Present a nursing situation in which you performed an assessment, including a assessment of a patient. Describe the environmental feature(s), equipment, and cardinal technique(s) you used during the assessment. As you remember the patient and nursing situation, describe his/her general survey and mental status at the time of initial assessment. Also identify and describe the type of pain the patient had in this situation. How was this pain resolved? (3:1-7)
Title: Nursing Assessment and Pain Management: A Case Study
Introduction:
Nursing assessment plays a crucial role in delivering effective patient care. This paper aims to describe a nursing situation wherein a comprehensive assessment was performed, involving the evaluation of a patient’s overall condition, environmental factors, equipment usage, cardinal techniques, general survey, mental status, and pain management.
Case Presentation:
In this case scenario, the patient in question was a 65-year-old male, Mr. Smith, who was admitted to the medical-surgical unit with complaints of severe abdominal pain, nausea, and vomiting. As a registered nurse, I undertook the responsibility of conducting his initial assessment to identify and address his presenting health concerns effectively.
Environmental Features and Equipment Used:
The assessment took place in Mr. Smith’s private room, which consisted of a hospital bed, bedside table, call bell, and necessary medical equipment such as a cardiac monitor, oxygen supply, and an intravenous (IV) infusion pump. The primary objective of assessing the environmental features was to ensure patient safety, comfort, and accessibility to essential resources.
Cardinal Techniques Employed:
During the assessment, several cardinal techniques were utilized to gather comprehensive patient data. These included observation, interviewing, percussion, palpation, and auscultation.
General Survey and Mental Status:
Upon entering the room, the initial observation comprised the general survey of Mr. Smith. He appeared to be in distress, exhibiting guarded movements and an hunched-over posture. His skin appeared pale, diaphoretic, and dry, indicative of potential dehydration. Vital signs revealed a blood pressure of 150/90 mmHg, heart rate of 110 beats per minute, respiratory rate of 24 breaths per minute, and a temperature of 99.2°F. These findings suggested the presence of pain and possible underlying pathology.
Mental status assessment revealed that Mr. Smith was awake and alert, but appeared anxious and restless. He was cooperative during the interview, although he occasionally exhibited signs of discomfort. His speech was clear and coherent, indicating intact comprehension and communication abilities. However, it was noted that he was primarily focused on his abdominal pain throughout the assessment.
Identification and Description of the Pain:
Mr. Smith described the pain as a sharp, cramping sensation in the upper abdominal region that radiated to the back. The pain was constant and exacerbated by movement, coughing, and deep breathing. This type of pain, characterized by its location and exacerbating factors, suggested a potential gastrointestinal etiology, such as acute pancreatitis or cholecystitis.
Resolution of Pain:
To address Mr. Smith’s pain, a multimodal analgesic approach was employed. Initially, a non-pharmacological intervention was implemented. This included providing a comfortable position with the head of the bed elevated, ensuring adequate rest, and relaxation techniques. Simultaneously, a thorough nursing assessment was conducted to rule out any physiological causes of pain.
Upon completion of the assessment, pain management interventions were initiated. Pharmacological interventions included the administration of intravenous opioids, specifically morphine, titrated to analgesic response and monitoring respiratory status closely. Non-opioid analgesics, such as acetaminophen, were avoided due to potential hepatotoxicity concerns. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) were withheld due to their potential to exacerbate gastrointestinal symptoms.
Conclusion:
This case study highlights the importance of a comprehensive nursing assessment and pain management approach in clinical practice. The assessment involved evaluating the patient’s general survey, mental status, and identifying the characteristics of pain. By utilizing appropriate equipment, environmental features, and cardinal assessment techniques, a holistic understanding of the patient’s condition was achieved. Effective pain management interventions were then employed, combining both pharmacological and non-pharmacological approaches to alleviate Mr. Smith’s pain. Ultimately, this case study emphasizes the crucial role of nursing in assessing and managing pain to promote optimal patient outcomes.