Acute Pain R/T Surgery AEB
Primary Nursing Diagnosis
Acute Pain r/t surgery AEB
Supporting Data
-“My pain is 4/10 if I don’t move.”
-“It’s 8/10 if I’m moving around.”
-“My back hurts. It hurts really bad. It’s like a knife stabbing me in the back.”
-Pt. winced when getting up from bed.
-Microdiskectomy
STG
The pt. will report a consistent pain level of 3/10 or less within 48 hrs. postoperatively.
Interventions with Rationale
-Assess pain level q2h
-accurate pain assessment is necessary to implement proper & efficient pain management-p. 368
-Administer pain meds as scheduled & prn
-it’s easier to control pain by “staying on top of it” instead of waiting for it to become unbearable-p. 372
-Develop a therapeutic relationship ċ pt, especially regarding pain at all times (Ex: encourage pt to express pain, provide support & understanding of pain, teach self-management
-Nurse that actively involves pt. in planning, implementing, & assessment of pain management enhances pt’s potential for satisfactory pain relief/reduction-p. 372
EBP Citation
Black, J, & Hawks, J. (2005). Medical surgical nursing, 8th Ed.
Evaluation
Goal not met; pt. continues to report pain 4/10 when not moving. Will continue plan of care.
Nursing Diagnosis #2
Impaired gas exchange r/t smoking AEB
Supporting Data
-Sleep apnea
-BiPAP at night
-Wheezes present on expiration
-Smoker
-2L NC ċ continuous pox prn
-spirometer
STG
The pt. will have POX reading of at least 93% during clinical shift.
Interventions with Rationale
-Measure POX sat q4h.
-POX level of less than 93% usually indicates need for increased supplemental O2-p. 853
-Assess resp. rate & rhythm q4h
-Uneven or irregular breathing can indicate airway obstruction-p. 826
-Auscultate lung sounds q4h
-listening to breath sounds ċ a stethoscope provides vital info for evaluating the client’s respiratory status-p. 826
-Encourage use of incentive spirometer q1h
-Incentive spirometry motivates the client to take responsibility for the progress of deep-breathing therapy-p. 832
EBP Citation
Craven, R, & Hinle, C. (2007). Fundamentals of nursing, 5th Ed.
Evaluation
Goal met; client POX was 94%.
Nursing Diagnosis #3
Risk for Ineffective sleep pattern r/t breathing difficulty
Supporting Data
-History of Sleep Apnea
-BiPAP at night
-Wheezes
-Smoker
-2L NC ċ continuous POX prn
STG
Pt. will report feeling rested during hospital stay.
Interventions with Rationale
-Ask pt. if he is feeling rested every morning after pt. wakes up.
-The single most important criterion for adequacy of sleep & rest is the client’s statement-p. 1171
-Ask pt. if he experienced sleep apnea every morning after pt. wakes up.
-Untreated Sleep apnea can increase chance of HTN, heart attack, & stroke-p. 1171
-Encourage BiPAP use qhs
-The client’s inspiratory effort triggers the ventilator, which pushes air into the lungs to help breathing-p. 841
-Explain benefits of cessation of smoking to pt. before D/C
-Smoking is the most important lifestyle choice affecting respiration-p. 821
EBP Citation
Craven, R, & Hinle, C. (2007). Fundamentals of nursing, 5th Ed.
Evaluation
Goal not met; client did not state feeling rested. Will continue plan of care.