Nursing Case Study on Pain

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  • 0:02 Nursing Case Study on Pain
  • 0:28 Assessment & Diagnosis
  • 2:21 Planning & Implementation
  • 5:05 Evaluation
  • 5:47 Lesson Summary
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Lesson Transcript
Instructor: Jennifer Reyes

Jennifer has taught Nursing in ADN, BSN, and MSN programs and has a Master's degree in Nursing Education.

This case study will help you apply the nursing process to a patient who is in pain from multiple injuries and requires pain management from the nurse.

Nursing Case Study on Pain

Anthony is a 59-year-old male who suffered a severe femur fracture, multiple pelvic fractures, and a lower lumbar fracture after a motorcycle accident. He underwent surgery and will be discharged to a rehab facility for further treatment in two days. Sarah, the nurse, plans to visit Anthony in his room first thing this morning. Sarah will use the nursing process of assessment, diagnosis, planning, implementation, and evaluation.

Assessment & Diagnosis

Sarah begins her process with assessment. As she enters the room, she finds Anthony lying very still in bed. He is breathing fast and does not wish to move or participate in the assessment. He grimaces from time to time. He states his pain is 4 out of 10 on a 0 to 10 pain scale. His vital signs are: heartrate 98, respirations 26, temperature 98.6, and blood pressure 140/87. Sarah reviews Anthony's documentation from other days to find his vital signs have been running high, like what she found this morning. Anthony has Percocet and ibuprofen ordered, but has only taken the ibuprofen three times in the last two days.

It is important to be aware of subjective and objective signs of pain. Subjective signs are indications of pain that may be personal or unique from patient to patient. How pain is perceived and rated can be influenced by a patient's personal background and culture, as well as previous experiences with pain and pain management. Subjective signs may not be measurable but may be observed by a practitioner or reported by the patient. Anthony reports a pain of 4 out of 10, but the nurse Sarah observes his stoic posture, his unwillingness to move or participate in care, and the grimacing on his face when as she assesses him. These are all subjective measures of his pain.

Objective signs refer to indications of pain that can be measured. For example, vital signs can be measured and compared to normal vital sign standards. In Anthony's case, his respirations, heartrate, and blood pressure are all higher than the normal standard and should indicate to the nurse that he is in pain. In addition, Anthony's refusal to participate in care is objective as it is measurable; he does not participate. These are Anthony's objective signs of pain.

Sarah makes a diagnosis. She believes that, even though he is rating his pain as a 4, he is in moderate to severe pain.

Planning & Implementation

Now Sarah moves into the planning part of her process. She knows that her plans should include both invasive and non-invasive pain management measures to help Anthony. Her first priority is to get Anthony's pain managed and under control before educating and teaching him about techniques he can use throughout his day.

Sarah offers Anthony pain medicine. He is reluctant and then finally agrees to take the ibuprofen. Sarah attempts to discuss with Anthony the benefit of taking the Percocet for such severe injuries. Sarah is patient and listens to Anthony as they discuss his pain options. Anthony finally expresses that he is concerned with becoming addicted to the Percocet, and that is why he has not taken it. After a long discussion, Sarah and Anthony decide that he should take the Percocet, and then she will teach him additional pain management techniques that he can use to cope with the pain.

Sarah continues to work with Anthony in the implementation part of the nursing process. She administers two Percocet per the physician order to Anthony and helps him sit up in bed and eat breakfast so to upset his stomach less. About 30 minutes after breakfast, Sarah explains to Anthony that now that the medication has had to time to be absorbed by the body, it would be a good time to get up and sit in the chair. With her assistance, Anthony is able to transfer to the chair, brush his teeth, and watch TV. The process takes about 40 minutes.

Sarah decides that Anthony is tired and offers to come back and teach him about non-invasive pain management techniques after he has had time to rest. This will allow for optimal response when she is teaching Anthony. After about an hour nap, Sarah rates Anthony's pain and determines that it is tolerable at a 3 out of 10. Sarah and Anthony discuss taking ibuprofen to help keep the pain down. Anthony agrees to take the medication to prevent the pain from increasing suddenly.

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