1 Student Name: Flores, Nicole A03538418 3.

4 Assignment Instructions: Read the scenario provided and develop at least two appropriate nursing diagnoses, goals, outcome criteria; interventions; and evaluation statements using the table provided. Outcomes are SMART specific, measureable, achievable, relevant, & timely. Scenario: Mr. Pitt , a 25 year old male, arrives in the ER with complaints of severe abdominal pain that he rates on a pain scale as a 10/10. The pain originated in the peri-umbilical area radiating to the right lower quadrant and has become localized. Mr. Pitt describes the pain as persistent and continuous and is sitting upright with his right leg flexed. The diagnosis of acute appendicitis is made by CT and ultrasound. Mr. Pitt is scheduled for OR emergently and is asking for his wife. He is anxious and inconsolable. VS: Temp 100.6 / BP 145/84 / HR 105/ RR 28/ O2 sats are 96%. Nursing Diagnosis & Goal Statement Acute pain r/t physical injury agent aeb pain in RLQ, radiating in peri-umbilical area and appendicitis Nursing Outcome Criteria Nursing Interventions Nursing Evaluation

---Patient will be able to reach a tolerable pain level within his comfortfunction level. During his hospitalization and time under my care -Patient goals are partially (12-hour shift). Pain will met until surgery is be assessed before, completed. Patient remains during (based on in pain until medications are vitals), and after ordered appropriately by the surgery. physician. Patient vitals remain within normal parameters and are being ---Patient will be avle to checked every 15 minutes. describe how unrelieved Upon beginning of surgery, pain will be managed patient will be monitored as while under my care stable. (12-hour shift). Patients pain will be assessed before, during and after surgery.

Assess pain level -Patient identifies in a client using a level of pain initially valid and reliable at 10 out of 10. self-report pain tool, such as the -Patient recognizes 0-10 numerical that pain is pain rating scale. temporarily The first step in alleviated with the pain assessment flexing of his right is to determine if leg. the client can provide a self-Patient is anxious report. Ask the and inconsolable, client to rate pain patient will be intensity or select provided pain descriptors of pain medication upon intensity using a doctors orders. valid and reliable self-report pain -Patient will be tool (Breivik et al, allowed for a brief 2008; Pasero et moment with his al, 2009). EB: wife prior to surgery Single-dimension if there is time. If pain ratings are not, family will be valid and reliable notified of the

as measures of impending surgery. pain intensity level (Breivik et al, -Vitals are being 2008). EBN: An taken every 15 investigation of minutes. nursing attitudes and beliefs about -Patient is pain assessment immediately ruled revealed that NPO prior to surgery. effective use of pain rating scales is often determined by the nurse's personal attitude about its effectiveness (Layman-Young, Horton, & Davidhizar, 2006). Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of adverse effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs. EBN: Obtaining an individualized pain history helps to identify potential factors that may influence the client's willingness

to report pain, as well as, factors that may influence pain intensity, the client's response to pain, anxiety, and pharmacokinetics of analgesics (Kalkman et al, 2003; Deane & Smith, 2008; Dunwoody et al, 2008). Pain management regimes must be individualized to the client and consider medical, psychological, and physical condition; age; level of fear or anxiety; surgical procedure; client goals and preference; and previous response to analgesics (Bhavani-Shankar & Oberol, 2009). Prevent pain during procedures if possible (e.g. venipuncture, heel punctures, and peripherally inserted intravenous catheters). Use a topical or intravenous local anesthetic as determined by individualized client status and

4 need. Intravenous catheter placement is one of the most common painful procedures performed in all ages and health care settings, often without anesthetic, despite research demonstrating effectiveness (Valdovinos et al, 2009). EBN: Topical anesthetic creams can decrease venipuncture and IV insertion pain significantly (Fetzer, 2002; Brown, 2009; Valdovinos et al, 2009). Explain to the client the pain management approach, including pharmacological and nonpharmacologic al interventions, the assessment and reassessment process, potential adverse effects, and the importance of prompt reporting of unrelieved pain. One of the most important steps toward improved control of pain is

a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control (APS, 2008). Teach and implement nonpharmacologic al interventions when pain is relatively wellcontrolled with pharmacological interventions. Nonpharmacologic al interventions should be used to supplement, not replace, pharmacological interventions (APS, 2009).

Anxiety r/t health status of -Patient will have vital appendicitis aeb anxious and signs that reflect inconsolable behavior and baseline or decreased impending emergency sympathetic stimulation surgery. while under anesthesia, during surgery, and after surgery while ---Patient goals are under my care (during a achieved. Patient baseline 12 hour shift). vitals are achieved after anesthesia and explanation -Patient will of processes for surgery, demonstrate some along with the presence of ability to reassure self his wife. Patient also is while during the care of reassured of his level of care physicians and nurses. during surgery and This will be achieved demonstrates understanding while under my care of anxiety prior to (during a 12 hour shift).

Assess the client's level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of anxiety). Consider using the Hamilton Anxiety Scale, which grades 14 symptoms on a scale of 0 (not present) to 4 (very severe).

-Patients vitals are taken every 15 minutes and achieve a baseline of normal values during and after surgery. -Prior to surgery procedures and processes are thoroughly explained to the patient and this achieves relief and comfort. -Patient is told that some anxiety is typical preoperative.

6 emergency surgery. Symptoms evaluated are mood, tension, fear, insomnia, concentration, worry, depressed mood, somatic complaints, and cardiovascular, respiratory, gastrointestinal, genitourinary, autonomic, and behavioral symptoms. EBN: Reliability and validity of the Hamilton anxiety scale have been supported by research (Flood & Buckwalter, 2009). EBN: Anxiety is a risk factor for major adverse cardiac risk events in persons with stable coronary artery disease (Frasure-Smith & Lesperance, 2008). If the situational response is rational, use empathy to encourage the client to interpret the anxiety symptoms as normal. EBN: The way a nurse interacts with a client influences his/her quality of life. Providing

psychological and social support can reduce the symptoms and problems associated with anxiety (Wagner & Bear, 2009). Intervene when possible to remove sources of anxiety. EBN: Anxiety has a negative effect on quality of life that persists over time (Sareen et al, 2006). Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the client's understanding. EBN: Effective nurse-client communication is critical to efficient care provision (Finke, Light, & Kitko, 2008). Teach the client/family the symptoms of anxiety. EBN: Information is empowering and reduces anxiety (Godfrey, Parten,

& Buchner, 2006). Provide family members with information to help them to distinguish between a panic attack and serious physical illness symptoms. Instruct family members to consult a health care professional if they have questions. EBN: Education on managing anxiety disorders must include family members because they are the ones usually called on to take the client for emergency care. Family members can be expert informants because of their familiarity with the client's history and symptoms (Carr, 2009).

Resources
The American Pain Society (APS): Principles of analgesic use in acute and chronic pain, ed 6, Glenview, IL, 2008, The Society. The American Pain Society (APS): Pain: current understanding of assessment, management and treatments, 2009. www.ampainsoc.org/ce/enduring.htm. Accessed July 6, 2009.

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