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A client with a Total Right Knee Arthroplasty

Abstract

The following is a plan of care for a patient who was diagnosed with degenerative arthritis of the right knee and was admitted for right knee arthroplasty. First is an introduction entailing the client’s medical diagnosis and chief complaint as well as other relative demographics such as age, sex, history of present illness and past medical and surgical history. Next is a complete nursing assessment and physical exam followed by pharmacotherapeutics, parenteral therapies and diagnostic and laboratory studies. Also included is one prioritized nursing diagnosis followed by two short term goals and one long term goal, evaluation of goals, and three prioritized interventions with scientific rationales. A reference list can be found at the end.

Nursing Care Plan for a Client with a Total Right Knee Arthroplasty

The following patient is a sixty nine year old Caucasian female. She was admitted on September 21, 2010 after electing to have a total right knee arthroplasty. She had been previously diagnosed with osteoarthritis of the right knee and all conservative therapy had failed. Her admitting diagnosis was degenerative arthritis of the right knee. The client had a long standing history of progressive problems with her right knee including two injuries. The first was a fractured right patella in 1983 when she slipped on some ice while getting her mail and the second was when she tore her meniscus in 2003 while working. She complained of swelling, increased pain with walking while going up and down steps, stiffness, locking of the joint, giving away and general weakness. It had been getting progressively worse over the last few years and she had found it hard to “get going” in the morning without extensive stretching and moving. She rated her pain and discomfort between a four and an eight depending on what she was doing. She described the pain as “sharp at times with a constant dull achy feel.” The patient has a medical history of an irregular heartbeat/atrial fibrillation, pneumonia, high blood pressure, sleep apnea, and coronary artery disease. She also has a surgical history including the removal of cysts from both right and left breasts, an appendectomy, a hernia, colostomy with reversal, arthroscopy of the right knee, a partial hysterectomy, gallbladder surgery and a tonsillectomy. Denies any history of serious childhood illness or injuries and states that she is up to date with all immunizations.

Height, Weight &Vitals

Weight

Height

Temperature

Pulse

Respirations

Blood Press.

210 lb.

No recent changes

64.5 in.

Informed by client

99.2 F

Obtained orally

76 min.

Left radial

+2 regular rate and rhythm

18 min.

Unlabored shallow regular rhythm

126/57

Obtained from left arm

Allergies

Food

Drug

Other

NKFA

NKDA

NKA

Miscellaneous data

The patient was awake, alert and oriented to person, place and time. The patient conversed fluently without hesitancy or difficulty. She had a pleasant disposition and upbeat attitude. She seemed to enjoy the extra attention she was getting. The patient is married and her husband is alive and well. She lives alone with him in a two story house that they own together. When asked of environmental or occupational risks she has faced in the past or presently, the client states that she is a retired licensed practical nurse and has had back pain “at times in the past” due to her work. She states that her right knee was especially bothersome to her since she was on her feet so much. Patient admits to recent difficulty and pain navigating up and down the stairs to her bedroom and states it will be a challenge when she gets back home after her surgery. The patient further states that her husband will help her until her knee is better and she can do it herself. She has one daughter who is also a nurse and works as a case manager. Patient states that she is happy with her life in general and “liked being a nurse but enjoys being retired.” She doesn’t think she would change much if given the opportunity. According to Ericson’s Theory of Human Development, she should be in the life stage of Integrity verses Despair. (Varcarolis, 2010) She appears to be in the stage of Integrity due to her positive feeling of self worth, contributions to society and her successful career as a nurse. She is happy in her marriage and feels they did a good job raising their daughter and states that she is “proud of her.” Patient is a full code status and has an advance directive. Patient denies use of recreational drugs or tobacco products but states she does, “drink socially, a couple drinks a week” and prefers gin and tonic. Patient also informs that she has been taking Crestor (5mg daily), Toprol XL (50mg BID), Nexium (40mg daily), Omega 3 Fish Oil, Glucosamine/Chondroitin, and a multivitamin daily. When asked of family history patient states that her father had a history of heart disease and diabetes and died of pancreatic cancer. Her mother died from ovarian or uterine cancer. Her brother was an alcoholic and had a history of heart disease and cirrhosis of the liver and died of a massive heart attack. Patient states that she doesn’t remember her grandparent’s history other than her grandfather on her dad’s side who died of a heart attack. When asked of her religious beliefs and practices client states that she is a Protestant, goes to church occasionally and has a pastor. When asked if she would like to speak with her pastor she states that she does not.

Physical assessment

Neurologic

Subjective. The patient denies any history of headaches, seizures, loss of consciousness, changes in sensation, tingling or difficulty with swallowing, speaking or hearing. Patient states that she doesn’t normally feel dizzy but that she felt dizzy earlier when standing. Patient also states that she uses glasses for reading. The client denies any vision disturbance or diplopia. Patient states that her pain is currently controlled at three out of ten but has gone as high as eight or nine out of ten since the surgery. It is especially bothersome when she moves the leg or uses the continuous passive motion device. She describes the pain as a “constant dull ache with more of a stabbing pain when I move.” It is contained to her right knee and the area surrounding the incision. Patient further states that the pain is well managed with the medication she is on and is currently about three out of ten.

Objective. The client is awake, alert and oriented to person, place and time. Patient is pleasant, cooperative, well groomed and sitting in the Fowler’s position. Verbal response is spontaneous, clear and coherent with appropriate vocabulary and general knowledge. Immediate, recent and remote memory is intact. Her pupils are equally round at four millimeters and reactive to light and accommodation. Patient has full extra ocular movement. No nystagmus was noted. Facial expressions are symmetrical with no facial droop. Shoulder shrug strength is plus five bilaterally. Her grip strength is plus five bilaterally. No arm drifts, or signs of weakness. Bilateral dorsiflexion is plus four. Bilateral plantarflexion is plus five. Knee lift on left leg is plus five. Did not test right knee lift secondary to current knee surgery.

Integumentary

Subjective. When asked if she has any history of skin problems or skin disease the client states that she gets an “occasional eczema like rash when her skin gets dry.” The patient states she treats the rash with regular, over the counter moisturizer. The client also states that she has a history of bilateral breast cysts which were aspirated and further states that she still has lumps in her breast. The client currently denies having any rashes, lesions, hair loss or changes in hair texture, nail disease or changes in nail texture and strength, or any other skin trauma other than “the big cut over my knee”. When asked about scars client states that she has several in her abdominal area from surgeries performed in the past.

Objective. The client’s skin is warm and dry with light pink under tones. No lesions, rashes, ecchymosis or erythema noted. Skin turgor is positive with no tenting. Mucus membranes and conjunctiva are moist and pink. Skin of the face, neck and extremities is wrinkled with decreased elasticity. Extensive skin pigmentation variations were noted over the entire body with concentrations on the extremities and face. These pigmentations are manifested as light brown, non-raised, irregular shaped spots ranging from approximately 3 mm to 9mm. Skin is intact excluding the surgical incision. The incision runs parallel with the leg and is located medially over the right patella and extends approximately 12 cm. The wound appeared slightly erythematic at the edges but is well approximated with no edema, drainage or odor. Surrounding skin is pink and warm to the touch. Client’s hair is finely textured, short and gray with no alopecia or pediculosis noted. Scalp mobile, non tender and dry with no lesions or rashes. Nails of all extremities are intact, convex, clear, smooth and well groomed with pink cuticles. No clubbing noted. Brisk capillary refill of less than three seconds noted bilaterally on upper and lower extremities.

Respiratory

Subjective. The client presently denies having a cough, dyspnea, or chest pain. Client also denies having a history of chronic respiratory infections or lung disease and denies taking any medications for respiratory disorders. However, client does state that she had pneumonia “a long time ago” and a pulmonary embolism in the 1970’s but hasn’t had any problems since. Patient also states that she has sleep apnea and has used Continuous Positive Airway Pressure (CPAP) at times at home but doesn’t really like to wear it. Client denies smoking or being exposed to environmental respiratory hazards in either her home or occupation. Client also states that she has experienced shortness of breath on exertion in the past but hasn’t really noticed any recently.

Objective. The client is relaxed and breathing room air without difficulty or distress. Her oxygen saturation is 93%. Skin is light pink with no cyanosis. Client’s respirations are rhythmic with unlabored, inaudible, shallow breaths at a rate of eighteen a minute. No retraction or use of accessory muscles noted. Trachea midline no deviation noted. Chest is symmetrical in shape with even expansion and contraction. Anteroposterior to transverse diameter is 1:2. No masses, crepitus or tenderness noted upon palpation of chest wall. All lungs fields clear to auscultation bilaterally. No adventitious or abnormal breath sounds. Spirometer located within reach on bedside table.

Cardiovascular

Subjective. When asked of a history of cardiac problems client states that she has a history of irregular heartbeat, coronary heart disease, hypertension and high cholesterol. Client states that before coming in for surgery she was on Toprol XL and Crestor. She received a cardiac catheterization in 2010 and states the “blood wasn’t flowing well to the left side of my heart.” Also states that she had palpitations that would “come and go” but hasn’t felt any recently. Patient denies syncope, edema or chest pain but does experience some fatigue with exertion.

Objective. The client’s medical history states that she has a history of hypertension, high cholesterol, irregular heartbeat/atrial fibrillation, and coronary heart disease. Client has a number twenty intravenous catheter in her right forearm with one half normal saline infusing at 83 ml and hour. The intravenous site is uncomplicated with no signs and symptoms of infiltration or infection. The upper extremities are warm and pink with no edema noted. Capillary refill is less than 3 seconds bilaterally. Bilateral radial pulses are strong with a regular rhythm at seventy six beats per minute. Lower extremities are warm and pink with a capillary refill of less than three seconds. Bilateral pedal pulses have a regular rhythm at seventy six beats a minute. No edema was noted. A distinct apical pulse was auscultated at the fifth intercostal space, left sternal border at seventy six beats per minute with a regular rhythm. No adventitious heart sounds or murmurs were noted. Client’s blood pressure was taken on the left arm at one hundred twenty six over fifty seven.

Gastrointestinal

Subjective. The patient states that she has gained some weight since retirement but has maintained a fairly even weight over the last six months. She tries to eat healthy and likes to cook. Client also states that she really doesn’t have any food allergies but eating too much lactose bothers her. When asked of her use of supplements, herbal preparations or medications taken at home client states that she regularly takes a multivitamin, Omega 3 fish oil, Nexium, Crestor, Glucosamine/Chondroitin, and Toprol XL. When asked of elimination patterns patient states that she typically has a bowel movement a day and is fairly regular. However she has not had a bowel movement since the morning of admission. Further states that she hasn’t eaten much since surgery because she feels nauseous due to the pain and medications. Client denies abdominal pain or vomiting. When asked of any history of diseases of the mouth stomach or intestines client states “I had a colostomy with reversal around 1995 for a ruptured diverticulum”. Also states she had her “tonsils out three or four years ago, gallbladder removed about three years ago and a hernia repair many years ago.” When asked if she knows what type of hernia she had states that she does not remember.

Objective. The client is on a cardiac diet. She completed approximately twenty five percent of her breakfast and fifty percent of her lunch. Upon inspection of the mouth, the lips are moist, pink and smooth with no lesions noted. Inner buccal mucosa is pink and moist with no lesions. Client’s teeth are all intact and gums are pink. No swelling, retraction, bleeding or lesions were noted. Her tongue is dull red, moist and symmetrical with a slightly rough surface. No swelling or lesions were noted. The client is obese with an abdomen that is symmetrically pendulous with no observable distention. Umbilicus is centered and inverted. Upon auscultation of the abdomen active bowel sounds are heard in all four quadrants. No resistance, tenderness or distention noted on palpation. Unable to assess stool due to client not eliminating.

Genitourinary

Subjective. The client denies the presence of pain on urination, frequency, urgency, dribbling, incontinence, hesitancy, or changes in her urine stream. The patient states that before her surgery she typically “went about four times a day.” Patient also denies vaginal discharge, pain, lumps or masses. Client also states that she had a partial hysterectomy.

Objective. The client had an indwelling Foley catheter and voided four hundred fifty milliliters of clear yellow urine. The Foley catheter was removed as per doctor’s order without complication at 1330. No bladder distention noted. The client deferred an exam of the genitals therefore a visual assessment of genitourinary system was not done.

Pharmacotherapeutics

Arixtra, (Fondaparinux) 2.5mg SQ daily, Mechanism of action- Binds selectively to antithrombin III potentiating the neutralization of factor X thus inhibiting thrombus formation by interrupting coagulation. Correlation - reduces the risk of pulmonary emboli due to lack of movement in the muscles. Evaluation of client- Patient remains free of embolism and/or peripheral blood clot. Client teaching- performed to educate the patient about the importance of post operative prevention of formation thrombus. Nursing Intervention- Administer medication as indicated.

Coumadin, (Warfarin) 5mg IV daily, Interferes with hepatic synthesis of vitamin K-dependent clotting factors thus preventing thromboembolic events. Correlation -being used prophylacticly as an antiembolitic treatment because of the patient’s history of atrial fibrillation keeping clots from forming which could lead to stroke, heart attack, and/or death. Raises the International Normalized Ratio (INR) thus reducing Prothrombin Time (PT). Evaluation of client- Patient remains free of emboli secondary to a history of an irregular heartbeat / atrial fibrillation as well as a history of pulmonary embolism in the past. Client teaching- aimed toward educating the client about the importance of preventing an embolism secondary to past medical history. Client must be educated about following up with treating physician while still taking Coumadin. Client must have INR lab values checked periodically throughout therapy. Nursing Intervention- Determine cardiac rhythm, note the presence of dysrhythmias. Observe for and note any signs of pulmonary emboli.

Colace, (Docusate Sodium) 100mg PO BID, Mechanism of action-Promotes incorporation of water into stool resulting in softer fecal mass. Correlation- used to soften stool making it easier to have a bowel movement. Evaluation of client- Patient has yet to have a bowel movement since the morning of surgery (9/21). Client teaching- emphasizes the monitoring of amount and frequency of bowel movements during the immediate post operative period. Pt is educated to report to healthcare provider the absence of or difficulty in passing stools. Nursing Intervention- Determine fluid intake to evaluate client’s hydration status. Review daily dietary regime, noting if the diet is deficient in fiber. Evaluate client’s medications which could cause/exacerbate constipation.

Ferrous Sulfate, (Iron) 325mg PO BID, Mechanism of action-Enters bloodstream and is transported to the liver, spleen and bone marrow where it is separated out and becomes part of the iron stores thus treating or preventing iron deficiency. Correlation -Used to prevent iron deficiency anemia as a result of decreased nutritional and dietary needs secondary to surgical procedure. Evaluation of client- Patient does not demonstrate signs and/or symptoms of anemia and patient’s hemoglobin and hematocrit are within normal limits. Client teaching- educate in the importance of iron stores in the role of adequate healing. Nursing Intervention- Review labs to determine if iron stores are adequate and hemoglobin and hematocrit are within normal limits. Review daily dietary regime, noting if diet is deficient in iron.

Lopressor, (Metoprolol) 50mg PO BID, Mechanism of action-Blocks stimulation of beta-adrenergic receptors decreasing blood pressure and heart rate. Correlation-Client has a history of hypertension. Evaluation of client- Patient has maintained a blood pressure within normal limits throughout her hospital admission. Client teaching- educating client about the importance of taking this medication daily as ordered in order to maintain a blood pressure within normal limits. Educate client on follow-up and screenings of blood pressure to ensure therapeutic effects. Nursing Intervention-Evaluate vital signs, noting changes in blood pressure, heart rate, and respirations.

Zocor, (Simvastin) 10mg PO Q hs, Mechanism of action-Inhibits an enzyme (HMG-CoA) responsible for catalyzing an early step in the synthesis of cholesterol thus lowering triglycerides, LDL and total cholesterol. Correlation- Patient has a history of coronary artery disease and high cholesterol. Evaluation of client- Unable to evaluate client’s cholesterol level – no cardiac risk labs drawn during this admission. Educate client in the importance of taking Zocor to reach and maintain a healthy cholesterol level for cardiovascular health. Nursing Intervention- Identify risk factors in client’s personal and family history. Note health values and expectations regarding healthcare.

Protonix,(Pantoprazole) 40mg PO Q day, Mechanism of action- Binds to an enzyme in the presence of acidic gastric pH preventing the final transport of hydrogen ions into the gastric lumen thus diminishing the accumulation of acid in the gastric lumen and lessening acid reflux. Correlation - Patient has a history of GERD. Evaluation of client- Client was able to verbalize a decrease/elimination of the symptoms of GERD. Client teaching- includes teaching the client to maintain the medication regime in order to receive maximum benefits. Teach client that this medication cannot be used on an as needed basis for intended relief. Nursing Intervention- Assess patient routinely for epigastric or abdominal pain as well as for frank or occult blood in stool, emesis, or gastric aspirate.

Morphine 3mg IV Q 3 hours PRN for severe pain. Mechanism of Action- Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Evaluation Patient was able to verbalize a 50% reduction in pain rating down to 4 out of 10 within 30 minutes of IV administration. Client teaching- educate on how and when to ask for pain medication. May cause drowsiness or dizziness. Instruct patient to call for assistance when ambulating. Nursing Intervention- Assess blood pressure, pulse, and respirations before and periodically during administration. Administer doses on a regular schedule and before pain becomes severe.

Percocet, (oxycodone/acetaminophen ) 5/325 1- 2 tabs PO Q 4 hours PRN for pain rating of 1-5 (1 tab) and 6-10 (2 tabs) on a verbal pain rating scale. Mechanism of Action- Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Correlation- Patient was having post operative pain of 8 out of 10 on a numeric pain rating scale. Evaluation - Pt was able to verbalize a 50% reduction in pain on a numerical analogue scale within thirty minutes of PO administration. Client teaching- encourage patient to turn, cough, and breathe deeply every two hours to prevent atelectasis. Nursing Intervention- Assess type, location, and intensity of pain prior to and 1 hour (peak) after administration.

Diagnostic and Laboratory Studies

Chemistry-General

Normal’s

09/23/10

09/22/10

GLUCOSE

60-100 mg/dL

116 H

101 H

BUN

7-17 mg/dL

13

23 H

CREATININE

0.7-1.5 mg/dL

0.8

1.0

SODIUM

137-145 mmo/L

142

142

POTASSIUM

3.6-5.0 mmo/L

4.2

4.5

CHLORIDE

98-107 mmo/L

107

108 H

CO2-VENOUS

22-30 mmo/L

23

22

ANION GAP

6-16 mmo/L

12

12

BUN/CREAT RATIO

5.0-35.0 mg/dL

16.3

23

OSMOLARITY

275-295 mOsm/kg

284

287

CALCIUM

8.4-10.2 mg/dL

8.4

8.6

Normal’s

09/22/10

WBC

RBC

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

MCHC

MPV

RDW

PLATELETS

PT

INR

4.0-11

3.5-5.1

11-15.2 g/dL

32-45 %

80-98 fL

27.6-34.5 pg

33-36 g/dL

7.4-10.4 um

11.3 -15%

140-380

9.4-13.6 sec

2-3

13.9 H

4.42

13.6

40.8

92.4

30.7

33.2

9.7

12.9

139 L

13.3

1.2 L

Analysis of Diagnostic and Laboratory Studies

Glucose

In people that are healthy levels of blood glucose fluctuate in direct response to food intake and fasting. For accurate test results it is important to observe fasting for eight to twelve hours. People with high blood sugar are at greater risk for infection and delayed wound healing. Phagocytic and chemotactic functions are inhibited when glucose levels are high thus prolonging the healing time (Porth, 2007). Bacteria are also known thrive on glucose and elevated levels can increase the risk for infection. The clients blood glucose levels were slightly elevated during her current admission. The normal range of serum glucose is 60-100 mg/dL. (Pagana, 2006) The client’s serum glucose levels were 101 and 116. The client’s glucose levels could be elevated due to physical and emotional stress of surgery, recent general anesthesia and use of post operative pain medications. The client is also on a beta blocker which can increase glucose levels.

Blood Urea Nitrogen (BUN)

Blood Urea Nitrogen (BUN) is used to measure the amount of protein waste or byproducts produced by the liver (urea nitrogen). The blood transports these waste products to the kidneys where it is filtered out and excreted in the urine. BUN is therefore directly related to the functional metabolism of the liver and the excretion ability of the kidneys and is a direct reflection of the functional ability of these two organs (Pagana, 2006). The client had an elevated BUN on her first post-op day. The level may have been elevated immediately after surgery due to physical stress of a major surgical procedure, fluid and blood loss causing dehydration secondary to the surgical procedure. On the second post-op day the client’s serum BUN level had returned to normal range.

Chloride

Chloride is a valuable electrolyte in the blood. It keeps the blood pressure, volume and pH of the body fluids in balance. Chloride follows sodium (cation) losses and helps to maintain electrical neutrality. Chloride shifts usually occur parallel to changes in sodium and bicarbonate levels (Pagana, 2006). The client in this case study did have a slightly elevated Chloride level on the first post-op day. The level was 108 and the normal range is 98-107. The client’s level was most likely elevated related to dehydration secondary to fluid and blood loss during the surgical procedure. On the second post operative day the client’s serum chloride level had returned to normal.

Platelets

The platelet count is an actual count of the physical number of platelets in the blood. Platelets play an important role in hemostasis with platelet aggregation followed by the coagulation factor cascade. Almost all platelets exist in the bloodstream but there are some platelets in the liver and spleen as well. Platelets survive on average of 7 to 9 days. (Pagana, 2006) The client in this case study had a slightly low platelet count. The most likely cause of this client’s decreased platelet count is secondary to blood loss and fluid loss during the surgical procedure.

Prothrombin Time (PT)

The PT or Prothrombin time measures the clotting ability of factors I (fibrinogen), II (Prothrombin), V, VII, and X. Depending on these factors the clotting time is either prolonged or shortened. When the PT is low, the PT is prolonged. (Pagana, 2006) Many factors can affect a patients bleeding time (esp. Coumadin, aspirin, and heparin can increase the PT). The client in this case study had a PT of 13.3 on her first post operative day and a PT of 15.1 on her second post operative day. The client’s increase in PT level was due to the administration of Coumadin and Arixtra as per doctor’s order (for prevention of post operative emboli).

International Normalization Ratio (INR)

In order to provide health care workers with uniform results around the country the PT results include the use of international normalized ratio (INR) value. The reported INR results are independent of the reagents or methods used. A therapeutic INR is can range from 2 to 3.5, depending on the clinical situation. (Pagana, 2006) The client in this case study was receiving Coumadin as ordered by the physician and had an INR of 1.4 on her second post operative day. The client was administered daily oral Coumadin starting on her day of surgery. The client’s INR value demonstrates that she has not yet reached a therapeutic level.

Prioritized Nursing Diagnosis

Alteration in comfort related to acute pain from surgical procedure as evidenced by guarding /protective measures and verbalization of pain as eight out of ten.

Short Term Goal One- Client will report pain level of four or less out of ten within fifteen to thirty minutes of receiving pain medication.

Short Term Goal Two- Client will demonstrate understanding of nonpharmacologic ways to alleviate pain by the end of shift.

Long Term Goal- Client’s pain level, without use of pharmacologic methods, will be equal or less than two out of ten on a numerical pain scale within one month of surgical procedure.

Intervention One- Assess client’s pain every four hours.

Scientific Rationale

The first step in treating a patient’s pain is to do a careful assessment including the many factors of pain. These factors include nature, severity, location, and radiation of pain (Porth, 2007). Carefully assessing a client’s pain helps doctors and nurses to better diagnose the source, manage and use proper modalities to treat the pain. There are many factors to consider during the assessment of a client’s pain and their abilities to express and report their feelings of pain. These elements include things such as their cultural background, economic status, social class, education level, and sex. (Smeltzer, 2010) There are many ways to formally assess and document wound pain. Some examples of pain scoring include the Wong-Baker FACES pain rating scale in which the client has to point to the face which best describes their pain intensity. (Bowers, 2009) This scale is most commonly used with children so that they can point to the face that best describes their pain and allows the healthcare provider to record the corresponding number. Another popular pain rating scale is the visual analogue scale which has a 0 to 10 continuum and the client can point to the point on the line that best describes how he or she is feeling. Then there is a numerical rating scale in which the pain simply states their pain on a 0-10 scale where 0 equals no pain and 10 equals the worst possible pain. Lastly, a verbal rating scale may be used in the client’s own words best describes his or her current pain ranging from no pain, mild pain, or moderate or severe pain.(Bowers, 2009) Deciding which pain assessment scale to use is best decided by patient preference. Patients that cannot communicate in a way to effectively use a pain scale must be assessed by their body movements and vocalizations (Blondal & Halldorsdottir, 2009). There is a tool called the Doloplus-2 scale which uses the observation of a patient’s behavior to determine their pain rating (Bowers, 2009). Most pain management literature states that a pain rating of four or more consistently by a patient dictates uncontrolled pain. Uncontrolled pain necessitates a reassessment of a client’s wound, consideration of any complications and careful initiation of new pain management methods. The best method for appropriate treatment of pain is for the healthcare provider to develop a relationship with their patient and to know how that patient reports and relates to their pain as well as what factors influence their pain.

Intervention Two - Administer pain medications as prescribed.

Scientific Rationale

Administration of pain medications should be provided to the client before the pain reaches the rating of severe and pain becomes debilitating to the patient. Pain control allows for the patient to remain comfortable while still being able to play an active role in his/her care plan (Porth, 2007). When pain is treated while it is at a rating of mild it is more likely that lower doses of pain medication will be administered. Therefore a patient’s risk of becoming dependent on opioid analgesics is lessened. Many healthcare providers have concerns about addiction when using stronger pain medications such as opioids for treating pain. It has been found that addiction to opioids when being used for acute pain is highly unlikely (Porth, 2007). Opioid analgesics bind to opiate receptors in the central nervous system. They alter the perception of and response to painful stimuli, while producing generalized central nervous system depression (Deglin & Vallerand, 2009). It is very important to monitor a patient’s level of consciousness, respirations, heart rate, and blood pressure before and during the administration of opioid analgesics. The initial central nervous system depression will decrease with consecutive doses of opioids. An important part of medicating a postoperative patients pain is making sure that the patient has a clear understand of when and how to approach his or her healthcare provider about their pain (Blondal & Halldorsdottir, 2009). The nurse plays an important role in this matter. Nurses must make their patients aware of their pain management options and comfortable with them to ensure that they are seeing the “big” picture regarding pain medications and pain control. It is a good practice for nurses to be aware of their patient’s pain and be the patient’s biggest advocate (Blondal & Halldorsdottir, 2009). Other agents or co-analgesics could be another pharmaceutical option for treating unrelieved post operative pain (Bowers, 2009). Non-steriodal anti-inflammatory drugs (NSAIDs) are always a good co-treatment as well and have proven to work well for the pain associated with a dressing change (Bowers, 2009). It is a good idea for the patient and patient’s family to come up with a plan for pain control before surgery if at all possible. This can save the patient a lot of confusion and frustration when it comes to being a part of their post operative pain management.

Intervention Three - Teach nonpharmacologic interventions for pain management.

Scientific Rationale

Nonpharmacologic interventions are not usually successful for the primary management of postoperative pain. On the other hand, nonpharmacologic methods can be very successful in conjunction with analgesic medications. (Smeltzer, 2010) Pain can be defined as an unpleasant sensory and emotional experience associated with actual and potential tissue damage (Porth, 2009). Within this definition it is indicated that nonpharmacologic methods could be used to treat pain. It clearly states that pain is an unpleasant emotional experience as well. There are many nonpharmacologic methods that nurses can teach patients to utilize in the management of their pain. These methods include: massage, thermal therapy, distraction methods, transcutaneous electrical nerve stimulation, distraction, relaxation techniques, guided imagery, hypnosis, music therapy, herbal therapy, chelation, therapeutic touch, reflexology, magnetic therapy, acupressure, emu oil, aromatherapy, homeopathy, and macrobiotic dieting. Distraction is a popular mode of nonpharmacologic intervention and can be explained in the context of the Gate Control Theory (Bowers, 2009). The Gate Control Theory is one of many theories along with the neuromatrix theory in which stimulation of nociceptors are responsible for the sensation of pain (Porth, 2009). These receptors are different than most sensory receptors because they will respond to several different forms of stimulation. Associations with surrounding stimuli that preceed painful events alters mood and narrow the attention to increase the perception of pain (Porth, 2009). Preparation of patients before surgery for use of nonpharmacologic interventions can promote patient and family satisfaction and a decrease in postoperative pain (Bowers, 2009). One study of patients’ who thought peaceful thoughts actually caused the activity of the pain centers of their brains to decrease (Boufis, 2009). It is an important part of pain management to encourage the patient that they have some control over their perception of pain.

Evaluation of Goals

The client for this case study was able to meet many of her goals before the end of the shift. The client was able to state a reduction in pain level from a stated seven out of ten on a numerical pain scale down to a rating of four out of ten within thirty minutes of receiving the ordered dose of intravenous morphine. The client was able to remain within a tolerable pain level with the pain medications that were ordered by the physician. The client states that since surgery she had trouble sleeping because of the pain. The client states she was able to sleep for five hours after being medicated. The client was also able to meet the second short term goal which was for client to demonstrate understanding of nonpharmacologic ways to alleviate pain by the end of shift. The client understands and was able to verbalize several methods to alleviate pain without or in conjunction with medications such as listening to music, reading or watching television as a distraction from the pain. The client’s long term goal was not possible to evaluate. The client’s long term goal is to report, without the use of pharmacologic methods, that pain is equal or less than two out of ten on a numerical pain scale within one month of surgical procedure. The client was going to rehabilitation care the day after the aforementioned assessment. This goal is achievable within the time frame as long as no complications occur.

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