CLIENT IN CONTEXT

PRESENT STATE Date Identified: December 10, 2009 1. Acute Pain r/t surgical trauma as manifested by presence of surgical incision at the dorsal area of right hand measuring 4 inches in diameter secondary to S/P Incision and drainage dated December 10, 2009 as manifested by facial grimacing, gnawing pain with scale of 6/10 with 10 as highest and 1 as lowest aggravated by sudden movement and relieved by immobilization. S.B.: Nociceptors/pain receptors are free nerve endings that are widely distributed throughout the body. Chemically-mediated activation of nociceptors can be initiated by: (1) cell wall distribution as a result of events such as injury, ulceration, tumor invasion, and cell necrosis; (2) inflammation; (3) infection; (4) nerve injury; and (5) extravasation of plasma from the circulatory system associated with edema, ischemia, or occlusion of vasculature. Source: Medical Surgical Nursing, 7th Ed, p. 434 by Joyce Black S.B: Usually of recent onset and commonly associated with a specific surgery, acute pain indicates that damage occurs, and no systemic disease exists, acute pain usually decreases along with healing, generally in less than 6 months, and usually in less than a month. Source: Bare and Smeltzer, MedicalSurgical Nursing, 9th ed, vol.1, p.176 Date Identified: December 10, 2009 2. Impaired skin integrity related to disruption of the primary surface of the skin secondary to S/P incision and drainage dated December 10, 2009 as manifested by presence clean, dry and intact dressing located at the dorsal area of right

INTERVENTION Independent Interventions: 1. Assessed pain using OLDCARTS. R: To identify severity of pain 2. Observed for nonverbal cues. R: Observations may/may not be congruent with verbal reports indicating need for further evaluation 3. Monitored vital signs. R: V/S are usually altered in acute pain. 4. Elevated right hand with pillow. R: Promotes comfort and aids in adequate circulation. 5. Used diversional activities such as watching television when patient experienced pain during movement. R: To distract the patient thus minimizing pain 6. Instructed to perform deep breathing exercises during episodes of pain. R: Promotes relaxation. 7. Provided quiet and calm environment. R: To decrease external stimuli and to promote comfort and relaxation. 8.Visited patient at regular interval R: To monitor patient properly. 19. Continually assessed characteristic of pain. R: To determine if patient was able to experience relief from pain.

EVALUATION Desired Outcome: Within 8 hours of nursing interventions, the client will be able to report a decreased in pain scale and demonstrate use of relaxation skills and diversional activities. Actual Outcome: December 10,2009 After 8 hours of student nurse-client interaction, the client was able to report pain scale of 5/10 with 10 as the highest and 1 as the lowest, aggravated by sudden movement, touch, and straining after trying to change position in bed and relieved by immobilization. Patient exhibited facial grimacing. December 11,2009 After 8 hours of student nurse-client interaction, the client was able to report pain scale of 3/10 with 10 as the highest, aggravated by movement, touch, and straining after trying to change position in bed and relieved by immobilization of the extremity. Facial grimacing was evident. December 12 ,2009 After 8 hours of student nurse-client interaction, the client was able to report pain scale of 3/10 with 10 as the highest, aggravated by movement, touch, and straining after trying to change position in bed and relieved by immobilization of the extremity. Facial grimacing was evident. Patient was also able to utilize diversional activity such as watching television.

Independent Interventions: 1. Assessed blood supply and sensation of affected area. R: To assess causative/contributing factors 2. Noted odors emitted from the skin or area of injury. R: To assess extent of injury.

Desired Outcome: Within 8 hours of nursing interventions, the patient will not manifest any signs of infection such as fever, pain, inflammation, redness, heat and foul smelling purulent drainage on the incision area and will be able to demonstrate behaviours that will