and Librach, L. (2013). Evidence-based approach to manage persistent wound-related pain. Current Opinion in Supportive and Palliative Care, 7(1), 86-94.
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