Case Study Grid

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Five factors of the patient’s history that demonstrate nursing needs

1) Client states continued post-operative pain.

2) Client has the inability to completely empty her bladder.

3) Client’s past health history shows infrequent physical examinations and had not performed breast self-examination.

4) Client currently weighs 89 lbs compared to her usual weight of 110 lbs.

5) Client expresses great concern over her future and the future of her two children.

Nursing Diagnosis 1: Acute pain R/T post-op surgery M/B verbalization of continued postoperative pain.

Desired Outcome 1:
Patient will use self-report pain scale to identify current pain level and report comfort-function goal in the next 12 hours. Desired Outcome 2:
Patient will perform ADLs and activities of recovery easily in the next 24 hours.
Nursing Intervention 1 Check the patient’s vital signs and use a valid self-report pain tool to assess pain level intensity. Administer non-opioid analgesic for mild to moderate pain, and an opioid analgesic for moderate to severe pain before painful procedures or increasing physical activity (Ackley & Ladwig, 2011).
Nursing Intervention 2 Assess the location of pain, intensity, characteristics, onset, duration, aggravating, and alleviating factors. Identify activities that cause or aggravate pain and offer pain medication prior to performing these activities.
Evaluation method Patient understands how to use the pain tool to report pain level intensity. Re-assess the patient’s activity tolerance 30 mins-1 hour after medication administration or performing non-pharmacological interventions.

Patient will understand how to use self-report pain scale to report intensity of pain from 0-10. Increased heart rate and blood pressure often indicates presence of pain. Assessing pain location, intensity, characteristics, onset,…...

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